Robert Jones and Agnes Hunt Orthopaedic Hospital...U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Agenda_Public.doc Frank Collins

$Page 1: Robert Jones and Agnes Hunt Orthopaedic Hospital...U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Agenda_Public.doc Frank Collins$
U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Agenda_Public.doc

Frank Collins 4358

Chairman

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PPAARRTT OONNEE -- PPUUBBLLIICC MMEEEETTIINNGG 1.0 Apologies: 2.0 Minutes of the previous meeting held on 29

th October 2015 Paper 01

3.0 Matters Arising

4.0 Declarations of Interest

SSTTRRAATTEEGGYY 5.0 2016-17 Planning Process/Tariff Update Verbal

6.0 Communications and Engagement Strategy Presentation

7.0 Patient Access Policy Paper 02

PPEERRFFOORRMMAANNCCEE 8.0 Month 07 Integrated Performance Report Paper 03

9.0 Vanguard Update Presentation

10.0 Referral to Treatment Target (RTT) Action Plan Update Paper 04

GGOOVVEERRNNAANNCCEE,, QQUUAALLIITTYY AANNDD SSAAFFEETTYY 11.0 Reports from Board Committees:

Audit Committee – 17th July &16

th October 2015 Paper 05

Business Risk and Investment Committee – 7th July &12

th October

2015

Paper 06

Quality and Safety Committee – 16th July &1st October 2015 Paper 07

12.0 2016-17 Board Committee Timetable Paper 08

13.0 Open and Honest Care in Your Local Hospital Paper 09

14.0 Revision to Trust Constitution Paper 10

15.0 Deloitte 2 Final Report Paper 11

16.0 Any Other Business:

Junior Doctor Industrial Action - Update

17.0 Questions from the Public

18.0 Date and time of next meeting: 9.30 a.m. on 28th January 2016, The Board

Room, RJAH Orthopaedic Hospital NHS Foundation Trust, Oswestry

Questions from the Public on Agenda items – time limit of 15 minutes There will be an opportunity for the public to ask questions on agenda items. These should be limited to two questions per person and the time in total for each person should be limited to five minutes. If topics are likely to exceed this, they should be the subject of discussions between the hospital management and the individual concerned or there should be a formal request agreed by the Trust Board for the item to be included on the next agenda. If questions are detailed and require information that is not instantly available, the hospital will respond to the question within ten working days. To resolve, in accordance with Trust Standing Orders, that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest. (Section 1(2) Public Bodies (Admission to Meeting) Act 1960)

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U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Paper_01_Minutes_of_the_previous_meeting_held_on_29_October_201

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Frank Collins 4358 Chairman


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PPRREESSEENNTT:: Frank Collins, Chairman John Grinnell, Acting Chief Executive Craig Macbeth, Acting Director of Finance Jayne Downey, Director of Nursing and Service Delivery Steve White, Medical Director Richard Clarke, Non-Executive Director (from item 29/10/14.0.) Ian Davis, Non-Executive Director Alastair Findlay, Non-Executive Director IINN AATTTTEENNDDAANNCCEE:: Ruth Tyrrell, Associate Director of HR

Ann Ashworth, Trust Secretary Steve Vaughan, Interim Director of Operations Julie Roberts, Acting Director of Nursing (Designate) Janet Cox, Minutes Secretary Chris Hudson, Communications Officer MEMBERS OF THE PUBLIC: Jan Greasley, Lead Governor George Rook, Patient Panel Member Dave Adams, Public Governor Pam Kingsley, Shropshire Star Daniel Heald, Oswestry Advertiser

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The Chairman welcomed everyone to the meeting – in particular John Grinnell in his role as Acting Chief Executive and Craig Macbeth as the Acting Director of Finance.

MMIINNUUTTEE NNOO TTIITTLLEE AACCTTIIOONN

29/10/1.0 APOLOGIES Apologies were noted from Hilary Pepler, Non-Executive Director. In addition, the Chairman explained that Richard Clarke, Non-Executive Director had been detained on other matters and would be joining the meeting later in the morning.

29/10/2.0 MINUTES OF THE PREVIOUS MEETING HELD ON 24TH

SEPTEMBER

2015 The minutes of the previous meeting were agreed as an accurate record of the proceedings.

29/10/3.0 MATTERS ARISING The Chairman went through the actions which were either complete, ongoing or diarised for future meetings. Specific updates were given as follows:

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Betsi Cadwaladr University Health Board (BCU) The Acting Director of Finance explained that a key meeting had been arranged for 5

th November to jointly discuss how

RJAH and BCU will manage capacity at RJAH in line with BCU’s overall orthopaedic waiting list. He reminded the Board of Directors of BCU’s financial challenges and the need to ensure that patients are treated at the appropriate time and to this end a co-ordinated waiting list is the preferred direction of travel. He agreed to keep the Board of Directors updated as further information is available. Tariff Consultation The Acting Chief Executive said that once the Tariff is released, an assessment of the viability of individual service lines will be undertaken and shared with the Board. He said that early indications are that this had improved since an earlier iteration but this would not be confirmed for a few weeks. Board Development Session This has been confirmed for the morning of 19

th November

2015 with further details to be shared in due course. CQC Inspection Update The Chairman asked that the Board’s collective appreciation of the way that the organisation had presented itself during the formal inspection, and subsequent unannounced visit, be formally recorded and gave his thanks to everyone involved. He added that he was very proud and impressed with the way the organisation had responded to the overall process of the inspection. The Acting Chief Executive then updated the Board of Directors on the inspection itself which had been undertaken on 6

th-8

th October 2015 and had involved 25-30 inspectors on

site. He said that the Executive Directors had received high-level feedback on the last day of the inspection which included positive comments around how open the staff had been and how supportive both staff and patients were of the hospital. The inspectors commented that this had been one of the best organised inspection they had undertaken and singled out Julia Palmer, Governance Manager, for her lead in making this happen. He asked that formal thanks to Julia Palmer be recorded and confirmed that she had already received this feedback. He said that following the inspection there was a two-week window for an unannounced visit to take place and this had happened on 15

th October 2015 when they had

undertaken a walk around the organisation. The next steps are awaiting the first draft of their report which the Trust will have opportunity to provide comments on, followed by a stakeholder event in early January 2016. This event will include the regulators, local health economy partners and the CQC after which the formal report will be received and the organisation notified of its rating. The rating will either be outstanding, good, requires improvement or inadequate. At this stage there is no indication of what the rating will be. He added that he wanted to pass on his thanks to all the staff for their support during the inspection. He concluded that he would inform the Board of Directors with any further updates in due course.

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The Director of Nursing and Service Delivery reiterated the comments made by the Acting Chief Executive and said that she welcomed the open and honest dialogue which had occurred between the Trust staff and inspectors during the feedback session on their last day at the hospital. She said that there had been no big surprises in the feedback given. A Non-Executive Director asked whether the organisation felt that the experience of inspectors had been what would have been expected and the Director of Nursing and Service Delivery confirmed that the mix of inspectors had been good comprising of clinicians, orthopaedic nurses, lay members and assessors. She commented that she had been impressed at the level of preparation work undertaken by the inspection team prior to arriving at the hospital and how this had been tailored to reflect the services provided. The Board of Directors noted the update.

29/10/4.0 DECLARATIONS OF INTEREST There were no new Declarations of Interest to record.

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29/10/5.0 STANDARDS OF BUSINESS CONDUCT POLICY AND STANDARDS

FOR BOARD MEMBERS POLICY The Associate Director of Human Resources presented the Standards of Business Conduct Policy which had been reviewed with a number of minor changes proposed. In addition she explained that a new policy has been developed, Standards for Board Members, which addresses the specific requirements for Fit and Proper Persons and professional Standards for Boards both on appointment and ongoing requirements. She said that both policies had been reviewed by the Audit Committee who recommended them for Board approval. A Non-Executive Director highlighted a number of typographical errors – section 5.4 made reference to section 3.4 which does not exist and section 9.3.2 makes reference to commercial sponsorship in section 16 which should read commercial sponsorship section 14. The Chairman asked if this policy related to both Executive and Non-Executive Directors and the Associate Director of Human Resources confirmed that this is the case. He then asked a supplementary question regarding the roll-out of the policies and the Associate Director of Human Resources confirmed that she will do this on an individual basis. The Board of Directors approved the Standards of Business Conduct Policy and approved the Standards for Board Members Policy, subject to correction of the typographical errors.

29/10/6.0 TREASURY MANAGEMENT POLICY The Acting Director of Finance presented the Treasury Management Policy which had been reviewed by the Business Risk and Investment Committee at its meeting on 12

th October 2015. He explained that amendments to the

policy had been highlighted in yellow for ease of reference and were mainly grammatical or points of clarification. He

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added that any reference to the Monitor Continuity of Services Risk Rating (CSRR) had been updated for the new Financial Sustainability Risk Rating (FSRR). He concluded that following discussion at the Business Risk and Investment Committee meeting, paragraph 4.6 had been redrafted so as not to preclude borrowings that would trigger a deterioration in the capital service capacity ratio. Such requests would require debate and approval by the Board of Directors. The Chairman of the Business Risk and Investment Committee thanked the Acting Director of Finance for this amendment and confirmed that this reflected the detailed discussion which had taken place at the meeting. The Board of Directors approved the Treasury Management Policy.

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29/10/7.0 MONTH 06 INTEGRATED PERFORMANCE REPORT The Acting Chief Executive introduced the Month 06 integrated performance report which was aligned to the Quarter 2 position which will be reported to Monitor. He said it was an important milestone for taking stock at the mid-point in the year and overall there had been some good performance, in particular within the domains of patient safety and patient experience. He said that the organisation continues to be challenged in delivering its access target and acknowledged that whilst the Quarter 2 open pathway (92% measure) had been achieved there are some ongoing challenges which need to be resolved. He added that the efficiencies domain had shown some improvement in month but these now need to be embedded to see the Trust maintain this improvement. He concluded that the finances are being impacted by a number of areas, not least one of which is the commissioner risks facing the Trust which are some of the most difficult issues he has had to address since he had joined the organisation. He said that it was important that the Board of Directors recognised and acknowledged where this may lead the organisation in terms of its year-end outturn. Domain 1 Patient Safety The Medical Director reported that all key metrics were rated green in month. He noted that there had been some incidents but these remain low compared to the volume of patients seen at the hospital. He highlighted the following exceptions:

There had been one patient death in month which was not unexpected.

Two patients were diagnosed with pulmonary embolism in month.

There had been one incidence of a grade two pressure ulcer in month.

Thirteen inpatient falls occurred in month with two patients experiencing low levels of harm.

Eleven medication incidents occurred in month with one patient requiring additional monitoring for 24-hours as a result of a prescribing incident.

Four patients were readmitted within 28-days of discharge which was within the target level in month.

A Non-Executive Director questioned whether the medication

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incident where Trust policy had not been followed was the same incident as had occurred previously. The Medical Director confirmed that it was a separate incident. Domain 2 Patient Experience The Director of Nursing and Service Delivery reported that patient feedback remained positive with over two hundred compliments received in month. She highlighted the following exceptions:

The results of the Friends and Family Test remained above 99% for positive recommendations. However, five patients stated they would not recommend the Trust with this being fed back to the relevant departments.

Eight complaints had been received in month.

Ten patients were classed as Delayed Discharges which was above (worse) the target. There appeared to be issues around Social Services which has been fed back to the Commissioners as this is a concern prior to the winter period. Additional Social Services support has been provided on Sheldon Ward which had been welcomed although it was noted that until patients are admitted to hospital they cannot be referred to Social Services (this is a national issue). This will continue to be monitored. There have been improvements in the number of delayed discharges on the MCSI with closer working with the specialised commissioners.

The Interim Director of Operations reported that:

All cancer targets were achieved in month.

The 92% open pathway target was maintained.

The English and Welsh 52-week waiting patients targets were breached with two English patients and one Welsh patient waiting over 52 weeks for treatment. He explained that the rules have changed with regards to patients choosing to wait and recording their unavailability and as a result their “clock” is paused – this will no longer be acceptable so it is likely that some patients will now become long waiters and the Trust will need to work with the CCG to manage this situation. He cautioned that this may become a challenge for the organisation as processes and systems linked to the Access Policy are changed to accommodate this.

Domain 3 Efficiency The Interim Director of Operations reported that seven of the ten metrics were rated green in month with improvement in a number of the metrics. He highlighted:

The Day Case rate was above target but below for surgical rates. Plans are in place to address this.

The Theatre Utilisation metric is being further developed.

The average length of stay metric is above the target and subject to daily review in advance of the new build.

The Outpatient productivity metrics are below

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standard but this is linked to the changes to the operational systems and the performance management of the booking process to ensure that patients are given appropriate notice.

The ‘did not attend’ rate is good in comparison to other organisations but improvements can still be made.

A Non-Executive Director referred to the three 52-week breaches and sought clarification on whether the organisation is subject to penalty even if it because the patient has chosen to delay their treatment. The Acting Director of Finance confirmed that he understood that this may be the case although the Welsh Commissioners would wish to discuss each individual case rather than apply a blanket penalty. The Acting Chief Executive asked at what point had the new rules been implemented and the Interim Director of Operations said that the formal guidance had been issued on 1

st October 2015 but the new rules were applied

retrospectively to 1st April 2015 in accordance with the

abolition of the admitted and non-admitted targets. The Acting Chief Executive said that work was being done to ensure that the theatre utilisation was as effective as possible. In addition he said that the Clinical Directors were developing a protocol for long term follow ups which would be implemented in the next few months. He said that this tied-in with the latest guidance around virtual clinics and is an interesting area of development for the organisation although he acknowledged that this is an area which the organisation needs to implement as it is behind others in this area. The Chairman of the Business Risk and Investment Committee commented that with the significant investment in theatres it is imperative that the theatre efficiency metrics start to deliver improvement. Domain 4 Resources The Acting Director of Finance reported that whilst a surplus had been achieved in month, this was lower than the planned value. He highlighted:

A surplus for September of £116k was achieved, £134k lower than plan.

The income targets were achieved but there were pressures in terms of the cost of delivery as a result of the ongoing use of private capacity to support the clearance of long waiting patients. Gaps in theatre usage and anaesthetic rota had also impacted on the position together with increased costs of OJP and overtime.

There had been non-recurrent costs associated with the recent governance investigation.

The Cost Improvement Programmed was on plan in month and full achievement continues to be forecast at year-end.

Cash balances reduced to £4.3m as a result of the half-yearly PDC dividends and the annual pre-payment on the Menzies theatres. In addition, £2.2m is owed by the organisation’s two main

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commissioners in respect of over-performance although an interim settlement of £650k had subsequently been received from Shropshire CCG during October.

The cumulative surplus at the month 06 point was £97k which is £250k behind plan. He said that in comparison to the same point in 2014-15, there had been a deterioration in the organisation’s financial performance. He added that a discussion was planned with Monitor to discuss a revised outturn.

The financial sustainability risk rating returned to a level 4 (lowest risk) as a result of returning to a cumulative surplus position.

A key area of focus will be triangulating the organisation’s own assumptions, on activity and income with Commissioners financial constraints which will be discussed later in the agenda.

The Chairman questioned why the over-performance of £2.2m from the organisation’s main Commissioners had not been paid and the Acting Director of Finance said that for Shropshire CCG payments were made against an agreed profile that excluded the additional activity completed in Quarter 1 associated with the RTT recovery plan. He said that the BCU contract was different in that the formal contract between the organisations does not recognise the historic additional activity delivered (500 cases). At BCU request, they had retained capacity pending them reaching agreement on this additional contract. However they are now looking to align their activity levels to the financial envelope rather than increasing revenue to support delivery. The Chairman then asked what the Acting Director of Finance’s assessment was regarding achieving the year-end surplus of £1m. The Acting Director of Finance said that there had been a number of non-recurrent pressures incurred to date regarding interim management costs and achievement of the £1m surplus was looking doubtful at this time. He said that Monitor had written to the organisation regarding agreeing a revised year-end forecast position and this was currently being reviewed and would be shared with the Board of Directors in due course. The Chairman commented that this statement would not be a surprise to the Board as it was aware that there had been a number of one-off costs incurred. The Chairman of the Business Risk and Investment Committee asked that when the figures are presented that it is clearly shown which are recurrent and non-recurrent costs. This was agreed. The Associate Director of Human Resources reported that:

Sickness had increased slightly at 2.81%.

The flu campaign was well underway.

Staff stability was below the 92% target although there were no trends or issues identified.

Appraisal was below target at 88% with Diagnostics and Theatres particular areas of below expected performance. Assurance has been given that all Diagnostics staff have been given dates for their appraisal.

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The Director of Nursing and Service Delivery reported that she had no concerns regarding staffing levels which are reported monthly against plan. Domain 5 External Perception The Acting Chief Executive reported that the Trust’s financial performance and sustainability risk rating was at level 4 and the governance rating remained ‘under investigation’ regarding RTT delivery and governance. The Chairman of the Business Risk and Investment Committee questioned when the investigation would be resolved and the Chairman said that he would be speaking to Monitor to ascertain when the investigation will formally conclude. The Board of Directors noted the month 06 integrated performance report.

29/10/8.0 2015-16 MID-YEAR REVIEW The Acting Chief Executive presented the paper which evaluated progress made at Quarter 2 in delivering the organisation’s strategic aims and objectives which had previously been agreed as part of the 2015-16 Operational Plan. He highlighted the areas of focus around developing a sustainable plan for the delivery of RTT; working with Commissioners to develop improved pathways to help manage demand levels which incorporates the wider QIPP schemes, some of which have slipped which has had an impact on contract performance; a final agreement with BCU on capacity required has yet to be reached with future capacity plans being developed; structural and technical issues from an IT perspective regarding the change management programme and the need for people to work differently; plans are in place with regards to recruitment of additional consultants to support RTT pressures supported by a sustainable theatres workforce and implementation of the leadership strategy which has recently been launched. He said that the Executive Directors are focussed on progressing these areas. He added that a number of strategic Executive to Executive meetings have been scheduled with the Trust’s two main commissioners in the coming months which will address the commissioner issues regarding demand and capacity and QIPP in more detail. The Director of Nursing and Service Delivery said that for one of the sub-specialties which is challenged (Foot and Ankle) a nurse is being sponsored to undertake an advanced nursing course to support those consultants in providing clinics. The Chairman questioned whether the report was shared with Monitor and the Acting Chief Executive confirmed that this is an internal document only. The Chairman of the Business Risk and Investment Committee said he was not comfortable with the BCU position and would like to add support to the Executive Directors in them developing a sustainable demand and capacity model which both parties can agree. The Chairman agreed as this impacts on the organisation in a number of ways.

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The Board of Directors noted the position in respect of the Quarter 2 review.

29/10/9.0 2015-16 QUARTER 2 BOARD ASSURANCE FRAMEWORK The Trust Secretary presented the 2015-16 Quarter 2 Board Assurance Framework which had been discussed at the Executive Team and had been changed as follows:

Risk 1150 (Future Fit Programme) has been increased to take into account current uncertainty in relation to orthopaedics.

Risk 1382 (Board Stability) has been added.

Risk 889 (Delivery of a Sustainable Spinal Surgery Service) has been removed as this risk is now incorporated into Risk 885 (RTT).

She added that the format had been changed to make it more ‘user friendly’. A Non-Executive Director questioned whether references to 2013 plans in Risk 822 (Risk of failure of key Trust systems due to a major incident) were still relevant. The Director of Nursing and Service Delivery confirmed that these were the latest available. The Board of Directors were in collective agreement that the changed format was much improved and made it easier to be reviewed. The Board of Directors approved the 2015-16 Quarter 2 Board Assurance Framework.

29/10/10.0 REFERRAL TO TREATMENT (RTT) REPORTING PROCESS REVIEW The Chairman introduced this item as the largest operational issue which is affecting the organisation at the present time. The Interim Director of Operations then presented a paper which provided an update on progress against the action plan reviewed by the Board of Directors in July 2015 following the review of the RTT reporting processes carried out by Deloitte LLP in March 2015. He said that the paper outlined the next steps in developing a sustainability plan and was to note rather than for approval. He highlighted that:

The Business Risk and Investment Committee had reviewed the action plan developed following the Deloitte Review.

The Access Policy had been delayed to take account of the updated guidance released on 1

st October 2015

but would be brought to the November Board of Directors meeting for approval.

He recognised the efforts made by his team in improving the position and confirmed achievement of the 92% measure for September and Quarter 2.

The recovery plan predicted no over 52-week waiters (English) at the end of September which had not been met.

38% of the organisation’s capacity is used to treat Welsh patients with 260 Welsh patients waiting longer than 36-weeks. In addition, patients have been transferred to RJAH have already waited over 52-

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weeks from Welsh Commissioners as part of an agreed plan to treat long waiting patients.

The operational team are reviewing demand and capacity of each sub specialty.

Operational processes and data management are being reviewed which is likely to impact on performance. In addition strengthened performance management and operational team management changes will be implemented.

A discussion had taken place with the Intensive Support Team to support delivery of a sustainable plan.

The Chairman queried whether the patients who were transferred to RJAH from BCU were subject to financial penalties. The Interim Director of Operations confirmed that most of these patients had now been treated and where they had already waited at BCU the trust would not be penalised for this. The Chairman thanked the Interim Director of Operations for his excellent overview and summary and clarified that the key points were as follows: there had been significant endeavour from clinical and non-clinical staff in responding to the difficulties of a few months ago; compliance had been achieved with the English standard at Quarter 2; the robustness of the actions to deliver sustainable compliance however were under question as it is predicted that the Quarter 3 compliance will not be achieved and there was concerted effort to ensure compliance moving forward with the development of a sustainable plan. The Director of Nursing and Service Delivery questioned whether the IST (Intensive Support Team) was the correct organisation to be providing guidance, support and assurance to the Board of Directors. The Interim Director of Operations said that their last review had been a narrow review which concentrated on the spinal area only and since this their review processes had also changed. He added that NHS England supported IST engagement with the organisation and they would undertake diagnostic work initially which would then be used with national best practice to develop a recovery plan and eventually a sustainable solution. The Acting Chief Executive commented that the Audit Committee had discussed the organisation getting an ‘holistic assurance’ on the lessons learnt from the RTT and suggested that an additional Audit Committee meeting would be convened to look at the scope of the IST review, internal and external audits and data quality review work to ensure that there were no gaps. A Non-Executive Director queried whether there was capacity outside the hospital for those sub specialties that had capacity constraints. The Interim Director of Operations said that there was limited capacity available at other NHS providers but it was important for the organisation to understand what capacity it had before it utilised external providers; in addition the use of the private sector is at premium cost and this needs to be balanced. He added that as part of the demand and capacity work which was being undertaken this would identify what the underlying demand is and what internal capacity is

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available. The Chairman commented that it was a complex scenario which was multi-layered. The Chairman of the Business Risk and Investment Committee commented that he was unhappy with patients waiting for treatment and he questioned whether the clinical priority of patients was being taken into account. The Interim Director of Operations confirmed that the clinical priority was not being distorted and the policy is quite clear in that patients should be treated in order of clinical priority. He added that the patients which are listed as ‘urgent’ are managed separately. The Medical Director commented that there was evidence that GPs were reclassifying patients as urgent to expedite their surgery. He said that this was unfair but that this was being managed by the organisation and reiterated that patients were being treated in line with clinical need. The Acting Chief Executive confirmed that the organisation was in active discussions with its commissioners and Monitor regarding the situation and the possible impact on its forecast position. The Chairman commented that the nature of the debate about this issue by the Board of Directors was evidence of the importance which it places on this issue and he said that it was important to remember that the numbers relate to patients and the organisation must never forget this. He thanked the Interim Director of Operations for his comprehensive update and the progress which had been made to date. He acknowledged that to deliver a sustainable plan which is robust, fair and effective may take some time. The Board of Directors noted the report and action plan.

GGOOVVEERRNNAANNCCEE,, QQUUAALLIITTYY AANNDD SSAAFFEETTYY

29/10/11.0 2015-16 QUARTER 2 MONITOR SUBMISSION The Acting Chief Executive presented the 2015-16 Quarter 2 Monitor Submission which provided assurance to the Board of Directors in relation to the key targets and declarations required by Monitor for the Quarter 2 performance return. A Non-Executive Director questioned whether the over-arching declaration in 4.10.1 was accurate given the need for the financial forecast to be reviewed and suggested that a footnote be included to reflect this. The Chairman and Acting Chief Executive agreed to review the wording prior to submission of the return. A Non-Executive Director questioned whether the narrative in 4.5.3, line 4 was correct as the Trust was highlighting a risk of meeting the open pathway target during Quarter 3. It was agreed that the word ‘not’ had been missed out of the sentence and the wording would be reviewed for future reports. The Board of Directors approved the Quarter 2 submission, pending the amendments being made.

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29/10/12.0 2015-16 QUARTER 2 INFECTION, PREVENTION, CONTROL AND

CLEANLINESS REPORT The Director of Nursing and Service Delivery presented the Quarter 2 Infection, Prevention, Control and Cleanliness

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Report which outlined the performance of the Trust against the registration requirements. She explained that activity to support these requirements was outlined in the report and is on trajectory against the annual work programme. She highlighted:

There had been no cases of reportable infections during the quarter.

Cleanliness scores had been maintained above the national and Trust target.

Staff training remains on target for 100% completion by year-end.

Patient satisfaction remains very high.

The Patient Led Assessment of the Care Environment (PLACE) took place in June with an action plan developed. The full report will be considered by the Infection Control Committee and reported to the Quality and Safety Committee and Board of Directors in due course.

Over 87% of staff have completed infection control training.

The link meetings continue supported by e-updates.

The CQC during their inspection had identified issues around patients, staff and visitors not using hand gels at the main entrance. To address this, new gel stations have been sited at the main entrance, posters reminding of the bare below the elbows policy. The way that this is audited has also been changed as well as the re-introduction of peer reviews on wards and departments. There is a perception that use of hand gels is not happening as this is not ‘visible’.

There has been an increase in Surgical Site Infections since April 2015 which has been reported to Shropshire CCG as a serious incident. The investigation is currently ongoing and is unlikely to be concluded in the usual timeframe (60 days). In addition there is a real possibility that the cause of this may never be established. She concluded that all that can be done regarding this internally had been completed and it was now for public health to undertake their review.

The Board of Directors approved the report.

29/10/13.0 2015-16 MID-YEAR SAFER STAFFING REPORT The Director of Nursing and Service Delivery presented the paper which updated the Board of Directors on the continual progress and proposed recommendations regarding the arrangements at the hospital in managing safe nurse staffing levels within the inpatient wards. She explained that the organisation reports its fill rates on a monthly basis and these are based on the plan for the month which in some instances may be above plan if additional support is required, for instance dementia or medical reasons. She said that on some occasions when wards are quieter, staff take leave or are redeployed to other wards which make the use of agency staff in ward areas very low. She added that recent adverts for staff had produced very good response rates, particularly from newly qualified staff and whilst they are waiting for their registration to be finalised, they have been gaining experience by working as HCAs. She explained that the areas requiring

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consideration and future investment were upgrade of iPAMs; introduction of an e-rostering system and theatre staffing data collection to meet the proposed start date of 1

st December

2015. She concluded that new guidance from Monitor encourages organisations to consider all staffing requirements on wards including AHPs, OTs etc and this is something which has already been introduced particularly on the spinal wards and Sheldon ward. She said that during the CQC inspection, the inspectors had been very complementary about the team working which had been demonstrated such as the overlap between therapists and nursing staff. She concluded that the ex-regional nurse (Ruth May) was now the Nurse Director at Monitor and one of her key portfolios was safer staffing and as part of the 6Cs workstream, she was keen to ensure safer staffing levels. The Acting Chief Executive referred to a multi-agency letter recently received on safer staffing which alluded to local organisations making sure staffing levels are locally determined acknowledging that the guidance needs to be fit for local services. The Director of Nursing and Service Delivery said that previously ratios such as 1:8 had been recommended but it had quickly been determined that this does not work for all organisations. The Board of Directors noted the content of the report.

29/10/14.0 2014-15 ADULT AND PAEDIATRIC SAFEGUARDING ANNUAL

REPORTS The Director of Nursing and Service Delivery presented the 2014-15 Adult and Paediatric Safeguarding Annual Reports and apologised for the delay in bringing these to the Board. She explained that these reports provided an overview of the work which has been undertaken and performance during 2014-15 in relation to adult and paediatric safeguarding board and the local health economy. She highlighted the following: Adult Safeguarding

Maintaining the safety of vulnerable adults is a priority.

Link nurses are available on wards and in departments and they are key to raising awareness.

Mental capacity training and Deprivation of Liberty Safeguarding (DoLS) training continued to be provided for all clinical and non-clinical staff.

Bespoke training has been provided by Staffordshire University to help staff recognise vulnerable adults.

The STAR assessment incorporates safeguarding to assess staff knowledge of policy and procedures.

Pre-operative dementia screening formed one of the 2014-15 CQUINs, the target of 90% was achieved.

An evaluation of the butterfly scheme now needs to be undertaken.

The quarterly safeguarding committee have continued.

There had been six safeguarding referrals during 2014-15.

There had been a slight increase across the adult safeguarding suite of training programmes apart from the DoLS.

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14

Work will continue in 2015-16 to progress actions from 2014-15.

The Chairman thanked the Director of Nursing and Service Delivery for reminding the Board of Directors that patient care is key and developing a dementia friendly environment is just one element of that. The Director of Nursing and Service Delivery thanked the Quality Matron, Anne Worrall, for the work which she has done and continues to do in promoting this important workstream. Paediatric Safeguarding The Director of Nursing and Service Delivery then presented the 2014-15 Paediatric Safeguarding report. She highlighted the following:

There are named doctors and nurses at the Trust for safeguarding children.

A child protection information sharing system had been introduced in a number of pilot sites during 2014-15. Unfortunately the introduction of this system in the local health economy has been delayed and whilst the organisation is keen for this to be progressed, it is reliant on local social care providers. In the meantime, if staff have any concerns regarding a child, they contact the local council or are reliant on referrers and families sharing this information.

Safeguarding training continued to be provided. The training matrix requires review as currently there is an unrealistic expectation that levels 1, 2 and 3 will be completed during new starters first year of employment. In addition it is important that new staff receive their high level training early in their employment with the organisation.

The named leads attend the interagency meetings regularly with information from external meetings cascaded through the safeguarding committee, paediatric forum, Alice Ward meetings and one minute briefings.

The named nurse received regular supervision sessions.

A number of policies and procedures are available to staff via the document centre.

Eight patients had been reviewed with issues under the safeguarding umbrella.

A number of audits had been undertaken during the year.

The Chairman thanked the Director of Nursing and Service Delivery for two very comprehensive reports and acknowledged that these two policies are at the heart of the package of care that the hospital aims to deliver to its patients. The Director of Nursing and Service Delivery commented that the key issue for her had been the responsiveness of staff highlighting when they were concerned about an issue and it was not just nursing staff. She added that the key to supporting patients is having staff awareness. The Board of Directors noted the 2014-15 Adult and Paediatric Safeguarding Annual Reports.

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15

29/10/15.0 2015-16 QUARTER 2 REPORT OF MEDICAL STAFF APPRAISAL

FOR REVALIDATION The Medical Director presented the report to the Board which updated on the appraisal and revalidation of Doctors. He commented that the key to maintaining and improving quality is an effective appraisal system where doctors have the opportunity to reflect on their training and be helped to improve the work that they do and for this to be kept up to date and refreshed annually. He explained that the report gave details of the Quarter 2 performance and included the comparator report on national standards which demonstrated that the organisation was performing significantly better than most organisations in a number of indicators except for one. He added that there had been difficulties in the past in training staff to be investigators and case managers but that this had now improved. He confirmed that out of the 13 doctors who were due to undertake an appraisal 8 had been completed and 5 had not. Out of those 5, 3 were accepted as having reasonable reasons for not completing and 2 were not accepted. Out of the 17 doctors who were due to be revalidated during the quarter, 15 had been revalidated and 2 had been deferred. He concluded his update by confirming that the Responsible Officer, Clinical Lead for Appraisals and the Training Manager had attended a West Midlands training event to maintain their accreditation and confirmed that the organisation was well represented in terms of managing the revalidation of doctors. A Non-Executive Director asked whether there were any restrictions placed on the two doctors whose revalidation had been deferred. The Medical Director confirmed that there were no restrictions in these two cases but this is assessed on a case by case basis. He added that the organisation has regular access to a General Medical Council (GMC) employment liaison advisor in relation to any matters which may cause concern. The Director of Nursing and Service Delivery commented that the guidance has now been received regarding nursing revalidation which is due to commence with effect from April 2016. The Board of Directors noted the content of the report.

29/10/16.0 2016-17 BOARD OF DIRECTORS MEETING DATES The Chairman presented the proposed 2016-17 meeting dates for inclusion in Board members diaries. The Board of Directors approved the proposed Board meeting dates for 2016-17.

29/10/17.0 AANNYY OOTTHHEERR BBUUSSIINNEESSSS There was no additional business to discuss.

29/10/18.0 QQUUEESSTTIIOONNSS FFRROOMM TTHHEE PPUUBBLLIICC Jan Greasley, Lead Governor, thanked the Director of Nursing and Service Delivery on behalf of the Council of Governors for the work which she had done whilst at the Trust and to wish her all the best for her future career.

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Weekend Working George Rook, Patient Panel member questioned whether the relevant staff (such as Diagnostics and Therapies) were available to support extended weekend working which was safe. He referenced a medication incident which had been reported that had happened over a weekend. The Director of Nursing and Service Delivery said that currently there was no medicines reconciliation on Saturdays but that the recently appointed Chief Pharmacist (who was due to commence employment in the new year) would be reviewing 7-day working for Pharmacy staff. She confirmed that therapies staff do work routinely on Saturday and plans were in place for this to be reviewed and potentially extended. This was especially important in light of the new theatre development. The Acting Chief Executive commented that he was keen for a sustainable 7-day service to be provided to patients which was safe and effective and this was an area of focus for him and his Executive Director colleagues to progress. The Medical Director added that he had spoken to other medical directors and very few have the volume of elective work like the RJAH. He said it would involve a wholesale culture and commitment change for staff (not to mention expense for the organisation) to work routinely at weekends and he agreed with the comment of the Acting Chief Executive that this was an area of focus for the organisation. Vanguard Project George Rook, Patient Panel Member said that he had read that the organisation was one of three organisations which had been successful in its bid for a Vanguard project and asked if those present could be advised of what that involves. The Chairman said that it was an exciting project for the organisation to be involved in and would form an agenda item on a future Board of Directors meeting. The Acting Chief Executive said that the project was very much in an embryonic stage and under the banner of the National Orthopaedic Alliance, it was looking to codify what good orthopaedic care looks like and replicate this across the country. He reiterated the comment by the Chairman that further detail would be shared at a future meeting. Director of Nursing and Service Delivery The Chairman said that whilst he had had the pleasure of working with Jayne for only the last 9 months, she had been at the hospital for 3 ½ years and it was with a heavy heart that the organisation was losing her. He said that she would be a ‘tough act to follow’ and the contribution which she had made to the hospital was evidenced by the papers she had presented at the meeting and went well beyond nursing. He thanked her for the excellent work which she had undertaken during her tenure and wished her every success in the future.

29/10/19.0 DDAATTEE OOFF NNEEXXTT MMEEEETTIINNGG:: Thursday 26

th November 2015 at 9.30 a.m. in the Board

Room.

CCHHAAIIRRMMAANN’’SS CCLLOOSSIINNGG RREEMMAARRKKSS The Chairman thanked everyone for their contribution and closed the public session of the meeting.

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17

BBOOAARRDD OOFF DDIIRREECCTTOORRSS MMEEEETTIINNGG

2299TTHH

OOCCTTOOBBEERR 22001155

SSUUMMMMAARRYY OOFF KKEEYY AACCTTIIOONNSS

Action Lead Responsibility

Progress

2299//1100//77..00-- MONTH 06 INTEGRATED PERFORMANCE REPORT Domain 4 Resources

Current and non-recurrent figures to be clearly presented in the revised year-end forecast.

Acting Director of Finance

Completed.

2299//1100//1111..00 2015-16 QUARTER 2 MONITOR SUBMISSION

Wording on the return to be revised prior to submission.

Narrative on the report to be checked.

Chairman/ Acting Chief Executive Acting Director of Finance

Completed. Completed.

Paper 02

U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Paper_02_Patient_Access_Policy.docx

BOARD OF DIRECTORS 26TH

NOVEMBER 2015

Executive Responsible Steve Vaughan, Interim Director of Operations

Paper prepared by (if different from above)

Category of Item Strategic Direction and Development

Performance and Governance

Context Previous Board discussion

Link to National Policy

Link to Trust’s Strategic Objectives

Risk if no action taken

Executive Summary

It has been necessary to update the Trust’s access policy in light of the findings from the Deloitte Review of waiting lists and to account for the revised guidelines published by NHS England on 1st October 2015.

Subject/Title Patient Access Policy

Nature of Report For Information

For Discussion

For Approval

Received or approved by Clinical Management Board Shropshire CCG Clinical Assurance Panel

Legal Implications

Recommendation The Board of Directors are asked to approve the policy

Acronyms Included NHS – National Health Service RTT - Referral to Treatment Target CCG – Clinical Commissioning Group

Paper 02



NOVEMBER 2015

PATIENT ACCESS POLICY 1. Introduction

The current Access Policy (v2.2) was approved in November 2013, with a review scheduled for November 2015. In the past six months the NHS has revised the monitoring and reporting of access for patients on referral to treatment pathways. Revised guidelines were issued on 1

st October 2015. In

addition, the Deloitte Referral to Treatment Reporting Process Review identified a number of issues linked to the current access policy and recommended a review/update. To meet the requirements of the revised guidance and recommendations the Patient Access Policy has been restructured and rewritten, following the structure from exemplar policies.

2. Key changes Owing to the radical nature of the update there are a significant number of changes to the policy meaning it is not possible to directly reference each change and the policy should therefore be read as if new. There are key changes in principle reflected within the policy which should be noted:

In June 2015, Simon Stevens and the Secretary of State for Health accepted a recommendation from Sir Bruce Keogh that the incomplete pathway operational standard should became the sole measure of patients’ constitutional right to start treatment within 18 weeks. As a result of the removal of the completed admitted pathway operational standard, there is no longer any provision to report pauses or suspensions for RTT waiting time clocks in monthly RTT returns to NHS England under any circumstances.

Patients who choose to wait longer than 18 weeks should have their wishes accommodated without being penalised. The tolerance of 8% set for achievement of the incomplete pathway waiting time operational standard is there to take account of the following situations that might lead to a longer waiting time:

o Patients who choose to wait longer for personal or social reasons; o Patients for whom it is clinically appropriate to wait longer (this does not include

clinically complex patients who can and should start treatment within 18 weeks); o Patients who fail to attend appointments they have agreed.

3. Review Process

An iteration of the draft policy was approved by the Clinical Management Board at its meeting on 9

th

November 2015. The draft policy has also been reviewed and agreed by the Shropshire CCG Clinical Assurance Panel as lead commissioner; their amendments have been incorporated within this draft.

Paper 02


In addition the draft has been reviewed by the NHS Intensive Support Team amendments incorporated. Welsh commissioners have also received a copy, though the guidance for Welsh patients has not changed.

4. Implementation Process

Standard operating procedures and relevant training will be in place for booking and access staff, with the roll out starting in December; this will dovetail with the formal training on RTT in place from the Deloitte LLP action plan.

5. Next Update/Review of Policy Given the changes incorporated within the policy and significant changes to operational processes and systems required in the forthcoming months, it is suggested the policy is reviewed and/or updated in six months (May 2016) before reverting to an annual review cycle. This will provide an opportunity to incorporate new findings from the NHS Intensive Support Team diagnostic exercise and recovery plan implementation.

6. Recommendation

The Board of Directors are asked to approve the policy. Steven Vaughan Interim Director of Operations 18

th November 2015

Version 3.0 Approved XXX

Patient Access Policy Current version held on the Intranet

Check with Intranet that this printed copy is the latest issue

Page 1 of 46

Title:

Patient Access Policy

Unique Identifier:

POL018

Document Type:

Policy

Version Number:

3.0

Status:

DRAFT

Responsible Director:

Director of Operations

Author:

Interim Director of Operations

Scope:

Trust Wide

Replaces:

Patient Access Policy Version 3.0

To be Read in Conjunction with the Following Documents: (list related policies)

Standard Operating Procedures (SOPs) Trust Safeguarding Policy Overseas policy

Keywords:

18 week standards, Referral to Treatment

Endorsed By:

Clinical Management Board

Date Endorsed

9

th November 2015

Approved By:

Board of Directors

Date Approved:

TBC – 26/11/15

Issue Date:

November 2015

Review Date:

May 2016

Security Level:

Open Access Restricted Confidential




Page 2 of 46

Policy Statement

This policy outlines the way in which the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation

Trust will manage patients who are waiting for appointments, investigations and or treatment on a referral-to-

treatment pathway.

Equality Impact

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (RJAH) strives to ensure quality of

opportunity for all service users, local people and the workforce. As an employer and provider of healthcare,

RJAH aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This

document has therefore been equality impact assessed by the Executive Team to ensure fairness and

consistency for all those covered by it regardless of their individuality. The assessment form is included in

Appendix 3.

Local Health Community Agreement

The policy has been reviewed and agreed by Shropshire Clinical Commissioning Group’s Clinical Assurance

Panel and shared with Welsh Local Health Boards.

VERSION CONTROL

Version

Number

Issue

Date

Revision

Date

Amendments

2.2 19/11/13 28/11/15 Current Policy

3.0 Nov 2015 May 2016 Rewrite/Restructure to account for the refreshed guidance produced by

NHS England on 1st October 2015.

Document Control

Control

Arrangements

This document should be reviewed annually in line with changes to relevant national

standards.

This is a controlled document and printed copies may not be up to date. Please check

the hospital intranet for the latest version and destroy all previous versions.

Associated Polices Recording and reporting referral to treatment (RTT) waiting times for consultant-led

elective care (1st October 2015)

Welsh Assembly Rules for Managing Referral to Treatment Waiting Times (2009)

NHS Constitution (27th July 2015)

Choice Framework (March 2015)

Everyone Counts: Planning for Patients 2014/15 to 2018/19 (20th December 2013)

NHS Cancer Plan (2000)/NHS Cancer Reform Strategy (2007) Version 8.1

Consultant to Consultant Policy (Shropshire CCG)

Procedures of Limited Clinical Value (Shropshire CCG)




Page 3 of 46

CONTENTS

Section

Page

1.0 Introduction 4

2.0 Key Operational Standards 5

3.0 Duties and Responsibilities 8

SECTION A – CONSULTANT LED REFERRAL TO TREATMENT

4.0 Summary of Rules 12

5.0 Referral Guidance 18

6.0 Referral Processes 22

7.0 Patient cancellations or failure to attend (DNA) – English Patients 23

8.0 Patient cancellations or failure to attend (DNA) – Welsh Patients 24

9.0 Hospital Initiated Cancellations 25

10.0 Clinic Outcome and Attendance Status 25

11.0 The management of Follow-up Appointments 25

12.0 Clinic Codes and Templates 26

13.0 Clinic Closure 27

14.0 Health Records Availability 27

15.0 Clinic session Cancellations, Reductions and Reinstatements 27

16.0 Management of Elective Waiting lists 28

17.0 Cancellations, Alterations and Failure to Attend for Admission 30

18.0 Maintaining Waiting Lists – Outpatient and Inpatient 31

SECTION B – CANCER ACCESS TARGETS GUIDANCE

19.0 Introduction to Cancer Standards 33

20.0 Cancer Waiting Times Clock Rules 33

21.0 Cancer Access Referral Guidance 35

22.0 Definition/Guidance for Patient Cancellations/Alterations 36

23.0 Cancer Patients who are Medically Unfit for Treatment 36

24.0 Transfers For Care/Treatment 36

SECTION C – DIAGNOSTIC ACCESS TARGETS

25.0 Referral Guidance – Diagnostic Investigations 38

26.0 Planned Diagnostic Investigations 39

SECTION D – SUPPORTING DELIVERY OF THE POLICY

27.0 Escalation Processes Where Demand Exceeds Capacity 40

28.0 Management/Performance Information 40

29.0 Audit 40

30.0 Policy Review 41

Appendix 1 – Definitions 42

Appendix 2 – Policy Risk/Impact Assessment 44

Appendix 3 – Equality Impact Assessment 45

Appendix 4 – Clinical Outcome Form

Appendix 5 – Draft Patient Access Policy Training Schedule

Appendix 6 – Standard Operating Procedures




Page 4 of 46

1.0 INTRODUCTION

1.1 Policy aims and rationale

1.1.1 The length of time that a patient needs to wait for hospital treatment is an important quality issue and is

monitored nationally. RJAH is committed to ensuring that patients receive their treatment in accordance

with the national objectives, the contracts agreed with both English and Welsh Commissioners and in line

with the eligibility of a patient’s right to treatment by the NHS.

1.1.2 This policy outlines the Trust’s approach taken managing patient’s access in line with relevant English and

Welsh guidance. This policy is intended to support delivery of the maximum commissioned waiting times

from referral to first definitive treatment, and is designed to ensure fair and equitable access to hospital

services in line with the NHS Constitution.

1.1.3 The policy’s overall aim is to ensure patients are treated in a timely and effective manner, specifically to:

Ensure that patients receive treatment according to their clinical priority, with routine patients and

those with the same clinical priority treated in chronological order;

Reduce waiting times for treatment and ensure patients are treated in accordance with agreed

standards (note: these are different for English and Welsh commissioners);

Provide an operational guide to managing patients in line with the national and local standards;

Define roles and responsibilities for key stakeholders;

Establish a consistent approach to managing patient access across the Trust, supported by

training and standard operating procedures; and

Ensure accuracy of all related data to support monitoring of performance and adherence to the

policy

1.2 Patient Choice for English Patients

1.2.1 Patients have a legal right to choose where they go for their first outpatient appointment, to change

hospital if they have had to wait longer than the maximum waiting times (18 weeks or 2 weeks to see a

specialist for suspected cancer) and to carry out a specialist test suggested by their GP. (See Choice

Framework 2015/16).

1.3 Principles

1.3.1 Entitlement to use the National Health Service free of charge is based on where a person normally lives

regardless of their nationality or whether they hold a British passport or have lived and paid National

Insurance contributions and taxes in this country in the past. Anyone who has lived lawfully in the UK for

at least 12 months immediately preceding treatment is exempt from charges.

1.3.2 The Trust relies on GPs and other referrers to ensure patients understand their responsibilities (including

provision of accurate demographics) and potential pathway steps and timescales when being referred.

This will ensure that patients understand the likely speed at which they will be treated, are able to accept

timely appointments when offered and are referred under the appropriate clinical guideline with pre-

referral diagnostics and reviews, for example completion of Oxford Hip/Knee Score questionnaire, are

completed in advance. (Reference should be made to Shropshire CCG guidelines).

1.3.3 Nothing should be done to limit treatment for patients who have a clinical need for it. The Trust also has a

responsibility to ensure no patient is added to waiting lists inappropriately.

1.3.4 Everyone involved with implementing the access policy should have a clear understanding of their roles

and responsibilities and seek additional training when they are unclear about this; core training is




Page 5 of 46

mandatory. Failure to adhere to this policy will be managed in line with relevant Trust policies, e.g.

Disciplinary Policy.

1.3.5 The policy should be applied consistently across all services.

1.3.6 Communications with patients should be timely, informative, clear and concise. The process of waiting list

management should be clear to patients.

2.0 KEY OPERATIONAL STANDARDS

2.1 National Standards

2.1.1 The following operational standards are mandatory in the NHS Contract and the performance thresholds

are detailed and reported monthly.

English Operational Standard Threshold

Referral to Treatment

Percentage of service users on incomplete RTT pathways (yet to start

treatment) waiting less than 18 weeks from referral

92% at Specialty Level

Cancer

Percentage of Service Users referred urgently with suspected cancer by a GP

waiting less than two weeks for first outpatient appointment

Operating standard

93%

Percentage of Service Users waiting no more than one month (31 days) from

diagnosis to first definitive treatment for all cancers

Operating standard

96%

Percentage of Service Users waiting no more than one month (31 days) for

subsequent treatment where that treatment is surgery

Operating standard

94%


subsequent treatment where that treatment is an anti-cancer drug regimen

Operating standard

98%


subsequent treatment where that treatment is a course of radiotherapy

Operating standard

94%

Percentage of Service Users waiting no more than two months (62 days) from

urgent GP referral to first definitive treatment for cancer

Operating standard

85%

Percentage of Service Users waiting no more than two months (62 days) for

first definitive treatment for cancer following a consultant’s decision to upgrade

the priority of service user

Local standard

85%

Cancelled operations

All service users who have their operations cancelled on the day of admission

(including day of surgery), for non-clinical reasons to be offered another

binding date within 28 days, or the service user’s treatment to be funded at the

time and hospital of their choice

All patients

Diagnostic test waiting times

Percentage of service users waiting less than 6 weeks from referral for a

diagnostic test

>99%




Page 6 of 46

Welsh Operational Standard Threshold

Referral to Treatment

Welsh Assembly Standard: Percentage of service users on incomplete RTT

pathways (yet to start treatment) waiting less than 26 weeks from referral

100%

Local Variation for Betswi Cadwaladr Local Health Board Standard:

Percentage of service users on incomplete RTT pathways (yet to start

treatment) waiting less than 52 weeks from referral

100%

Local Variations for Powys Local Health Board Standard:

Spinal Disorders, Upper Limb & Foot/Ankle: Percentage of service users on

incomplete RTT pathways (yet to start treatment) waiting less than 40 weeks

from referral

Other specialties: Percentage of service users on incomplete RTT pathways

(yet to start treatment) waiting less than 26 weeks from referral

100%

100%

Cancer

Service Users referred urgently with suspected cancer by a GP waiting more

than two weeks for first outpatient appointment

No standard in place –

manage in line with

English standards

Percentage of Service Users waiting no more than one month (31 days) from

diagnosis to first definitive treatment for all cancers

Operating standard

98%

Percentage of Service Users waiting no more than two months (62 days) from

urgent GP referral to first definitive treatment for cancer

Operating standard

95%

Diagnostic test waiting times

Percentage of service users waiting less than 8 weeks from referral for a

diagnostic test

>99%

2.2 Internal Standards

2.2.1 To support effective performance across the operational pathways, the Trust has the following standards

for internal compliance.

Internal Standard Threshold

Referral to Treatment Pathways

Receipt of referral to registration of referral on trust systems 1 working day

Receipt of referral to appointment booked 5 working days

Receipt of Appointment Slot Issue (ASI) report to capacity identified by

relevant sub-specialty

3 working days

Receipt or Production of Referral either internally or from another organisation

to Registration

3 working days

Review of Referral Letters by Clinician to ensure appropriate classification or

service

5 working days from the

date appointment made

Outpatient Attendance Status to be completed In real-time during the

clinic session

Patient Clinic Outcome and Coding Status to be completed End of clinic status as

part of clinic ‘check out’




Page 7 of 46

Internal Standard Threshold

Notification of Clinic Template Changes 7 days minimum notice

Hospital-initiated cancellations No more than 2 in

succession

Clinic Session Alterations (eg a clinic session cancellation or reduction) No more than 10% of

cancelled sessions

provided with <6 weeks’

notice

Decision to Treat date to the date patient added to the inpatient waiting list 2 working days

Slot Utilisation – percentage of planned appointment slots used in a clinic

session

95%

Session Utilisation – percentage of planned (in job plan) clinic sessions taking

place

85%

Session Utilisation – percentage of planned (in job plan) theatre sessions

taking place

80% (with adjustment for

Trauma commitments)

DNA Rate – percentage of patients failing to attend an agreed outpatient

appointment

6.5%

Clinic Session Closure (no routine patient additions to the clinic) 72 hours prior to clinic

session

Theatre session planning, notification of cancellation of an in job plan session 6 weeks

Theatre session planning, lists closed down 2 weeks

Theatre session planning, individual list lock down 7 days in advance




Page 8 of 46

2.3 Internal Pathway Standards

2.3.1 The length of time a patient needs to wait for hospital treatment is an important quality issue and is a

visible and public indicator of the efficiency of the hospital services. At RJAH the anticipated pathway

should be:

Pathway Internal Standard

England

Maximum wait from referral to first outpatient attendance 6 weeks

Maximum wait from referral to completion of diagnostics 11 weeks

Maximum wait from referral to treatment 18 weeks

Betsi Cadwaladr Local Health Board




Powys Local Health Board: Spinal Disorders, Upper Limb & Foot/Ankle




Other Welsh Patients




3.0 DUTIES AND RESPONSIBILITIES

3.1 Chief Executive

3.1.1 The Chief Executive is ultimately accountable to the Trust Board for ensuring that effective processes are

in place to manage patient care and treatment that meet national and local targets and standards as set

out in the Trust’s Service Level Agreement with commissioners, and for achieving these targets.

3.2 Director of Operations

3.2.1 The Director of Operations is the Executive Lead for clinical operations and is therefore responsible:

Through the Clinical Directors, Divisional Managers and Deputy Director of Operations for

ensuring that effective processes are in place to manage patient care and treatment that meet

national and local targets and standards as set out in the contracts with Commissioners.

With Clinical Directors, Divisional Managers and Deputy Director of Operations for achieving

access targets, including Referral to Treatment Times, NHS eReferral Service (patient

appointment systems) and cancelled operations.

For implementing effective Trust-wide monitoring systems to ensure compliance with this policy

and avoid any breaches in targets.




Page 9 of 46

With Clinical Directors, Divisional Managers and Deputy Director of Operations for monitoring

progress against achievements of the targets and taking action to avoid any potential breaches.

With Clinical Directors, Divisional Managers and Deputy Director of Operations for managing any

actual breaches in achieving targets.

For keeping the Trust Board and Trust Executive informed of progress in meeting access targets

and any remedial action taken.

3.3 Clinical Directors, Divisional Managers and Deputy Director of Operations

3.3.1 Clinical Directors and Divisional Managers are responsible for complying with the Policy and performance

thresholds by effectively managing waiting times and, therefore, proactively managing inpatient, outpatient

and diagnostic waiting lists is essential. In particular, they must ensure compliance with notice periods

defined for cancellation of direct clinical activity and ensure processes are in place to manage this

effectively.

3.3.2 In addition the Deputy Director of Operations will line manage the Patient Access Manager/booking teams

and will lead the weekly Patient Treatment List review meeting.

3.4 Patient Access Manager

3.4.1 The Patient Access Manager will:

Ensure that correct rules are applied and that staff throughout the organisation are both aware of

these rules and supported with necessary training;

Monitor waiting list positions across the Divisions and work proactively to ensure that robust plans

are developed to ensure delivery and address any underlying issues such as lack of capacity

versus demand.

3.5 Consultants and their teams

3.5.1 Consultants and their clinical teams are responsible for working within the guidelines outlined, complying

with the operational performance thresholds and Standard Operating Procedures in the Policy. In

particular, they are responsible for explaining the patients’ responsibilities in terms of being available

within 18 weeks for any potential treatment and must provide sufficient notice of direct patient care activity

to minimise the impact on the patient experience.

3.5.2 Consultants as senior clinicians must be aware of the various routes that patients enter their referral

pathways; including the NHS e-referral system, telephoned urgent referral, personal GP letter, transfer

from the private sector, services provided at other NHS providers (in both planned and unplanned care

settings). In addition, consultants need to be aware of the differences between in pathways where a new

referral will be required; for example, a subsequent procedure agreed as part of the original decision to

treat does not need a new referral however where a new condition is being treated a new referral would

be required.

3.5.3 Providing patient information leaflets related to the relevant clinical condition to support the patient and

careers with treatment options and decision making at the time of the appointment

3.6 Information Lead

3.6.1 The Information lead is responsible for the provision of regular management reports to support on a daily,

weekly, monthly and ad hoc basis for use by Trust managers and clinical/booking teams and reporting to

external sources. The Information Lead will provide support to the month end validation process and

produce the monthly submission for authorisation by the relevant Executive Director, prior to submissions

to Secondary Users Service (SUS) and Clinical Commissioning Groups.




Page 10 of 46

3.6.2 The Information lead will provide data quality reports to assist the tracking on RTT pathways and to

provide appropriate assurance to the Trust’s Board through a robust regular audit process.

3.6.3 Have responsibility for the validation team and monthly validation of the waiting list and feedback of the

“lessons learnt” through this process back up through to divisional and booking teams.

3.7 Central Appointments Team

3.7.1 The inpatient and outpatient booking teams will ensure that on a daily basis individual patient pathways

are proactively managed in line with the principles outlined in this policy. They will ensure that training

needs analysis occurs with necessary training being provided and that Standard Operating Policies are

identified, written, regularly reviewed and adhered to. They will be responsible for ensuring that waiting

lists are proactively managed and that patients are booked for their treatment within the English and

Welsh guidelines. Liaison between the booking staff and individual Consultants will ensure that patients

are listed according to the time they have been on the waiting lists, unless deemed medically urgent.

3.7.2 The inpatient and outpatient booking teams will ensure that for the booking of routine appointments, all

patients should be provided with reasonable notice of an offer of admission (i.e. a choice of 2 dates with at

least 3 weeks’ notice). Where clinical urgency dictates the notice period is shorter, choices should be

offered and agreed with the patient in person and confirmed with a letter.

3.8 Medical Secretaries

3.8.1 Medical Secretaries are responsible for ensuring that their practices are consistent with the Policy and that

they are working within the Standard Operating Procedures at all times. They must ensure that systems

are in place to support effective waiting list management. They are also responsible for ensuring that RTT

pathway status’ is recorded appropriately and in a timely manner.

3.9 Commissioners

3.9.1 Commissioners are responsible for ensuring that the contract with the Trust has sufficient capacity to

ensure that the access targets within this Policy can be adhered to and to ensure that referrers are familiar

with the contractual arrangements.

3.10 GPs and Other Referrers

3.10.1 GPs and Other Referrers are responsible for ensuring that patients are ready and available to receive

treatment within the operational standards outlined in this Policy and are aware of their responsibilities in

terms of attending agreed appointments or admission dates. Referrals will be in line with agreed

guidelines as outlined in this policy.

3.11 Outpatients Department

3.11.1 All outpatient staff are responsible for working within the guidelines outlined in this Policy and in line with

the Standard Operating Procedures. In particular, they are responsible for complying with the Internal

Standards to support this Policy and for escalating issues with capacity as appropriate.

3.11.2 Ensuring relevant clinical condition patient information is available in the clinic areas for the medical teams

to offer to patients.

3.12 Patients

3.12.1 Patients are responsible for being available for treatment within the timescales available to them within

this Policy. They must ensure that RJAH has been notified of any change to their demographic details and

should make every effort to attend all appointments provided for them. Patients must inform their GP of




Page 11 of 46

any changes in their medical condition that may affect their attendance or clinical priority. Where a

parent/guardian/carer is supporting the patient, they should undertake to ensure that the patient fulfils their

responsibilities. Patients who no longer wish to have surgery/treatment, for whatever reason, must advise

both their GP/referrer and the hospital consultant.




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Section A

Consultant Led Referral-to-Treatment Guidance

Consultant-led services are subject to the 18 week referral to treatment target for English patients, see

section 2.1 for Welsh standards. The pathway commences with a ‘clock start’ date and closes with a

‘clock stop’ date at the point of first definitive treatment. A patient’s first definitive treatment is an

intervention intended to manage a patient’s disease, condition or injury and avoid further intervention. All

patients must be managed according to their clinical urgency and within the operating standard.

The Rules Suite Summary below provides an overview of these factors but further information should be

obtained from the Recording and reporting referral to treatment (RTT) waiting times for consultant-led

elective care guidance (NHS England, 2015; Welsh Assembly, 2009).

4.0 SUMMARY OF RULES

4.1 Clock DOES NOT start

4.1.1 There is a range of activity that is not subject to the referral to treatment 18 week target. Referrals for

these services do not start an RTT clock:

Outpatient services not led by a Consultant

Direct Access Diagnostic Services

Any subsequent activity AFTER a clock stop has been initiated for treatment (unless subsequent

treatment is required (see next section))

Where active monitoring is required during activity that is not part of an 18 week RTT period

4.1.2 Relevant National RTT Status Codes – Clocks Not Applicable. All relevant steps in the patient pathway

must be recorded using nationally recognised RTT Status Codes. This includes a range of codes to

identify that a clock is not applicable. These must be added accurately and in a timely manner and are:

Code 90 After treatment (i.e. any activity after first

definitive treatment has occurred)

It is unlikely this code would be used for a

new outpatient appointment

Code 91 Active monitoring during activity not part of

18 week RTT period

Should never be used for a new outpatient

appointment

Code 92 Patient not yet referred for treatment,

undergoing direct access diagnostic

To be used by diagnostic services only

Code 98 Activity not applicable to 18 weeks (e.g.

obstetrics, dietetics, etc)

4.2 Clock Starts – Referral Guidance

4.2.1 A waiting time clock starts when any care professional or service permitted by an English NHS

Commissioner or Welsh Local Health Board to make such referrals, refers to:

(a) A consultant-led service, regardless of setting, with the intention that the patient will be assessed and,

if appropriate, treated before responsibility is transferred back to the referring health professional or

general practitioner (GP);

4.2.1.1 The date of receipt by RJAH is the clock start date for these categories of referral. In the

case of an E-referral system referral, the clock start is recorded as the date that the

patient converts their Unique Booking Reference Number (UBRN).




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4.2.1.2 If a patient is booked into a Clinical Assessment or Advice and Guidance Service the

clock starts on the date the GP referred the patient, not the date of the appointment.

(b) An interface, referral management or access service, which may result in an onward referral to a

consultant-led service before responsibility is transferred back to the referring health professional or

general practitioner (GP).

4.2.1.3 In general, if this service has only assessed the patient then the clock start will commence

on the date that the referring service received the referral from the patient’s GP.

4.2.1.4 If the interface service provided a first definitive treatment that was subsequently

determined to be unsuccessful, or if the patient is referred on following active monitoring,

then the clock start date will be when RJAH receives that referral.

4.2.1.5 The interface, referral management or access service must provide details of the clock

start date when referring the patients to the Trust using the appropriate form.

4.3 Self-Referrals

4.3.1 A waiting time clock also starts upon a self-referral by a patient to the above services, where these

pathways have been agreed locally by commissioners and providers; for patients where a ‘window’ to self-

refer back to their clinician has been set, a maximum time should be with the patient e.g. 3 months, and

recorded in the notes.

4.3.2 The clock start date will not be the date of contact by the patient but following ratification of the referral by

a care professional permitted to do so. In order to ensure this is recorded correctly the date of ratification

must be noted on the referral letter.

4.4 Consultant to Consultant Referrals

4.4.1 The following should be read in conjunction with the Consultant-to-consultant referrals policy (September

2015)

http://edms/doc/Pollib/Consultant%20to%20Consultant%20(C2C)%20referrals%20Shropshire%20Clinical

%20Commissioning%20Group%20Patients%20Policy.docx

4.5 Consultant to Consultant Referrals (same condition)

4.5.1 If the referral is from one consultant-led service to another for the same condition (e.g. clinician refers to a

colleague who may sub specialise in the management of a specific condition) the clock start is the date

the initial referral was received by RJAH. Consultant-to-consultant referrals for the same condition do not

start new RTT clocks.

4.6 Consultant-to-Consultant Referrals (different condition)

4.6.1 These types of referrals are not permitted by Commissioners unless this would cause unnecessary delay

in care that would affect the patient’s wellbeing and should be referred back to the GP or GP/referral

management centre (The exceptions are as described in the Consultant to Consultant policy, which

includes concept of referred pain see link above.

4.7 Consultant-to-Consultant Referrals (from an emergency setting to an elective setting)

4.7.1 When a clinician in an emergency setting (including at other hospitals, e.g. Wrexham, Shrewsbury, etc)

makes an outpatient referral requesting that the patient is reviewed on an elective basis, the clock starts

on the date that the consultant decides to refer and not the date when the referral is received (except for

http://edms/doc/Pollib/Consultant%20to%20Consultant%20(C2C)%20referrals%20Shropshire%20Clinical%20Commissioning%20Group%20Patients%20Policy.docx

http://edms/doc/Pollib/Consultant%20to%20Consultant%20(C2C)%20referrals%20Shropshire%20Clinical%20Commissioning%20Group%20Patients%20Policy.docx




Page 14 of 46

Welsh patients, where the date received is recorded). These referrals should only be made where referral

back to the GP would cause unnecessary delays in care that would affect the patient’s wellbeing.

4.7.2 In cases where a patient has been initially admitted on a non-elective pathway (an emergency setting) and

it is identified that they require further treatment as an elective patient, the start of the RTT clock is the

date that a decision to list was made. It is imperative that the date of decision to list is clearly noted in the

medical records.

4.7.3 Where a decision to list cannot be made during the non-elective episode (e.g. the team caring for the

patient need to refer to another specialty for further advice or to carry out the procedure), the RTT clock

will start on the date of referral to the other consultant-led team. Again, this must be clearly noted in the

medical records.

4.7.4 If referrals to RJAH are required from other hospitals an Inter Provider Transfer Administrative Minimum

Data Set (IPT MDS) should be completed to ensure all appropriate data is recorded.

4.8 Other Reasons for a Clock Start

4.8.1 Upon completion of a consultant-led referral to treatment period, a new waiting time clock only starts:

(a) When a patient becomes fit and ready for the second of a consultant-led bilateral procedure.

4.8.2 It is imperative that the date the patient becomes fit and ready is clearly noted in the patient’s medical

record and confirmation that the procedure meeting commissioning standards, e.g. relevant Oxford score.

(b) Upon the decision to start a substantively new or different treatment that does not already form part of

that patient’s agreed care plan;

4.8.3 The clock should start at the point the decis6ion to treat is made and this must be clearly noted in the

patient’s medical record. The decision about whether treatment is substantively new or different from the

patient’s agreed care plan is a clinical one that must be made locally by a care professional in consultation

with the patient.

(c) Upon the patient being re-referred to a consultant-led, interface, or referral management/assessment

service as a new referral;

4.8.4 When a patient has been discharged back to the care of the referring healthcare professional, any new

referral, even if this is for the same condition that has worsened or an original treatment plan hasn’t

worked, must start a new clock in line with the guidelines previously mentioned.

(d) When a decision to treat is made following a period active monitoring;

4.8.5 The clock should start from the date the decision to treat is made and this should be clearly noted in the

patient’s medical records.

(e) When a patient rebooks their appointment following a first appointment DNA that stopped and nullified

their earlier clock.

4.8.6 The section on patients who do not attend their appointment provides further detail on this aspect (Section

7).




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4.9 Relevant National RTT Status Codes – Clock Start

4.9.1 All relevant steps in the patient pathway must be recorded using nationally recognised RTT Status Codes.

These must be added accurately and in a timely manner and are:

Code 10 First activity in referral to treatment period OR subsequent different period

Code 11 End of active monitoring – first activity at the start of a new RTT period

Code 12 Consultant review – new RTT for a separate condition

4.10 Clock Continues

4.10.1 When the patient is continuing on a pathway and does not meet the criteria for a clock stop (see next

section), their RTT position must be recorded accurately and in a timely manner. For example, they may

require further investigations to be carried out or they are added to a waiting list. Their continuing care

prior to a treatment decision being made may possibly be carried out at a different hospital and this should

also be recorded accurately and in a timely manner.

4.10.2 Where a patient requires ‘thinking time’ of less than 2 weeks, their clock continues see 4.13.1.4 below.

4.11 Relevant National RTT Status Codes – Clock Continues


These must be added accurately and in a timely manner and are:

Code 20 Subsequent activity prior to treatment (eg diagnostic investigation required, further outpatient

appointment required, patient added to the inpatient waiting list)

Code 21 Transfer to another healthcare provider (eg to another hospital)

4.12 Clock Stops for Treatment

4.12.1 A clock stops for treatment when a first definitive treatment (clinical judgement) has started such as:

4.12.1.1 Treatment provided by an interface service.

4.12.1.2 Treatment provided by a consultant-led service.

4.12.1.3 Treatment provided by a therapy or healthcare science intervention provided in

secondary care where this is determined as the best way to manage the patient’s

disease, condition or injury and avoid further interventions.

4.13 Clock Stops for Non-treatment reasons

4.13.1 A waiting time clock stops when it is communicated to the patient, and subsequently to their GP and/or

other referring practitioner without undue delay that:

(a) It is clinically appropriate to return the patient to primary care for any non-consultant-led treatment in

primary care;




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4.13.1.1 The clock stops as the wait for the hospital consultant-led service and pathway ends.

(b) A clinical decision is made to start a period of active monitoring;

4.13.1.2 Active monitoring (watchful waiting) caters for periods of care without (new) clinical

intervention, e.g. 3 monthly routine check-ups. This is where it is clinically appropriate to

monitor the patient in secondary care without clinical intervention or further diagnostic

procedures, or where a patient wishes to continue to be reviewed as an outpatient, or

have an open appointment, without progressing to more invasive treatment. Active

monitoring can be initiated by either the patient or the clinician, e.g. if they wish to see

how they cope with their symptoms without treatment.

4.13.1.3 Active monitoring should not be applied for short periods of time (2 weeks) and it

should not be applied where a patient does not want to have a particular diagnostic

test/appointment or other intervention but wants to delay the appointment.

4.13.1.4 Where a patient requires thinking time of longer than 2 weeks to make their decision

about whether to undergo a surgical intervention, the clock can be stopped and a period

of active monitoring applied. The patient should be given a further follow-up outpatient

appointment and if they then decide to proceed a new clock will start and the patient,

subject to clinical urgency, will be picked sequentially, longest wait first. Otherwise they

remain on an active pathway.

4.13.1.5 Scoliosis patients often have complex physical, psychological and social needs which

can mean that for many reasons surgery may not be considered a viable option. In line

with Clinical Exceptions to NHS Constitutional Right, for all referrals to the Scoliosis

Service, requiring surgery will be placed on a planned waiting list as per local

agreement.

(c) A patient declines treatment having been offered it.

(d) A clinical decision is made not to treat.

(e) A patient DNA’s their first appointment following the initial referral that started their waiting time clock,

provided that the provider can demonstrate that the appointment was clearly communicated to the

patient;

(f) A patient DNA’s any other appointment and is subsequently discharged back to the care of their GP,

provided that:

It can be demonstrated that the appointment was clearly communicated to the patient;

Discharging the patient is not contrary to their best clinical interests;

Discharging the patient is carried out according to local, publicly available/published, policies on

DNA’s;

These local policies are clearly defined and specifically protect the clinical interests of vulnerable

patients (e.g. children) and are agreed with clinicians, commissioners, patients and other

relevant stakeholders.

4.14 Relevant National RTT Status Codes – Clock Stops


This includes a range of codes to identify that a clock is not applicable. These must be added accurately

and in a timely manner and are:




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Code 30 Start of first definitive treatment To be used regardless of whether a patient is

discharged or not, eg a patient may have

received treatment but is still under the care

of the consultant

Code 31 Start of active monitoring – initiated by

patient

For patients on a non-admitted pathway only

Code 32 Start of active monitoring – initiated by care

professional


Code 33 Patient did not attend very first appointment

(e.g. first OP appointment/diagnostic

appointment)


Code 34 Decision not to treat by clinician or used for

any subsequent DNA’s after the first

appointment (eg follow-up appointments)

Code 35 Patient declined offered treatment

Code 36 Patient died before treatment

4.15 Clock Pauses – ENGLISH PATIENTS

4.15.1 Clock Pauses can no longer be applied to patients on an admitted waiting list.

4.16 Clock Restarts for Patients who ‘Could not Attend’ – WELSH PATIENTS ONLY

4.16.1 The following can only be applied once to each stage of a Welsh patient’s pathway and a reasonable offer

must have been made/agreed with the patient.

4.16.2 Patients who notify the hospital that they can no longer attend a previously agreed appointment for any

stage along the pathway should be treated as a ‘Could Not Attend’ (CNA). A patient may have multiple

CNAs within their RTT period, but only one CNA within each stage of the pathway.

4.16.3 On the first CNA within a stage of the pathway, the clock should be reset to the date on which the patient

notifies the organisation of their inability to attend the appointment. A new appointment should be made as

soon as the patient is available.

4.16.4 On the second CNA within the same stage of the pathway, the patient should be removed from the waiting

list, and responsibility for ongoing care returns to the referrer. Appropriate notification of removal must be

given to the patient and the referrer.

4.16.5 If the consultant responsible for the patient considers that they should not, for clinical reasons, be

removed from the pathway following a second CNA, the clock will continue and no further adjustment or

reset can be applied.

4.16.6 Please refer to specific standard operating procedure.

4.17 Patients who wish to delay their treatment for longer periods of time – ENGLISH PATIENTS

4.17.1 Some patients, e.g. teachers or the self-employed, may wish to delay their treatment for longer periods of

time. For example, a teacher may wish to delay treatment until the summer holidays. Where this

happens the patient’s pathway should remain open, and notes made within the medical record of the

reasonable offers made (i.e. choice of dates given with 3 weeks notice) and the period of unavailability.




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4.17.2 There is no set maximum length to a patient initiated delay, however clinicians should provide booking

staff with guidelines as to how long (in general) patients should be allowed to defer their treatment without

further clinical review. Patients requesting a delay longer than this should have a clinical review to decide

if this delay is appropriate. If the clinician is satisfied that the proposed delay is appropriate then the Trust

should allow the delay, regardless of the length of wait reported.

4.17.3 If the clinician is not satisfied that the proposed delay is appropriate then the clinical risks should be clearly

communicated to the patient and a clinically appropriate procedure date agreed; if the patient refuses to

accept the advice of the clinician then the clinician must act in the best interest of the patient.

4.17.4 It is not acceptable to refer a patient back to their GP simply because they wish to delay their appointment

or treatment.

4.17.5 If the clinician feels it would be in the best clinical interest of the patient to discharge the patient back to

the care of their GP and inform them that treatment is not progressing then this must be made clear to the

patient. This must be a clinical decision, taking the healthcare needs of each individual patient into

account. If the patient’s requested delay is for longer than 6 months (26 weeks) or would mean they

would receive their treatment >40 weeks, the patient should be informed they may be referred back to

their General Practitioner following a review of their case. The delay should be recorded and escalated to

the CCG at the next Planned Care Working Group.

4.18 Patients who wish to delay their treatment for longer periods of time – WELSH PATIENTS

4.18.1 Prior to a reasonable appointment being agreed (i.e. cannot be managed in line with ‘Could Not Attend’

guideline), when a patient notifies RJAH they are unavailable due to social reasons, an adjustment to the

RTT period may be appropriate. When the period of unavailability is:

Less than two weeks, no adjustment may be made;

Between two and eight weeks, an adjustment may be made for the full period of time that the

patient is unavailable;

More than eight weeks, the patient should be returned to the referrer and the RTT period will

end.

4.19 Patients who are medically unavailable – ENGLISH & WELSH PATIENTS

4.19.1 When a patient is unavailable due to a short-term medical condition, an adjustment to the RTT period may

be made.

If, in the opinion of a suitably qualified healthcare professional, the patient has a condition which

will be resolved within 21 days, the patient should remain on the active waiting list and an

adjustment may be applied. The adjustment should start from the date of the decision that the

patient is medically unfit to the date that the patient is declared fit for the procedure. This period

must not exceed 21 days in each stage of the pathway.

If a patient is reviewed after the expected recovery period and recovery has not been effective,

or a further condition has developed, the patient should be returned to the referring clinician, or

another clinician who will treat the condition, and the RTT period will end.

A second 21 day period cannot be applied within the same stage of the pathway.

5.0 REFERRAL GUIDANCE

The Trust will work with Clinical Commissioning Groups and Local Health Boards in developing booking

and choice systems. Where appropriate, explicit referral guidelines will be agreed between services and

those who make referrals. If a consultant/service deems that a referral is not suitable, it will be

returned/rejected to the referrer with an explanation or changed to a more appropriate service for the

needs of the patient.




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Referrers should be encouraged to use generic referrals which can be allocated to an appropriate

Consultant with the shortest waiting time through the e-Referral booking system where applicable.

Referrers should ensure that the patient’s demographic details are up to date and all relevant information

is included in the referral letter (eg past medical history, current medications). The referral letter should

also identify:

The commissioner approval reference if the patient is being referred for a low priority procedure

or details of why outpatient consultation is being requested to determine if they meet the

exception criteria;

If the patient requires transport and what their mobility is;

If the patient requires an interpreter service, what language for and how we should make contact

with them;

If the patient has a disability that requires RJAH to make contact with them in a particular way,

e.g. partially sighted person requiring an appointment letter with larger font;

If the patient is considered to be a vulnerable adult;

If the patient is a military veteran; and the referral is linked to their military service

If the patient is an overseas visitor who is not entitled to free NHS care (so that the appropriate

charges can be made). This should be discussed with the patient prior to the referral being

made.

As a general principle, before a referral for treatment is made, the Trust expects the patient to be both

clinically fit for assessment and possible treatment of their condition, and ready to start their pathway

within 2 weeks of the initial referral. The criterion for assessment includes (but is not limited to):-

Patients who smoke should have been referred to their local smoking cessation service and

ideally should have stopped smoking prior to referral.

Patients who are overweight should have lost weight by the time they are referred. Specifically,

patients with a BMI>40 are unlikely to be suitable for hip and knee replacement surgery at this

hospital.

Teeth and gums should be healthy and free from infection.

Pre-existing medical conditions (e.g. hypertension) should be well managed and controlled.

The patient’s skin should be intact and free from infection.

For likely hip and knee joint replacement procedures the Oxford Hip and Knee Scores should be

within best practice, Commissioner tolerance and based on clinical decision.

The patient meets all criteria associated with Procedures of Low Clinical Value in accordance

with specific Commissioner policies.

Patients who do not meet the pre referral criteria will have the referral rejected as an inappropriate referral

and the GP informed. The GP is responsible for informing the patient in this instance. Inappropriate

referrals will be monitored and summary reports made to the Shropshire Clinical Commissioning Group

Planned Care Working Group.

5.1 Process for Referrals Received that Require Commissioner Approval

5.1.1 Patients should not be referred for treatment that is not routinely funded as determined by the

Commissioner’s current guidelines. Commissioner approval should be sought prior to referral and,

therefore, an approval reference should be detailed on the referral. Where this approval reference is not

detailed, and the referral letter does not detail the reasons for consultation in terms of meeting exception

criteria, contact will be made with the GP in the first instance to clarify.

5.1.2 All commissioners Procedures of low clinical value policies must be adhered to.




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5.1.3 If the patient’s consultation identifies that they meet the exception criteria for a low priority procedure they

will be referred back to their GP with the appropriate details so that approval can be sought. The patient

should be re-referred once this has been received and this should be clearly detailed in the referral letter.

5.2 New Referral Waiting Times

5.2.1 RJAH will endeavour to provide a first new outpatient appointment within 6 weeks of referral for routine

clinical matters and within 3 weeks for urgent clinical matters, for English commissioners and 8 weeks for

Welsh.

5.2.2 RJAH does not recognise a ‘soon’ category for outpatient referrals.

5.3 Outpatient Capacity (New Patients)

5.3.1 Under direct booking, in circumstances where a patient calls the national Appointments Line and an

appointment slot is not available within the Trust, the national e-Referral Telephone Appointments Line

(TAL) will forward the referral request details (UBRN) by email to the Trust. The patient pathway starts

from the date the TAL sends the electronic request to the Trust on the Appointment Slot Issues Report

(ASI).

5.3.2 It is RJAH’s responsibility to ensure capacity is available to meet demand in line with the forecast annual

activity and, therefore, contracted levels of activity. Therefore, RJAH’s appointment service must be

notified of the lack of appointment availability for patients on the ASI Report within 2 working days of

receipt to ensure sufficient time is given to contact the patient and to comply with the internal target of

appointing within 5 working days. RJAH will liaise directly with the patient to mutually agree a date for their

appointment.

5.4 Patient Choice of Consultant

5.4.1 Under the English NHS Constitution and 2015/16 Choice Framework patients have the right to express a

preference as to which consultant they wish to be referred to and to have that preference met where

practical. RJAH may be able to offer patients an earlier date with another consultant and should advise the

patient of this. Patients may only be transferred to another clinician if they have explicitly agreed to this. If

the patient declines the offer to transfer then this must not affect their waiting time.

5.4.2 Some patients may state that they prefer to be seen/treated by a doctor of a particular gender. RJAH will

comply with the patient’s wish if this is possible. Referrers are asked to ensure that this request is included

in the referral letter. If the service does not employ a doctor of the required gender within the requested

specialty, RJAH reserves the right to return the referral letter to the GP.

5.4.3 For Welsh patients, if a transfer is offered and declined their clock can be reset. This must be

appropriately documented.

5.5 Misdirected Referrals

5.5.1 If a referral has been made and the speciality of the Consultant does not match the needs of the patient,

the Consultant should cross-refer the patient to an appropriate colleague where such a service is provided

by the Trust. In this instance the 18 week clock is still running.

5.5.2 If the referral is for a service not provided by the Trust then the referral letter will be returned to the referrer

with a note advising that the patient needs to be referred elsewhere. In this instance the 18 week clock will

stop. With the Choose and Book system, where a referral is rejected by the clinician, the referrer is

responsible for seeking alternative care provision and communicating this to the patient.




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5.6 Tertiary Referrals

5.6.1 For English patients, a tertiary referral received by the Trust will be expected to include the 18 week

national mandatory Inter Provider Transfer Administrative Minimum Data Set (IPT MDS), which includes

the date the original Trust received the referral. Consultants referring patients to other providers are

required to use the mandatory national 18 week IPT MDS template for each referral. If the IPT MDS form

is not received, contact should be made with the referrer to request this information. This should be

provided within 3 working days or the referral should be returned to the sender.

5.6.2 For Welsh patients, the date of receipt is recorded as the clock start; referrals will be routed per the Local

Health Board processes.

5.7 Internal Referrals (Consultant to Consultant Referrals)

5.7.1 Every effort will be made to ensure that patients are seen in the correct clinic at the outset of the RTT

pathway; however if, following the initial consultation, a decision is made that the patient should be seen

by another specialist the RTT clock will continue to tick from the original referral date.

5.7.2 Referrals for a different, unrelated condition to the original referral (excluding urgent referrals, suspected

cancer referrals and other agreed exclusions) must be discharged and referred back to the GP to support

patient choice.

5.7.3 Consultant to consultant referrals should only be made for the following reasons:

Suspected cancer referrals

Clinically urgent referrals e.g. patients requiring an urgent cardiology assessment pre-

operatively

Cross specialty referrals related to the original condition

Referrals to a service only accepting Consultant referrals e.g. specialist children’s services

Where it is deemed appropriate for a Consultant to Consultant referral as part of the 18 week

pathway for a new condition, for example at pre-operative assessment. Under these

circumstances the 18 week clock may be stopped and a new 18 week pathway will commence.

5.7.4 When a consultant provides a peripheral clinic but has no operating rights at that Trust, e.g. community or

Shrewsbury and Telford Hospitals, and need to refer the patient to RJAH for surgery a referral to

themselves is permissible, the full minimum dataset (see 5.7.5 below) must be completed, however the

ongoing nature of care means any subsequent outpatient appointment will be classed as a follow up.

Note: patients should not be referred to RJAH for ongoing outpatient care or to access diagnostic

services, these should be delivered in line with the provider Trust’s contractual arrangements.

5.7.5 The 18 week IPT MDS template will be used for consultant to consultant internal referrals so as to ensure

good data quality. The preferred routes for internal referrals to be sent to the Appointments Office are

electronic or hand-delivery. These referral systems offer the least opportunity for loss or delay between

referring and the referral being received. If a clinician decides to send a referral through the internal post

the burden will be upon him/her to ensure the Appointments Office has received the referral within 3

working days.

5.8 Transfer of Care Following a Consultant Leaving RJAH

5.8.1 Where patients are transferred from one consultant to another because Consultant A leaves the Trust and

patients are transferred to Consultant B) the RTT clock will continue.




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5.9 Military Veterans

5.9.1 All military veterans are entitled to priority access to NHS hospital care for any condition, as long as it's

related to their service, whether or not they receive a military pension and length of service is not taken

into consideration. They should be seen in an outpatient setting within 4 weeks where their condition is

classified as routine and should be treated in accordance with their clinical priority for treatment so as not

to disadvantage clinically urgent patients who are not military veterans.

5.10 Referral of Private Patients to NHS Care

5.10.1 In line with the ‘Code of Conduct for Private Practice: Recommended Standards of Practice for NHS

Consultant’, patients who choose to be treated privately are entitled to NHS services on exactly the same

basis of clinical need as any other patient. All patients wishing to change from private to NHS status must

be referred back to their GP or the GP/referral management service for Welsh patients, so that choice can

be offered for their onward referral to the NHS.

5.10.2 On receipt of such a referral at RJAH, consultants should help to ensure that the following principles

apply:

Patients referred for an NHS service following a private consultation or private treatment should

join any NHS waiting list at the same point as if the consultation or treatment were an NHS

service.

Their priority on the waiting list should be determined by the same criteria applied to other NHS

patients and; in addition

Should a patient be admitted to an NHS hospital as a private inpatient, but subsequently decide

to change to NHS status before having received treatment, there should be an assessment to

determine the patient’s priority for NHS care.

5.11 Referral of NHS Patients to Private Care

5.11.1 Where a patient chooses to be treated privately rather than receiving NHS care, the consultant must refer

the patient back to the care of their GP detailing all relevant clinical information to ensure there is no delay

in the patient’s ongoing care.

NB: This does not apply to patients who are being treated in the private sector as a result of capacity

shortfalls.

6.0 REFERRAL PROCESSES

6.1 Registering and Allocating Referrals

6.1.1 E-Referrals for directly bookable services will already be registered onto PAS automatically and

appointment dates will already be given except where capacity is not readily available.

6.1.2 For indirectly bookable services, the date of contact by the patient is classed as the date of referral. All

referrals made outside of e-Referral will be entered on to PAS within one working day of receipt at the

Appointments Office. The referral with appointment booking details will then be passed on to the specialty

for acceptance or rejection by the clinician.

6.1.3 If the referral is rejected by the clinician, the Appointments Office will reallocate the referral to the correct

specialty or refer back to the referrer. Accepted referral letters will be stored in a centrally accessible folder

to ensure Health Records can access these for health records to be prepped for clinic.

6.1.4 If the GP has identified particular requirements for the patient as detailed in section 5.0, these must be

detailed on PAS. This will ensure that any rearranged appointments or requests for admission are made in

a format or method that is suitable for the patient.




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6.2 Logging of New Referrals When a Referral Already Exists

6.2.1 If a patient is already under the care of RJAH and another referral is received for a different condition this

will be classed as a new referral. If a referral is received for the same condition (e.g. request for another

appointment or an appointment to be brought forward) and the patient has previously been discharged

from the service the referral will be classed as new. If the patient is still under the care of the service and

has been seen recently or has an appointment in the future then the letter will not be registered as a new

referral and instead will be passed on to the relevant Consultant for action.

6.3 Clinical Prioritisation of Referrals

6.3.1 All referrals received through the e-Referral system will be reviewed by the appropriate consultant within 5

working days of the appointment being made.

6.3.2 The consultant must accept the referral if appropriate to do so, reject the referral or change the service as

necessary. Failure to do this will result in patients being turned away from the outpatients department as

they have unknowingly been referred incorrectly.

6.3.3 For paediatric referrals, consultants must vet all referrals and mark them for the appropriate clinics, time

scale and person.

6.4 Closing Referrals Opened in Error

6.4.1 If a referral is opened in error, the user closing the referral must always enter ‘Clerical Error’ as Reason for

Closure and should ensure that the corresponding RTT Pathway is removed.

7.0 PATIENT CANCELLATIONS OR FAILURE TO ATTEND (DNA) – ENGLISH PATIENTS

7.1 Patient Cancellation/Alteration of NEW Outpatient Appointment

7.1.1 If a patient no longer requires their new appointment, the outpatient waiting list entry is removed and the

18 week clock stopped. The referrer must be informed of the patient’s decision to cancel their referral.

7.1.2 The clock continues if a patient chooses to alter their appointment to a later date unless they do this on 2

consecutive occasions. RJAH should endeavour to ensure that the cancellation does not result in an

extended waiting time beyond 10 weeks.

7.2 Patients Who Do Not Attend (DNA) an Outpatient Appointment

7.2.1 Patients who do not attend a new appointment will be automatically removed from the waiting list and

referred back to the care of their GP with the exception of vulnerable patients (unable to make informed

decisions) and children. Note: it is necessary to demonstrate the appointment was clearly communicated

to the patient.

7.2.2 Children who DNA should be specifically managed in line with the specific Trust’s Child DNA policy.

7.2.3 It is necessary to nullify the record, therefore removing from numerator and denominator in the RTT data

returns.

7.2.4 For urgent new referrals and follow-up patients only, the patient’s health records must be reviewed prior to

the Consultant leaving the clinic and a decision made regarding offering a further appointment. If a further

appointment is not offered then the referrer and patient will be informed. If the Consultant deems it

necessary for the patient to receive a further appointment then a new referral must be logged which starts

a new 18 week clock.




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7.2.5 If patient contacts RJAH within 21 working days of the DNA’d appointment date with genuine reasons for

failing to attend, e.g. on holiday when an appointment letter was sent to them or admitted in hospital

elsewhere, their referral will be re-opened and a new appointment agreed with them providing reasonable

notice. The RTT clock will start from the date that contact was made by the patient.

7.3 Patients who DNA subsequent appointments

7.3.1 Patient DNAs at any other point on the RTT pathway will not automatically stop the RTT clock, if the

patient is being discharged back to the care of their GP as per the national rules. The action of

discharging the patient will stop the clock provided that:

It can be clearly demonstrated that the appointment was clearly communicated to the patient;

Discharging the patient is not contrary to their best clinical interests, which may only be

determined by a clinician;

Discharging the patient is carried out according to local, publicly available, policies on DNAs

These policies are clearly defined and specifically protect the clinical interests of vulnerable

patients and are agreed with clinicians, commissioners, patients and other relevant

stakeholders.

7.3.2 If the above criteria are fulfilled the RTT clock stops on the date that the patient is discharged back to the

care of their GP.

7.4 Patients who DNA more than once for a New or Follow-up Outpatient Appointment

7.4.1 All patients who fail to attend on a second occasion will be automatically removed from the waiting list and

referred back to the care of their GP, with the exception of vulnerable adults and children. It is the

responsibility of the clinic outcome recorder to identify a patient who has DNA’d previously and ensure this

action is taken.

7.5 Patients who Cancel Two or More Consecutive Appointments

7.5.1 Patients who cancel two or more consecutive outpatient appointments (including pre-operative

assessment appointments) will not be offered a further appointment. The patient’s case should be referred

to the owning consultant for review and a decision made as to whether the patient should be discharged

back to the care of the GP. If a decision is made to discharge the patient back to the care of their GP, the

consultant must write to the patient and the GP notifying them of this decision. The RTT pathway should

be closed by the consultant’s secretary in this instance unless the decision was made in an outpatient

setting.

7.6 Discharge and Cancelling of Outpatient Referrals Following a DNA/Cancellation

7.6.1 When a patient DNA’s or cancels their appointment and the decision is made to discharge the patient, the

receptionist or member of staff responsible must discharge the patient on PAS. The receptionist or

member of staff responsible must ensure the patients referral is always closed and updated the reason for

discharge as Patient DNA. A letter to the GP and patient must be produced and sent following every case

of discharge.

8.0 FAILURE TO ATTEND (DNA) – WELSH PATIENTS

8.1 Patients who have not kept a reasonable appointment at any stage along the pathway and have failed to

tell the hospital in advance that they will not be attending are identified as a ‘Did Not Attend (DNA)’. If the

patient does not attend, the clock stops and the patient should be returned to the referrer.

8.2 If the patient is re-referred, or if the referrer seeks to reinstate the patient within a given timescale, a

reinstatement should take place at the clinically most appropriate place on the pathway and a new 26

week clock would start at the receipt of the referral.




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8.3 If a Consultant overrides the DNA protocol for clinical reasons then the clock would continue whilst the

Provider actively seeks to make contact with the patient.

8.4 The DNA guidance above does not apply to children, if a child DNAs an appointment at any stage of the

pathway their 26 week clock should continue.

9.0 HOSPITAL INITIATED CANCELLATIONS

9.1 Hospital-initiated cancellations are to be avoided wherever possible. Compliance with partial booking

rules, waiting times for new patients, leave notice periods and appropriate planning for services should

minimise the requirement for RJAH to cancel patients booked into clinics.

9.2 Where this is unavoidable (e.g. sickness), previous cancellations should be taken into consideration and

RJAH will ensure that patients are not cancelled more than twice in succession. Patients should not be

moved to an appointment that is more than 4 weeks ahead of their current appointment without clinical

involvement in this action. Clinicians must review each affected patient’s case within 5 working days of

request.

9.3 If a clinician takes a decision to cancel a patient (e.g. a slot needed for an urgent patient); they must liaise

with the Divisional Manager regarding their RTT status. If the patient to be cancelled is identified as a

breach (or will become one within 6 weeks) the clinician must work with the relevant Divisional Manager to

solve the potential breach.

10.0 CLINIC OUTCOME AND ATTENDANCE STATUS

10.1 All patients must have their clinic attendance recorded on PAS (Lorenzo) to ensure the activity is

recognised. This should be recorded in real-time (on the day of clinic) and all staff in an outpatient setting

are responsible for ensuring this is complied with.

10.2 Clinic outcome forms capture important details to ensure that RJAH correctly reports RTT performance

and that any outpatient procedures are recorded and coded so that RJAH receives the appropriate income

for these (Appendix 4). It is the responsibility of all staff in a clinic setting to ensure that an outcome form is

completed for all patients. The RTT status must be accurately captured in line with the 18 week Rules

Suite Guidance (see link in the Introduction).

10.3 The outcome and procedure for coding recorded on this form must be entered in PAS (Lorenzo) by the

person responsible for this duty, e.g. a receptionist, at the end of the clinic session but no later than 2

working days of the clinic closure.

10.4 Discharge When Treatment Complete

10.4.1 When a patient is discharged from a clinic, the receptionist or member of staff responsible (i.e. nurse)

must discharge the patient on PAS. The receptionist must ensure the patient’s referral is always closed. A

letter to the GP and patient, if requested, must be produced and sent following every case of discharge by

the responsible person.

11.0 THE MANAGEMENT OF FOLLOW-UP APPOINTMENTS

11.1 Follow up appointments must only be arranged where it is deemed clinically necessary and in line with

discharge protocols where these are available. Where patients require a follow up appointment, this

should be agreed and arranged prior to leaving clinic for urgent review (i.e. within the following 3 months).

Where urgent review is not required (i.e. review in 3 months or more), a waiting list entry should be

created ensuring the appropriate ‘appointment due by’ date is entered as indicated by the clinician and




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any tests or investigations required on arrival at the appointment are detailed on PAS. The patient’s GP

must be informed of the timeframe for subsequent follow-up.

11.2 Each Divisional Manager is responsible for managing the Follow-up Outpatient Waiting List in conjunction

with the clinicians, ensuring that all patients are booked an appropriate follow-up in the agreed timescale

and with reasonable notice.

11.3 Where Demand Exceeds Capacity – Partial Booking

11.3.1 Partial booking systems should not affect the timescales by which the patient has been notified for their

review. However, at times demand may exceed capacity and this should be proactively managed by the

responsible Divisional Manager and Consultant. Where it is not possible to see patients within 4 weeks of

the agreed timescale for their follow-up appointment the Directorate Manager will agree appropriate action

with individual clinicians to address the problem. The responsible clinician should review each patient’s

case within 5 working days of the request. Letters to patients asking them to contact RJAH for an

appointment will be suspended for services who do not have capacity until such time that this is provided

by the Division.

11.3.2 Where there are clinical concerns within specialties that have major shortfalls in capacity that cannot be

resolved internally this needs to be escalated through the risk management system and appropriate action

agreed with commissioners.

11.4 Partial Booking Process and Process for Non-Respondents

11.4.1 Where capacity is available, patients will be sent a letter six weeks prior to their expected review date

requesting them to contact RJAH for an appointment. Two attempts at different times of the day will be

made to contact the patient after 3 weeks if they have not been in touch. The GP surgery will be contacted

to check if their contact details are correct if no contact can be made. The consultant will be notified of

these patients and will be asked to advise whether the patient can be referred back to the care of their GP.

The consultant will be expected to do this within 10 working days to ensure that action can be taken prior

to their expected review date.

12.0 CLINIC CODES AND TEMPLATES

12.1 Clinic codes and standard templates within subspecialties must be set up and reviewed on an annual

basis to support the annual activity planning process and to ensure that performance measures are valid.

This should include:

Validation that the clinic code is still in use; and

Review of the clinic template compared to demand and new-to-follow-up ratio performance.

12.2 Where changes are required to a clinic template, these must be authorised by the Divisional Manager for

that service. Divisional Managers are responsible for quantifying the effect of clinic template changes on

their capacity to treat patients and where necessary ensuring that capacity is put in place to treat patients

by their waiting time target.

12.3 Change Required to an Existing Clinic Template

12.3.1 Where changes are required to the template the Choose and Book Administration Team must be

informed. If adequate notice, at least 7 working days, is not provided, it is possible that changes may not

be made by the required date.




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12.4 Introduction of a New Clinic Session/Template

12.4.1 It is the responsibility of the Divisional Manager to agree arrangements at the business planning stage

with supporting departments (e.g. imaging, pharmacy, facilities, medical engineering) to ensure that

adequate resources are provided to enable all aspects of the new clinic to run effectively. It is essential

that this process includes the room requirements and this should be agreed with Outpatients. Where clinic

room capacity is not available in hours, consideration may need to be given to evening or weekend

sessions, therefore, having an effect on the proposed job plan.

12.4.2 Once a full evaluation of the new clinic session has been undertaken, the Divisional Manager will ensure

that authorisation is gained from the Director of Operations at least 7 weeks in advance. This does not

include replacement clinic sessions or changes to existing clinic templates.

13.0 CLINIC CLOSURE

13.1 To minimise the impact on patient experience, inefficiencies for resources and costs associated with last

minute ‘routine’ patient additions to outpatient clinics, the clinic session will be closed 72 hours prior to the

appointment date. Where there is a clinical requirement for this operational standard to be over-ruled, the

consultant will contact the Appointments Office to provide authorisation.

14.0 HEALTH RECORDS AVAILABILITY

13.1 A patient’s health records must be available for all outpatient appointments. If they are not available, this

may result in the patient being cancelled and RTT waiting times delayed as a result. To ensure that the

patient’s health records are prepared in advance of the clinic session, the Health Records Department will

pull the notes that are present in the library 7 days in advance.

13.2 Health Records outside of the main library will be obtained by the Outpatient Team no less than 4 days in

advance of the clinic session. Where health records are not released for clinic preparation by the person

or department currently holding them, they will be responsible for that clinic preparation (eg ensuring

history sheets for recording the consultation and patient labels are available) AND for delivery of the notes

to the clinic setting – not to the Outpatient Department.

13.3 As the patient’s health records are required for all appointments, the retrieval and preparation of the notes

for short-notice additions will be the responsibility of the Consultant’s medical secretary or nurse

responsible for the clinic unless they are in the library.

13.4 Note: The trust is going paperless during 2015/16 and all records will then be scanned.

14.0 CLINICAL DECISIONS MADE OUTSIDE OF OUTPATIENT AREAS

14.1 There may be instances where a clinician reviews test results outside the Outpatient setting with the

intention of informing the patient and their General Practitioner of the outcome e.g. results normal and

discharged; requires follow up to discuss results. In this instance the clinician is required to document the

outcome in a clinical letter to the patient and/or GP.

14.2 Following this each medical secretary will be required to complete the outcome of attendance screen in

PAS (Lorenzo) with the appropriate RTT status code AND if appropriate add a waiting list entry and/or

create an appointment as per the Standard Operating Procedures supporting this Policy.




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15.0 CLINIC SESSION CANCELLATIONS, REDUCTIONS OR REINSTATEMENTS

15.1 Clinic Session Cancellations or Reductions

15.1.1 All clinic session changes must be made with appropriate notice so as not to affect the patient experience,

i.e. with more than 6 weeks’ notice. Clinical Teams must provide appropriate notice of their leave

requirements and it is the responsibility of Divisional Managers to ensure that the processes supporting

authorisation of such leave result in at least 6 weeks’ notice being provided to the Outpatient Team. RJAH

requires that no more than 10% of clinic cancellations or reductions are made with less than 6 weeks’

notice and in order to comply with this, and allow for administrative processes following submission, a

minimum of a further 2 weeks’ notice prior to leave request submission should be allowed, i.e. a total of 8

weeks’ notice where clinical activity is going to be affected.

15.2 Short-Notice Clinic Sessions Cancellations or Reductions (e.g. <6 weeks notice)

15.2.1 If a short notice cancellation is necessary, e.g. due to sickness, where appropriate the clinician/Divisional

Manager should arrange cover of the list with colleagues within the speciality, ensuring that all relevant

staff are informed of any change. Where appropriate patients will be pooled within specialities unless

clinical or governance issues dictate this is inappropriate. It is not appropriate for clinic sessions to be

reduced or cancelled at short notice to attend meetings if patients are affected and where this cannot be

avoided clinical review of the patients will be undertaken within 2 working days of the

cancellation/reduction being requested or preferably beforehand.

15.2.2 Corporate departments should consider appropriate notice when requiring clinical attendance at

meetings/events.

15.3 Clinic Reinstatements

15.3.1 Clinic Sessions cannot be reinstated without 4 weeks’ notice.

15.4 Additional Clinic Sessions (OJP)

15.4.1 Where additional clinic sessions are required, 4 weeks’ notice must be provided in order to ensure the

appropriate staffing levels are planned in advance. The only exception is additional clinic sessions for 2ww

referrals.

16.0 MANAGEMENT OF ELECTIVE WAITING LISTS

During an 18 week pathway (or 26 weeks for Welsh patients), it may be identified that a patient requires

admission for treatment requiring addition to an inpatient waiting list. These patients are classed as being

on the ‘admitted pathway’ for RTT performance monitoring purposes. Admitted patient pathways cover

patients on the elective or booked admission waiting list. Planned admissions are excluded from 18 week

monitoring.

16.1 Adding Patients to a Waiting List

16.1.1 When a patient is admitted to the waiting list, validation of a patients’ RTT status should be undertaken to

ensure the appropriate breach date is recorded.

16.1.2 A patient should only be placed on an active waiting list for surgery if:

The patient is clinically ready, fit and available to undergo surgery

There is a sound clinical indication for surgery following pre-operative assessment

There is a real expectation of performing the operation within a reasonable time in relation to the

patent’s clinical priority.




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16.1.3 The consultant in charge has overall responsibility for defining the patient’s planned procedure and

associated resources/stock requirements. This should be recorded on the trusts theatre system,

Bluespier, in line with the Theatres Scheduling and Booking Procedure.

16.1.4 Clinicians must not place a patient on a waiting list to reserve a place against the possibility that treatment

may be necessary in the future. If the clinician requests an opinion, as may be the case for a patient with

angina, a consultant-to-consultant referral can be made for an opinion after the patient is added to the

waiting list where it is believed that the patient is clinically ready and fit for the procedure. In this instance

the 18 week clock continues.

16.1.5 Patients should be added to the waiting list on PAS (Lorenzo) within 2 working days of the decision being

made to treat. Patients for elective surgery under general anaesthetic will undergo pre-operative

assessment or be included in the enhanced recovery programme. Patients admitted for elective surgery

will undergo MRSA screening prior to admission.

16.2 Patients Requiring Admission Under Two Separate Specialties

16.2.1 Where patients are under the care of two separate specialties for two separate conditions and both

conditions require admission for treatment, the Booking and Scheduling Team will contact the relevant

consultants at the point of dual listing. The consultants must confer and determine which procedure takes

clinical priority notifying the Booking and Scheduling Team within 5 working days. The consultant whose

procedure has a lower clinical priority must write to the patient to explain what steps will be taken next,

e.g. contact will be made X weeks following the surgery for X. The patient’s pathway for this referral will be

changed to active monitoring and the consultant performing the first procedure will be responsible for

notifying the consultant for the second procedure when this has been completed.

16.3 Children Under the Age of Two Requiring Admission

16.3.1 Any child under the age of 1 should not be listed for elective surgery at RJAH. Prior to listing a child (aged

between 1 and 2 years old) for elective surgery, all requirements of Paediatric admission policy must be

met and documented accordingly.

16.4 Admission Dates

16.4.1 All patients must be admitted on the day of their operation, unless the Pre-Operative Assessment Team or

Clinician clearly identifies a clinical need to dictate otherwise; this must clearly be recorded on PAS

(Lorenzo). Patients should be provided with reasonable notice of an offer of admission (i.e. a choice of 2

dates with at least 3 weeks’ notice).

16.4.2 Patients should be prioritised in order of clinical need first and foremost and then in RTT breach date

order. In order to comply with clinical need.

16.4.3 Patients will be provided with reasonable notice of an offer of admission (2 dates with 3 weeks’ notice). If

they decline these dates and a third offer with reasonable notice is provided which they subsequently

decline, the consultant will be informed and, if deemed appropriate, the patient will be removed from the

waiting list. The patient will be referred back to their GP in this instance and both the patient and GP will

be informed of this decision in writing.

16.5 Planned Waiting Lists

16.5.1 Patients on a planned waiting list are waiting to be admitted as part of planned sequence of treatment or

investigation. Patients on the planned waiting list are not routinely on an RTT pathway. The planned list

may include:




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Patients who require periodic review as an inpatient/day-case in order for an ongoing condition

to be monitored (e.g. surveillance cystoscopy);

Patients for whom the clinical team may request that a period of time elapses following initial

treatment before any subsequent treatment is undertaken (e.g. a Trauma & Orthopaedic

surgeon may request that metalwork inserted to support healing of a fracture is only to be

removed after a certain period of time);

Patients undergoing a series of treatments (e.g. a patient may attend for a course of pain-

relieving injections on a 3-monthly basis);

The procedure has to be performed at a set point linked to a clinical criteria, e.g. where a child

needs to be 4 years old before a procedure can be performed OR where the date of admission

is determined by the needs of the treatment, e.g. a child needs to be a certain size.

16.5.2 The planned waiting list must not be used to hold patients who wish to defer surgery or are unable to have

surgery due to underlying medical conditions.

16.5.3 All patients on the planned list must have an ‘expected date of admission’ which should not be exceeded.

When a patient on a planned list does not have the procedure within four weeks of the planned date they

will be managed in accordance with RTT rules and an RTT clock will start.

16.6 Capacity for Planned Waiting List Patients

16.6.1 In planning capacity, Divisional Managers must take into account patients waiting for planned procedures

and take into consideration that they may require a series of treatments throughout the year. Where a

series of treatments/investigations are required only the next treatment/investigation due will be added to

the waiting list. Therefore, when planning capacity requirements these must be taken into account.

16.7 Spinal Disorders – Complex Surgery

16.7.1 Patients placed on planned lists who require complex spinal surgery, will be scheduled for surgery and

managed as planned patients per 16.5.3 above.

16.7.2 A specific planned waiting list for this cohort of patients will be produced on a monthly basis (for all

patients, differentiating between English and Welsh Commissioners) and will be reviewed monthly at the

Planned Care Working Group, with English CCGs.

16.8 Bilateral Procedures

16.8.1 Bilateral procedures are defined as surgical operations performed on both the right and left side of a

patient’s body. Where this procedure is necessary in two operative sessions, the 18 week clock will be

stopped following the first operation/treatment. At the point the patient becomes fit and ready for the

second stage of the treatment, a new 18 week clock will start and this must be clearly recorded in the

medical records.

17.0 CANCELLATIONS, ALTERATIONS OR FAILURE TO ATTEND FOR ADMISSION

Cancellations or alterations of an admission date can occur prior to, or following, the acceptance of an

admission date.

17.1 Patient Cancellation BEFORE Admission Date Agreed

17.1.1 If a patient is uncertain about going ahead with treatment, the relevant clinician will be notified and asked

to provide an update for the waiting list status in writing. It may be appropriate to discharge the patient and

refer them back to their GP, where their ongoing care will continue to be managed within primary care. If

and when the patient feels ready for treatment they can ask their GP to re-refer them. Referral back to the




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GP in this scenario would stop the RTT clock and a new RTT clock would start when the Trust receives a

new referral.

17.1.2 Welsh patients are allowed to self-refer back in for up to 6 months when removed from waiting list for

reasons other than treatment, this starts a new RTT clock.

17.2 Patient Cancellation AFTER Admission Date Agreed

17.2.1 If a patient no longer requires their operation and wishes to cancel their appointment date and hence their

18 week pathway, the waiting list entry is updated and closed on PAS (Lorenzo) and the 18 week clock

stopped. This request should be discussed with the relevant clinician and the GP informed of the decision

made.

17.3 Patient Alteration AFTER Admission Date Agreed

17.3.1 If a patient wishes to alter their admission date the clock continues. (For Welsh patients see Could Not

Attend guidelines)

17.4 Hospital Initiated Cancelled Operations on the Day of Admission

17.4.1 If a patient’s first definitive treatment is cancelled on the day of admission for non-clinical reasons the 18

week clock continues, e.g. due to lack of theatre availability. Patients must be readmitted within 28 days of

the original admission date. This should be escalated to the Divisional Manager if this will result in an

unexpected breach of the 18/26 week target OR a waiting time that now exceeds 35 weeks.

17.4.2 If a patient’s first definitive treatment is cancelled on the day of admission for clinical reasons and:

The patient no longer requires treatment, the clock stops, e.g. after admission, it is discovered

that the patient is not clinically suitable for the operation, the situation is discussed with the

patient and it is agreed the surgery will not be performed. The patient is discharged and the RTT

clock will stop.

The patient is deemed temporarily unfit for surgery, e.g. for a chest infection, then the RTT clock

should continue to tick and another date agreed when they are fit.

17.5 Failure to Attend for Admission (DNA)

17.5.1 Patients who do not attend for a procedure will be automatically removed from the waiting list subject to

meeting the criteria outlined in section 7.3, Patients who DNA subsequent appointments, with the

exception of vulnerable patients, e.g. cancer patients and children. If the patient falls into these categories

or had been prioritised as urgent the patient’s health records must be reviewed by the Consultant and a

decision made regarding offering a further admission date.

18.0 MAINTAINING WAITING LISTS – OUTPATIENT AND INPATIENT

18.1 All waiting list entries will be made using the Standard Operating Procedures governing this process.

Waiting lists should be kept up to date by staff with waiting list management responsibility using data

received from various sources. To ensure consistency and the standardisation of reporting all waiting lists

are to be maintained using the Trust’s Information system. All waiting list entries must be made within the

Patient Administration System, manual card based/diary systems are not acceptable; entries in the

Bluespier theatre system need to be will not automatically populate the Patient Administration system and

therefore entry in both is necessary.

18.2 ALL staff responsible for managing outpatient waiting lists must ensure they validate the waiting lists on a

weekly basis to include the review of:

Long waiting patients without dates for outpatient or inpatient care including planned procedures




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Long waiting patients with a date outside of their 18 week breach date (open pathways)

Long waiting patients with an outpatient appointment date outside of their expected review date

(closed pathways)

Duplicate Referrals

Outstanding ‘Logs’

CAB Outpatients for Booking List (TAL/ASI report)

18.3 Waiting list data will be published on working days via the information distribution system. Summary data

will be made available to the weekly Patient Tracking List and Activity meetings.

18.4 Escalation Process where Demand Exceeds Capacity

18.4.1 Where demand exceeds capacity and patients cannot be admitted within their 18 week breach date, this

must be escalated to the Divisional Manager for that specialty. Patients classified as ‘routine’ and have

waited more than 8 weeks for an admission date must be reviewed by their consultant to ensure the

procedure is still required and/or their condition has not deteriorated warranting a change in classification.

18.5 Transfers to the Private Sector for NHS Treatment

18.5.1 A Divisional Manager may request authorisation from the Directors of Operations and Finance to transfer

patients for NHS treatment to the private sector to ensure they are treated within 18 weeks. The following

process should be followed:

Provisional list of patients identified to be reviewed by the Clinical Lead for appropriateness.

Contact made with private provider to negotiate terms of contract to include:

Tariff for procedure

Who will provide pre-operative assessment

Who will provide outpatient follow-up

Whether medical devices/prostheses are required and who will provide them

Whether repatriation to UHSM will occur at a set period of time following surgery

Final list of appropriate patients for transfer contacted by RJAH to enquire if they accept transfer

for treatment.

Confirmed patients details provided to private provider and RJAH advised of admission date.

Admission date added to PAS and health records provided.

Health records returned following admission with appropriate documentation from private

episode of care copied and retained in RJAH records.

PAS updated with accurate RTT outcome of admission.

18.6 Procedures of Low Clinical Value Requiring Commissioner Approval

18.7 Patients should not be referred for a low priority procedure unless commissioner approval has been

sought in advance. Patients should not be added to the waiting list unless the approval reference has

been provided in the referral letter.

18.8 If a patient requires a procedure of low clinical value, this should be explained to the patient and the

appropriate authorisations are agreed before the decision to treat is made and patient added to the waiting

list. The 18 week clock will continue during this process.




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Section B

Cancer Access Targets Guidance

19.0 INTRODUCTION TO CANCER STANDARDS

19.1 All staff should refer to this section of the Policy for patients on a suspected or confirmed cancer pathway

in the first instance. However, this section of the Trust’s Patient Access Policy should be read in

conjunction with the remainder of the Policy. Many of the general guidelines in the Patient Access Policy

can be applied to patients on a cancer pathway.

19.2 This policy outlines the access expectations of the patient journey from the point of referral to the start of

treatment under the cancer-waiting-times rules. It sets out the principles that will apply at the different

stages of the journey to ensure that the rules and guidelines for cancer pathways are applied fairly and

consistently, and in ways that deliver the intended benefits for NHS patients and NHS organisations.

19.3 Recognising there are differences in the rules, notably no 2week wait referrals, for Welsh Commissioners,

given the very small volume of patients treated per annum, the Trust will manage in line with English

guidelines for all patients. Note: if any issues arise, escalate to the Patient Access Manager.

19.4 Patients excluded from monitoring under the cancer standards

19.4.1 Any patient:

With a non-invasive cancer;

With a carcinoma in situ;

Basal cell carcinoma (BCC);

Who dies prior to treatment commencing;

Receiving diagnostic services and treatment privately. However, where a patient chooses to be

seen initially by a specialist privately but is then referred for treatment under the NHS, the

patient should be included under the existing and/ or expanded 31-day standard;

Where a patient is first seen under the two-week standard, and then chooses to have diagnostic

tests privately before returning to the NHS for cancer treatment, only the two-week standard and

31-day standard apply. The patient is excluded from the 62-day standard as the diagnostic

phase of the period has been carried out by the private sector.

20.0 CANCER WAITING TIMES CLOCK RULES

20.1 Clock Starts

20.1.1 A two-week wait clock starts when any health-care professional, or service permitted by the commissioner

to make such referrals, refer a patient with suspected cancer and when the provider receives such

referral. If the patient goes ‘straight-to-test’ following a 2-week wait (2WW) referral the receipt of the

referral is the clock start and the date of the test is the ‘date first seen’ under the 2WW rule.

20.1.2 A 31-day pathway commences for two reasons:

When a decision to treat has been made – the clock starts from the point at which the decision

to treat is made and agreed with the patient.

When a second and/or subsequent treatment is determined – the clock starts from either the

point of decision to treat OR the earliest clinically appropriate date (ECAD) to delivery that

treatment.

20.1.3 The date of decision to treat should be clearly recorded in the patient’s medical records. Patients will be

advised of the need for treatment/ surgery, but the decision-to-treat date will not be confirmed until the

clinician is in receipt of all relevant diagnostic test/investigation results to support the treatment/




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management plan. The 31-day cancer waiting time clock will commence at this point. The original 62 day

clock will remain unchanged.

20.1.4 A 62-day pathway commences on receipt of a 2-week wait (2ww) referral OR upgrade of a routine referral

following suspicion of a cancer diagnosis. If the patient goes on to have a cancer diagnosis then treatment

has to be delivered 62 days from receipt of the 2ww referral or date of the upgraded routine referral.

20.2 Exceptions

20.2.1 Children referred with suspected cancer, are subject to a 31 day wait from the date of receipt of referral to

treatment.

20.3 Clock Stops for Treatment and Non-Treatment

20.3.1 The definitions for Cancer Access Pathways are the same as 18 week Pathways except for:

The date of admission for surgery will stop the clock (not the date of actual treatment); and

If a patient refuses altogether to have the key diagnostic test(s) to diagnose cancer but

continues to be cared for by RJAH, they will be removed from the 62 day pathway, but only in

circumstances where there are no other appropriate tests/procedures the patient is willing to

undergo which would potentially diagnose the cancer and the patient is made aware of the

consequences.

If the patient agrees at a later stage to have the test(s) and is subsequently diagnosed

with cancer, they will be monitored as a 31 day cancer pathway once a decision to treat

has been agreed.

20.4 Patient Alteration of 2WW Appointment (either Outpatient or Diagnostic)

20.4.1 If the patient chooses a date outside the 2-week deadline they will remain within the 2-week wait cohort

and the 62-day cohort if cancer is confirmed. No clock stops are allowed as the operational standards take

into account an element of patient choice.

20.5 Patient Fails to Attend 2WW Appointment (DNA)

20.5.1 When a patient does not attend (DNA) their first appointment following the initial 2-week wait referral they

will not be returned to their GP, but instead the clock will be reset from receipt of referral to the date upon

which the patient rebooks their appointment.

20.5.2 If the patient DNAs multiple (two or more) appointments following their 2-week wait referral the patient will

be referred back to their GP.

20.5.3 The DNA guidance above does not apply to children. If a child DNAs an appointment, at any stage of the

cancer waiting times pathway, their clock should continue, and they should be managed in line with the

Trust’s Children’s DNA policy, if necessary the GP should be informed.

20.6 Patient Not Contactable

20.6.1 Where a patient does not respond to communication to agree a date for an appointment, the patient will

be discharged and returned to the GP and the clock will stop. The Trust Out-Patient Call Centre team will

liaise with the referrer to confirm that this has happened and to indicate that the patient would need to be

referred again if treatment is still needed. If the patient subsequently contacts the Trust within 21 working

days with a reasonable explanation, e.g. on holiday or admitted elsewhere, the original referral will be

used (rather than requesting a new one from the GP) and a new clock start date initiated from the point of

contact.




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20.7 Hospital Initiated Cancellations for Outpatients or Diagnostic Tests

20.7.1 In the event that the Trust cancels a patient’s appointment, the cancer waiting time clock will continue. In

the event that a repeat diagnostic test is required the cancer waiting time clock will continue. In all cases it

is the Trust’s responsibility to re-book the patient and treat within the maximum referral treatment times.

This can include, and only with the prior agreement of the patient, a decision to transfer the care to

another provider if the cancer pathway cannot be delivered in the required timeframe.

20.8 Step-Down from a Cancer Pathway

20.8.1 When a patient steps down from a cancer pathway, the RTT pathway will be managed from the date of

original referral.

20.9 Demand Exceeds Capacity for 2ww Referrals

20.9.1 Shortfalls in capacity for 2ww referrals must be escalated by the Out-Patient Call Centre team to the

Divisional Manager immediately. This should be via telephone and not email. The Directorate

Management team should respond to requests for additional capacity within 24 hours. Where capacity is

not provided within 24 hours, the Director of Operations will be notified.

21.0 CANCER ACCESS REFERRAL GUIDANCE

21.1 A tumour-specific 2WW referral proforma must be used to refer patients with suspected cancer. The

decision to refer for a suspicion of cancer must be discussed openly with the patient by the GP. Failure to

do this may result in the patient being contacted for a suspected cancer appointment when they were

unaware this was the case.

21.2 Up-grading Non-2ww Referrals

21.2.1 A consultant can upgrade a patient from a routine to urgent referral. Patients can be upgraded by the

consultant or another member of the team:

When triaging or reviewing the referral;

After the first diagnostic test; or

Following an MDT discussion.

21.2.2 Once upgraded the patient will be managed as a 62-day pathway (date of upgrade request to first

treatment within 62 days). The clock start date is the date the referral is upgraded not the date it is

received.

21.3 Down-grading Referrals

21.3.1 A 2WW referral can only be downgraded prior to first appointment in secondary care after discussion and

agreement with the referring GP/GDP. The referring GP/GDP alone has the ability to downgrade such

referrals.

21.4 Patient Choice

21.4.1 If the referral is urgent or a suspected cancer and a doctor of the required gender is not available (due to

leave or absence), RJAH will comply with the patient’s wishes and agree a suitable appointment

date/time, but this may not be within the required standards for urgent or suspected cancer referrals.

21.5 Referrals from Private Practice to the NHS for Treatment




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21.5.1 Where a patient wishes to transfer to an elective NHS pathway for treatment, following a private

consultation, a 31-day cancer pathway will commence once a decision to treat has been agreed, or at

receipt of referral if decision-to-treat date was in the private consultation period.

21.6 Definition of Reasonable Notice

21.6.1 The definition of reasonable notice for patients on a cancer pathway is any offered appointment between

the start and end point of 31 and 62 day standards, however, consideration will be given to the individual

patient circumstances when arranging appointments with them.

22.0 DEFINITION/GUIDANCE FOR PATIENT CANCELLATIONS /ALTERATIONS

22.1 Inpatient Cancellation/Alteration(s)

22.1.1 Where a patient wishes to change the date of an inpatient or day-case admission they should be

appointed a date of their choice and the decision details recorded. No adjustment is permissible at this

point.

22.1.2 If the patient is not willing to accept any dates (i.e. declining cancer treatment) this will be escalated to the

treating clinician to agree an appropriate care plan with the patient and/or GP prior to removing the patient

from the elective waiting list; the referring clinician should be notified in writing and the 62-day cancer

pathway monitoring will stop.

23.0 CANCER PATIENTS WHO ARE MEDICALLY UNFIT FOR TREATMENT

23.1 Short-Term (<3 weeks duration)

23.1.1 A patient will be considered to be medically unfit in the short-term when suffering from a condition or co-

morbidity which prevents the continuation or delivery of treatment, but which is likely to be resolved in less

than three weeks. At any stage of the cancer pathway the patient will be re-booked at a time when they

are likely to be fit.

23.2 Long-Term (>3 weeks duration)

23.2.1 A patient will be considered to be medically unfit in the long-term when suffering from a condition or co-

morbidity, which prevents the continuation or delivery of treatment, but which is unlikely to be resolved in

less than three weeks.

23.2.2 If a patient’s treatment plan changes or their cancer is re-staged, due to them being medically unfit in the

long-term or where management of a co-morbidity takes precedent over the management of the cancer

and the delay could be considered long term, active monitoring may be applied where this is appropriate,

with the patient’s full agreement and understanding. Active monitoring will not be used as a substitute for

thinking time or in circumstances where palliative care is the most appropriate treatment.

23.2.3 Where active monitoring is applied, a new 31-day/2nd or subsequent cancer-waiting-times clock will

commence once the patient becomes fit to continue with their original treatment plan.

24.0 TRANSFERS FOR CARE/TREATMENT

24.1 Transfers to Independent Providers

24.1.1 Where a patient is referred from an NHS Provider to an independent-sector organisation as part of their

NHS cancer pathway, the clock will continue and the NHS Provider will be responsible for the monitoring

and reporting of performance for the patient’s cancer pathway. The admission date at the independent

provider is taken as the start of treatment and will stop the clock.




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24.2 Inter provider transfers

24.2.1 The minimum core Inter-Provider Transfer dataset should accompany the transfer of patients between

providers.




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Section C

Diagnostic Access Targets (6 week rule)

The Diagnostic Imaging Dataset (DID) is a monthly data collection covering data on diagnostic imaging

tests on NHS patients in England. It includes estimates of GP usage of direct access to key diagnostics

tests for cancer, for example chest imaging and non-obstetric ultrasound. A target of 6 weeks was

introduced from the point of referral to the point the test is carried out and, to support this, the DID reports

on imaging activity, referral source and timeliness.

25.0 REFERRAL GUIDANCE – DIAGNOSTIC INVESTIGATIONS

25.1 Referrals to these services are not subject to an 18 week RTT target but do have to comply with the 6

week diagnostic target as detailed above

25.2 Making a referral

25.2.1 When it is identified that a patient requires a diagnostic investigation, the clinician should fully complete

the request at the time of the decision to request. Missing information on the request card or electronic

request will delay the process. Consideration should be given to Imaging Protocols and appropriateness of

requests in relation to IRMER regulations or clinical requirements, e.g. no metal foreign bodies present if

requesting a MRI scan.

25.2.2 Requests made in respect of cancer patients should be marked as such to ensure appropriate

appointments are allocated. Failure to do this will result in a longer wait.

25.3 Clock Starts

25.3.1 The clock starts on the date the referral is made – NOT the date it is received.

25.4 Clock Pause – English Patients

25.4.1 The clock cannot be paused for diagnostics.

25.5 Clock Pause – Welsh Patients

25.5.1 Could Not Attend and Patient Delay pauses can be applied to the pathway, see section 4.16 & 4.18.

25.6 Clock Stop

25.6.1 The clock stops at the point the diagnostic investigation has taken place. For recording purposes in-month

breaches are accepted. For example, if a patient’s 6 week target is 10 June, a date up to and including 30

June will count as successfully meeting the target.

25.7 Delays in Receipt of Referral

25.7.1 Where a request has been received via the internal mail and a significant delay has occurred the referrer

will be contacted to discuss whether the referral is still required. If it is not required, then the patient should

be contacted and informed at the same time as the test is cancelled. If it is still required, the original date

of request is used and, therefore, the wait time will be consistent with the 6 week rule

25.8 Imaging Prioritisation of Referrals




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25.8.1 All paper request cards will be logged on to the Radiology Information System upon receipt within one

working day. The referral will then be protocolled according to the Department’s Standard Operating

Procedures. An appointment will be agreed with the patient within 48 hours of protocolling.

25.9 Reasonable Notice

25.9.1 A choice of dates should be offered to the patient; the drive to reduce referral to scan time means this will

often be below three weeks. A patient is able to choose to wait for their scan, this does not stop the clock.

25.10 Patient Cancellation/Alteration of a Diagnostic Appointment

25.10.1 If a patient chooses to alter a diagnostic appointment, the patient will be offered another appointment

within three weeks of the original appointment. If a patient chooses to cancel a diagnostic appointment,

the appointment will be cancelled on the Radiology Information System and the referrer informed.

25.11 Patients Who DNA a Diagnostic Appointment

25.11.1 If a patient fails to attend a diagnostic appointment the referrer will be informed and a decision made as to

whether re-referral is required, e.g. the patient may be a vulnerable adult. This needs to be in line with

DNA policy described in section 7.

25.12 Patients Who are Waiting for More Than One Diagnostic Test

25.12.1 Patients waiting for two separate diagnostic tests/procedures concurrently should have two independent

waiting times clocks – one for each test/procedure.

25.12.2 Alternatively if a patient needs test X initially and once this test has been carried out, a further test (test Y)

is required – in this scenario the patient would have one waiting times clock running for test X. Once test X

is complete, a new clock is started to measure the waiting time for test Y.

26.0 PLANNED DIAGNOSTIC INVESTIGATIONS

26.1 Surveillance tests that are planned for a specific date or need to be repeated at a specific frequency are

not included in the DM01 monthly return for the time that these patients are on planned list. These patients

should be booked in for an appointment at the clinically appropriate time and they should not have to wait

a further period after this time has elapsed. For example, a patient due to have a re-test in six months time

should be booked in around six months later and they should not get to six months, then have to wait

again for non-clinical reasons.

26.2 When patients on planned lists are clinically ready for their test to commence and reach the date for their

planned appointment, they should either receive that appointment or be transferred to an active waiting list

and a waiting time clock should start (and be reported in the relevant waiting time return). The key

principle is that where patients' tests can be carried out immediately, then they should receive the test or

be added to an active waiting list.

26.3 Surveillance or follow-up tests/procedures that are not planned for a specific date, but that will be

undertaken on an ad hoc basis or at an undecided time in the future, are not categorised as planned waits

and, therefore, these patients should be placed on an active waiting list once the decision to test/referral

for a test has been made and waits reported in the DM01 return.




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Section D

Supporting delivery of policy

27.0 ESCALATION PROCESSES WHERE DEMAND EXCEEDS CAPACITY

27.1 All people responsible for managing an outpatient, inpatient or diagnostic waiting list are required to

proactively escalate shortfalls in capacity to the relevant Divisional Manager immediately. The Divisional

Manager and Clinical Lead for the specialty, or modality, concerned will work together with clinical

colleagues to plan for additional capacity to meet demand and, therefore, the Patient Access Policy

requirements. Shortfalls in capacity will be reported at the Patient Access Board where actions to resolve

this will be requested.

27.2 Additional capacity requirements should not, wherever possible, incur additional costs to the organisation.

Where these costs cannot be avoided, the Divisional Manager should ensure that all costs and potential

impact on supporting services is taken into consideration and approved.

27.3 Where demand exceeds capacity on a consistent and regular basis and is outside of the annual activity

plan, the Director of Operations will notify the relevant commissioners.

28.0 MANAGEMENT/PERFORMANCE INFORMATION

28.1 Information for Managing 18 Weeks

28.1.1 A RTT patient tracking list (PTL) for admitted patients is made available via the intranet to Divisions. It is

imperative that the PAS (Lorenzo) system is accurate at all times to ensure the weekly 18 week return and

Waiting List situation report is correct.

28.2 Information for Managing Cancer Access Targets

28.2.1 The cancer PTL is available on a spreadsheet and is reconciled to PAS and Open Exeter tracking.

28.3 Information to Monitor

28.3.1 Data returns will be submitted to Monitor to meet the statutory requirements as published in the Data

Manual.

28.4 Other Reports

28.4.1 Divisions will also be provided with access to the following reports (this list is not exhaustive):

Number of outstanding logged referrals

Patients added to the an inpatient waiting list, including conversion rates by GP, specialty and

consultant (distributed to GPs)

Patients on planned lists

Cancer waiting times report

Outpatient Dashboard including slot utilisation, session utilisation, DNA rates and clinic

cancellation performance

Diagnostic waiting lists

29.0 AUDIT

29.1 Regular audits of compliance with the policy will be in place; these will be agreed with and reported to the

Audit Committee.




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30.0 POLICY REVIEW

30.1 The Patient Access Policy will be reviewed in six months and then on an annual basis to take account of

any changes in national guidance/ new directives.

30.2 Necessary changes throughout the year will be issued as amendments to the Policy. Such amendments

will clearly reference the section to which they refer and indicate the date on which they were issued.




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Appendix 1

Definitions The following is a list of the definitions issued by the Department of Health that are used in this policy.

18 week Referral To Treatment (RTT) period The part of the patient’s care following initial referral which initiates a clock start, leading up to the start of the first definitive treatment or other 18 week clock stop point.

Active monitoring Where it is clinically decided to start a period of monitoring in secondary care without clinical intervention or diagnostic procedure at that stage.

Active waiting list (elective waiting and elective planned)

The list of elective patients who are fit and able to be treated at that point in time. The active waiting list is also used to report national waiting time statistics.

Admitted pathway

An admitted pathway means the patient requires admission to hospital, as either a day-case or an inpatient to receive their first definitive treatment.

Cancelled operations/procedures If the Trust cancels a patient’s operation or procedure on the day of, or after admission for non-clinical reasons – the Trust is required to rearrange treatment within 28 days of the cancelled date or within standard wait time whichever is soonest.

e-Referral e-Referral (was Choose and Book) is a national electronic referral service that gives patients a choice of place, date and time for their first Consultant outpatient appointment.

Chronological order (in turn) The general principle that applies to patients categorised as requiring routine treatment. All routine patients should be seen or treated in the order they were initially referred for treatment.

Clock Pause

Applies to WELSH PATHWAYS ONLY. A period during which the patient has stated they are socially unavailable, their RTT clock is ‘paused’ for this specified period. A patient requested clock pause applies when a patient is unable to accept TCI date given with reasonable notice, resumes ticking on date patient is available again, or accepts an alternative TCI.

Clock Start Any referral to a Consultant-led service starts an 18 week clock. Any referral to an interface service (all arrangements that incorporate any intermediary levels of clinical triage, assessment and treatment) start an 18 week clock. May include self-referrals to these services where agreed by Commissioners and providers. Clock starts on the date that the provider receives notice of the referral or UBRN conversion date if through choose and book.

Clock Stop

Clock Stop – First definitive treatment Defined as an intervention intended to manage a patient’s disease, condition or injury and avoid further intervention (what constitutes first definitive treatment is a matter for clinical judgement, in consultation with others as appropriate, including the patient). Clock Stop – Non-treatment Patient returned to primary care for treatment, including therapy based. Clinical decision to start a period of active monitoring. Patient declines treatment.




Page 43 of 46

Clinical decision not to treat.

Converts their UBRN When an appointment has been booked through choose and book, the UBRN (unique booking reference number) is converted.

Decision to admit Where a clinical decision is made to admit the patient for either day case or inpatient treatment.

Decision to treat Where a clinical decision is taken to treat a patient as an inpatient, day case or outpatient setting.

Did Not Attend (DNA) Patients who have agreed or been given reasonable notice of their appointment/treatment and who without notifying the Trust fail to attend.

Elective admission/elective patients Inpatients are classified in 2 groups, emergency and elective. Elective patients are so called because the Trust can ‘elect’ when to treat them.

Elective Planned Patients admitted having been given a date or approximate date at the time that the decision to admit was made. This is usually part of a planned sequence of clinical care determined mainly on clinical criteria.

Elective waiting Patients waiting elective admission.

First definitive treatment An intervention intended to manage a patient’s disease, condition or injury and avoid further intervention. What constitutes first definitive treatment is a matter of clinical judgment in consultation with other as appropriate, including the patient.

Incomplete or Open pathways Patients either on an admitted, non-admitted or diagnostic pathway still waiting for treatment.

Non-admitted pathway A non-admitted pathway means the patient does not require admission to hospital to receive their first definitive treatment eg treatment is given or prescribed in outpatients.

Outpatients Patients referred by a general practitioner (medical or dental) or another Consultant/health professional for clinical advice or treatment.

Patient Tracking List (PTL) Patient Tracking List, a report used to ensure the maximum waiting time standards are achieved by identifying all patients that will breach current wait time standards.

Reasonable offer

Any date mutually agreed between the patient and the organisation, given with at least 3 weeks’ notice, with a choice of at least two dates offered. If a patient verbally accepts a short notice date, for waiting time purposes thereafter, this is treated as reasonable notice.

RTT Referral to Treatment, from December 2008 the maximum waiting time for NHS patients is 18 weeks from referral to treatment.

TCI (to come in) A proposed future date for elective admission.

UBRN Unique Booking Reference Numbers used for choose and book. The patient is notified of this on their appointment request letter when generated by the referrer through choose and book. The UBRN is used in conjunction with the patient password to make or change an appointment.




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Appendix 2 Policy Risk/Impact Assessment

Title of Policy: Patient Access Policy

1. What clinical/corporate safety and effectiveness issues does this policy address? What Trust-wide assurance issues does this policy address (include a reference to the appropriate NHSLA and/or Healthcare Commission Standard)?

This policy details the main principles that apply when patients are referred to the hospital for treatment, providing assurance that the process is transparent, timely, comprehensive and consistent. The policy ensures that the Trust is compliant with National guidelines and standards, particularly with respect to the 18 week Referral To Treatment standard.

2. What are the risks if this policy is not endorsed?

Breach of Commissioner and/or national waiting time standards. Breach of Information Governance requirements. Delays to patient’s care.

3. What are the operational requirements for this policy to be implemented?

Changes to existing working practices supported by detailed operating procedures. Changes to reporting arrangements to support the management and monitoring of National standards.

4. What are the financial requirements (if any) to support implementation?

To support potential changes to functionality of healthcare records team.

5. What are the training requirements to support the implementation and is this training programme currently in place?

Role-based training programme on the new policy and associated processes/procedures to be set-up and implemented. Ongoing training will be provided for new starters.

6. Has the equality impact assessment form been completed and considered?

Yes

7. What are the systems/processes that are required to implement this policy (action plan to be attached)?

Training plan and SOPs in place to support operational delivery of the policy. Structured and recorded team meetings at department level and the weekly waiting list meeting support effective communication.

8. Has an audit proposal been agreed to monitor the implementation of the policy (audit proposal to be attached)?

Following the Deloitte LLP review of waiting list management processes a new audit programme is being developed to independently assess compliance with the policy.

9. What are the Governance monitoring measures/data that provide corporate/clinical feedback/assurance relating to the effectiveness/outcomes expected?

Daily monitoring reports, summarised reporting to the Board of Directors and through the performance framework of the Trust at monthly Divisional performance reviews. The complaints process is also utilised to identify trends relating to potential non-compliance with the policy. Additionally performance is reviewed via contract meetings.

Committee approval: Comments: Signature: Chair of the Committee Version number and date: 3.0 November 2015 Review required by: September 2014




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Appendix 2 Equality Impact Assessment – From Old Policy Needs Review

EQUALITY IMPACT ASSESSMENT (EqIA) FORM

STAGE 1 – STANDARD SCREENING

Name of the proposed policy/service/function: Patient Access Policy

Status of policy/service/function:

Proposed

Draft

Existing

Other

Author(s) of the policy/service/function:

Interim Director of Operations

Date created:

November 2015

Date for review:

May 2015

What are the main aims of the function, service or policy or proposed function, service or policy?

The purpose of this policy is to outline the Trust and Commissioner Requirements and the operating standards for managing patient access to secondary care services from referral to treatment, then discharge to primary care. The policy covers the processes for booking, notice requirements, patient choice and waiting list management for all stages of a referral to treatment pathway (RTT).

What are the intended objectives and outcomes of the function/service/policy?

This policy outlines the way in which the Trust will manage patients who are waiting for appointments, investigations

and or treatment on a referral-to-treatment pathway.

Ensure that patients receive treatment according to their clinical priority, with routine patients and those with

the same clinical priority treated in chronological order;

Reduce waiting times for treatment and ensure patients are treated in accordance with agreed standards

Provide an operational guide to managing patients in line with the national and local standards;

Define roles and responsibilities for key stakeholders;

Establish a consistent approach to managing patient access across the Trust, supported by training and

standard operating procedures; and

Ensure accuracy of all related data to support monitoring of performance and adherence to the policy

Does the function, service or policy affect any of the following groups of people?

Group Yes / No?

Is this a positive or negative impact? (+/-)

Why? Please explain your reasons.

Racial Group Any race, colour, nationality, ethnic or national backgrounds (please specify)

No

N/A

N/A

Gender Men, Women, Transgender

No N/A N/A

Disability Any disability eg. Learning Difficulties /Disability or Cognitive Impairment, Mental Health Need, Sensory Impairment or Physical Disability (please specify)

No N/A N/A

Sexuality Gay/lesbian, Bi-sexual, Heterosexual

No N/A N/A

Age Younger People (17-25) and children, Age groups between 25 and 70 and / or Older People (70+)

No N/A N/A

Religion or beliefs Any religion / Faith Group (please specify)

No N/A N/A

NOTE:




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The Waiting times in Wales, reflected in the policy, are different from those set by the NHS in England.

What evidence has been used to screen the function, service or policy? (eg. monitoring data, consultation, focus groups, local population data)

Patient feedback, PALS comments, complaints, CQUINS questionnaire

What monitoring arrangements are in place for the future?

Incorporated within policy

Signature Date 18th November 2015

If a negative or adverse impact has been identified please proceed to Stage 2 and undertake a FULL ASSESSMENT


2266 NNOOVVEEMMBBEERR 22001155

Executive Responsible Craig Macbeth, Acting Director of Finance


Executive Directors







Executive Summary

The Trust’s Month 7 Performance Report is detailed in the attached paper.

Received or approved by

Legal Implications None

Recommendation It is recommended that the Board note:

The performance during October 2015 (Month 7).

Acronyms and Abbreviations

VTE – Venous Thromboembolism DVT – Deep Vein Thrombosis PE – Pulmonary Embolism CQUIN – Commissioning for Quality and Innovation Payment Programme RTT – Referral to Treatment UCL – Upper Confidence Limit LCL – Lower Confidence Limit BADS - British Association of Daycase Surgery I&E - Income and Expenditure C. difficile – Clostridium difficile (bacterial infection) MRSA – Methicillin-resistant Staphylococcus aureus (bacterial infection)

Subject/Title October (Month 7) Integrated Performance Report


For Discussion

For Approval

Paper 03

U:\Trust Board & Committees\Public Trust Board\2015-16\November 2015\Paper 03 Month 07 Integrated Performance Report

1

BOARD OF DIRECTORS

INTEGRATED PERFORMANCE REPORT

OCTOBER 2015

1. Introduction 1.1 The integrated performance report has been developed in order to assist the Board

in monitoring the delivery of key performance metrics against local and national targets.

1.2 The report covers the five key domains of: - Patient Safety, Patient Experience, Resources, Efficiency and External Perception.

1.3 Performance measurement targets within these domains are based on the following

The core standards set nationally by Monitor, NHS England, Welsh Assembly Government and the Care Quality Commission

Any locally agreed Commissioner driven targets including CQUIN quality improvement

Internal performance targets in line with the Trust’s Annual Operating Plan objectives.

1.4 The scorecard format provides an overview of the performance within each domain

with further detail of specific metrics in graphical and tabular format.

1.5 The scorecard utilises two graphical presentation methods; line graphs and statistical process control (SPC) charts. SPC charts enable the analysis of the variability of a metric relative to average performance. Data points within the upper and lower limits are linked to natural variation in performance levels.

1.6 In August, Monitor published a revised Risk Assessment Framework. The changes included monitoring in-year financial performance and the accuracy of planning. These two measures were combined with the previously used continuity of services risk rating to produce a new four-level financial sustainability risk rating detailed as follows:

Liquidity

Capital Service Capacity

I&E margin

Variance in I&E margin as a % of income Changes to relevant policies such as the removal of the admitted and non-admitted referral to treatment targets have also been reflected in the scorecard.

2. Chief Executive’s Overview

2.1 This month’s report outlines that whilst we continue to deliver safe care and our patients rate our services highly we remain challenged in meeting our access targets. Whilst the underlying causes for this are demand pressures exceeding our capacity we also need to significantly improve our operational processes.

2.2 The need to improve our operational processes and to reduce the times our patients

are waiting for treatment will form the basis of a formal recovery plan which is under development. The core principle of the recovery will be to ensure we are making decisions and taking actions that are clinically driven and in the best interest of our patients. In the meantime our performance against our access targets causes’ significant risk of contract penalties being applied which would put pressure on our finances.

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2.3 We have included in the report a revised forecast of our year-end financial position

which reflects the in-year pressures we face. To maintain this forecast position we will need strong financial control and to manage the risk of potential contract penalties. The financial position of the local health economy adds to this risk.

2.4 We have made some progress in our efficiencies where it is particularly pleasing to

see the improved performance on daycases against the BADs target. We remain above our average length of stay target which is an area that requires further focus as this aligns with the pathway requirements of the new admission unit and theatre build.

2.5 Given the level of the challenges we face and the wider sector risk we must maintain

our overall focus on delivering outstanding patient care whilst we work hard to improve our waiting times for patients

3. Performance Overview 3.1 Domain 1 – Patient Safety

3.1.1 Overview – Seven of the nine key metrics were rated as green in month. Although

there are a small number of incidents the Trust continues to scope areas of improvement. No hospital acquired infections occurred during October. The following exceptions are noted for month 7.

3.1.2 Mortality Rates – There were no patient deaths during October.

3.1.3 Serious Incidents – There was one serious incident in October where a patient sustained a fracture whilst jogging in the gym. This has been investigated as part of Trust protocol and considered at the Clinical Effectiveness Committee.

3.1.4 Hospital Acquired VTE (DVT or PE) – Two patients were diagnosed with pulmonary embolism during October. Both patients were diagnosed post-operatively following total hip replacements. The patients had been risk assessed and prophylaxis was in place. Two incidents a month is within the monthly tolerance level of three

3.1.5 Hospital Acquired Pressure Ulcers – Pressure Ulcers are graded on a scale from 1 to 4, with grade 1 relating to minimal harm and grade 4 being full skin loss and highest level of harm. There were two incidents in October which is above the monthly tolerance of one case. Both patients acquired grade two pressure sores. One of the patients was assessed as having vulnerable skin. In both cases, the sores had healed prior to discharge.

3.1.6 Clinical Quality – Inpatient Falls (Harms) – Fifteen inpatient falls occurred during October where three patients each fell twice. At the time of their fall, seven patients were not complying with medical advice. Compared to activity levels, this correlates to 2.07% of activity. Three patients experienced low level harm of a skin tear (1), a controlled faint (1) and bruise (1) as a result of their falls. Three incidents resulting in harm is above the monthly tolerance level of two, but remains within the normal variation range.

3.1.7 Medication Errors (Harms) – Seventeen medication incidents relating to patient care at the hospital were recorded during October which were categorised as Prescribing (2), Administration (5) Dispensing (2), Storage (6), Incorrect medication advice to patient (1) and Medication dose or strength unclear (1).

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Two patients required closer monitoring as a result of the prescribing incidents. With a tolerance level of two incidents per month, the metric is rated as ‘green’ in October.

3.1.8 28 day Readmission Rates to RJAH – Six patients were readmitted as an emergency within 28 day of initial discharge in September 2015. All patients were readmitted in relation to wound issues.

3.2 Domain 2 - Patient Experience

3.2.1 Overview – The Trust continues to collate patient feedback via a number of sources including social media, NHS Choices and direct correspondence. The feedback continues to be positive with over one hundred and forty compliments received throughout the month. The following exceptions are noted for month 7

3.2.2 NHS Friends & Family Test – The Friends and Family metrics within the scorecard is a combined measure representing the percentage of both inpatient and outpatients that would and would not recommend the Trust. In line with the national metrics, passive responses are not included within calculations. During October 99.03% of patients stated that they would recommend the Trust. The number of patients who stated they would not recommend the Trust remains low with just one patient in October who failed to comment why they gave this response. Our response rates remain better than the national averages which show that 96% of inpatients recommend Trusts with 1% not recommending.

3.2.3 Complaints – Seven complaints were received during October which is within the monthly tolerance level of nine. There were four complaints regarding clinical care which related to attitude of staff on ward (1), outcome of surgery (2) and a patient was unhappy with the communication received regarding their Outpatient appointment (1). There was a further three operational complaints which were regarding the waiting time in Outpatients (1), cancellation of surgery (1) and referral issues between GP and Trust (1). Each complaint is currently under review in line with the Trust’s Complaints Policy.

3.2.4 Access to Bone Tumour Services – All cancer targets were achieved in month.

3.2.5 Access to Services - English – During October our performance deteriorated to 87.3% against the 92% open pathway performance target for patients waiting 18 weeks or less to start their treatment. An anticipated deterioration was reported to the Board in September relating to a growing backlog associated with demand which is coupled with changes in application of the Trust’s access policy which has resulted in more long waiting patients.

3.2.6 Patients waiting over 52 weeks –English and Welsh commissioners have a zero tolerance policy on patients waiting over 52 weeks to start treatment. At the end of October there were 25 English patients waiting over 52 weeks. Clinical Commissioning Groups are aware of this issue, remedial actions are in place; there were four patients without treatment dates which are now being expedited. Welsh long wait patients are being managed in line with revised contract arrangements.

3.2.7 Theatre Cancellations – In October there were two patients, one English and one

Welsh, who were breaches of the standard to be offered a subsequent date for

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surgery within 28 days following their initial cancellation. There were issues with capacity that led to this but both patients have now had surgery in November.

3.3 Domain 3 – Efficiency

3.3.1 Overview – Activity levels were strong during October across all three metrics. There was still a need to outsource 26 cases to the private sector as consultant schedules could not be fully accommodated within our internal theatre capacity. Some metrics are ‘amber’ rated in October as step changes to targets take effect and ongoing reviews to the management of patient pathways must continue to ensure these targets show improvement in the remainder of the year. Detailed exceptions to planned performance in October were as follows:

3.3.2 Daycase Performance – The proportion of patients treated as daycase dipped during October to 49.60% of patients being treated as daycase compared to a 51% target. There has been a continued focus on the specific procedures within the BADS framework. As a combination of this and October’s casemix the performance increased to 89.45%, meeting the 88% target and seeing this specific metric rated ‘green’.

3.3.3 Theatre Efficiency – Staffed theatre lists were under utilised in October at 96.06%.

There is ongoing work to ensure theatre capacity is fully utilised that will support the delivery of activity targets for the remainder of the year.

3.3.4 Average Length of Stay – The average length of stay of 4.40 days was above the

target of 3.6 days or less in October. The average continues to be distorted by a small number of patients that require a longer period of inpatient rehabilitation. The enhanced recovery target of 52% continues to be maintained with a rate of 59.67% of patients being discharged in 3 days or less.

3.3.5 Outpatient Productivity – Unutilised clinic slots due to patients not attending their appointments is a financial and operational burden on Trusts nationwide. During quarter 1, the national DNA rate was 9%. October saw the first of two step changes to the target before year end and October’s performance is reported just ahead of this at 5.22%. This will continue to be monitored over the next few months in order to reach the 5% target set for quarter 4.

3.3.6 New to Follow Up Ratio – The new to follow up ratio dipped below the target level during October with the ratio of 1:2.24 being below the target of 1:2.02. The continuing work to review Demand and Capacity within the Trust includes looking at the policies for follow up to ensure patients are only brought back to hospital for review where clinically required and the delivery of these follow up appointments.

3.4 Domain 4 – Resources

3.4.1 Overview – A surplus of £188k was made in month which was £210k lower than planned. There were two significant factors that impacted our performance in month; Contract penalties for breach of the open pathway and 52 week targets were estimated at £200k pending full validation. Additionally we recognised one off costs of c£100k associated with the governance review. Without these factors we would have exceeded the planned position.

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Whilst activity and income performed strongly in month this generated additional over performance of £0.8m against our two main Commissioners both of whom are financially constrained. Discussions are ongoing with Shropshire to reach an end of year agreement whilst for BCU we have agreed to delay further non urgent bookings into 2016/17 that will lead to an increase in waiting times in excess of the current level of 52 weeks. A care and communication strategy for patients affected is currently under discussion. Year to date our surplus has increased to £285k which is £458k behind our plan. Our EBITDA margin is 4.7%, lower than plan by 0.9%. Our risk rating under Monitor’s new financial sustainability risk rating calculation has remained at a level 4 overall (lowest risk). As we look towards the end of the year we have recognised a number of in year pressures arising from the governance review and subsequent interim management arrangements, delivery pressures associated with waiting time targets and potential reduced levels of BCU activity. The combined impact of these has impacted on the deliverability of our £1m plan surplus and we now expect to deliver a reduced surplus of £0.1m. This will be impacted further once the implications of contract penalties linked to the RTT recovery plan have been fully scoped and any associated resources required to support the delivery of the recovery.

The key features of the month 7 financial performance are detailed below:

3.4.2 Income - Overall clinical income exceeded plan in month by £192k post the provision

for contract penalties of £200k. Internally delivered activity was strong and further supported by the transfer of 26 cases to the private sector (although this placed further pressure on the cost base).

Whilst private patient income fell short of plan by £33k, this was offset by strong RTA income which exceeded plan by £76k.

3.4.3 Expenditure – Pay budgets over spent by £133k of which the majority related to

non-recurrent costs. Additionally there were high levels of out of job plan payments undertaken to deliver increased outpatient activity. Agency nurse spend was 1.85% and well within the target of 3% set by Monitor. Further controls are expected to be introduced later in the year that place a cap on the premium costs charged for agency workers for all staff groups. Non pay costs exceeded plan by £306k driven by increased implant costs linked to case mix complexity and increased volume, rental of private sector capacity to facilitate treatment of long wait patients, interim consultancy costs and recruitment costs.

3.4.4 Cost Improvements – Cost efficiencies of £268k were recognised in month, which

was £5k behind plan. Cumulatively we have identified efficiencies of £1,589k which is £37k above plan. These were delivered from a broad range of schemes with the most material areas being income generation and procurement. We continue to forecast delivery of the full savings programme although this is contingent on a number of work streams which we continue to monitor closely.

3.4.5 Cash Balances increased by £0.6m to £4.8m as we received an interim settlement of contract over performance from Shropshire CCG. We utilised a further £1m of our capital investment loan to support the Theatre and Tumour Unit development leaving us with £6.4m remaining to draw down.

The cash position is behind plan by £1.5m and continues to be impacted by commissioner debtors relating to differences between activity delivered and formal

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contract profiles. At the end of October this amounted to £2.4m from our two main Commissioners. Our forecast cash balance for the end of the year has reduced to £5m from an original plan of £5.5m. This has been driven by the forecast reduced surplus net of capital slippage.

3.4.6 Capital Expenditure in month amounted to £0.86m, the majority of which related to

the construction of the new Theatres and Tumour unit. On a cumulative basis we have spent £3.8m. Whilst this is £3.1m behind plan most of this relates to the change in cash flow profile for our Theatres and Tumour Unit development which is expected to track back to the original profile over the next few months. This does not reflect a change in the delivery of the project which is planned for completion in September 2016. The outpatient redevelopment scheme planned for the year will now be deferred until 2016/17 as the scope of the scheme has exceeded the original budget and will require a full business case for full consideration of the Board.

3.4.7 Sickness Absence – Sickness absence for October remained virtually unchanged at

2.98%, with long and short term absence at very similar levels. Trust sickness absence has remained below 3% for 6 of the past 7 months and benchmarking continues to rank the trust as the lowest 12 month rolling and in month absence rates for the West Midlands.

The Flu campaign has been well received, with all allocated vaccines used and more now on order. The annual Healthy Horizons health and wellbeing event is being held on 1

st December and staff will be able to access a variety of resources including flu

vaccines.

3.4.8 Staff Stability Index – The stability index for October reduced to 90.91% which is just below (worse than) the 92% target. As this is the second consecutive month below target the following exception report stating areas below the target is included for information. Corporate 88%

3.4.9 Staff Appraisal – Staff appraisals in October increased marginally to 88.44% Trust

wide of staffing having undertaken an appraisal within the past 12 months. This continues to be just below the 90% target. Due to the ongoing under-performance the following exception report stating areas below the 90% target is included for information.

Diagnostics 67% Theatre 88% Surgery 88%

3.4.10 Staffing Establishment – The Trust monitor staffing levels twice daily and this is reported to NHS England monthly. All escalation processes have been followed to ensure patient safety is maintained with the shift fill rate of 98.70 above the target of 90. The monthly Unify table is shown below.

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3.5 Domain 5 – External Perception

3.5.1 Our risk rating under Monitor’s new financial sustainability risk rating remains at a level 4 (lowest risk).

3.5.2 Monitor’s published ratings continue to show that they are investigating governance

concerns triggered by breaches of the referral to treatment target. For the purposes of the scorecard we have flagged this as ‘amber’.

4. Recommendation 4.1 It is recommended that the Board:

Note the performance for October (Month 7)

Craig Macbeth Acting Director of Finance

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Balanced Scorecard - Trust

October 2015 - Month 7

Month Key Metric Actual YTD Change Forecast Month Key Metric Actual YTD Change Forecast

Oct-15 Infection Control g g same g Oct-15 Friends & Family Test g g same gOct-15 Serious Incidents a a worse g Oct-15 Number of Complaints g g same gOct-15 Never Events g g same g Oct-15 Theatre Cancellations a g worse gOct-15 Unexpected Deaths g r same r Oct-15 Delayed Discharges a a better aOct-15 Clinical Quality a a worse g Oct-15 Access to Bone Tumour Services g g same gOct-15 Medication Errors (Harms) g g same g Oct-15 Access to Services - English r a worse rOct-15 Pressure Ulcer Assessments g g same g Oct-15 Patients Waiting Over 52 Weeks r r worse rOct-15 28 Day Emergency Readmission Rate g g same gOct-15 CQUIN g g same g

↑

← →

↓

Month Key Metric Actual YTD Change Forecast Month Key Metric Actual YTD Change Forecast

Oct-15 Sickness Absence a g same g Oct-15 Demand for Services r a worse aOct-15 Staff Stability Index a g same g Oct-15 Activity - Surgery g g same gOct-15 Staff Appraisal a a same a Oct-15 Activity - Medicine a a worse gOct-15 Safe Staffing - % Shift Fill Rate g g same g Oct-15 Daycase Performance g a same gOct-15 Net Surplus r r worse r Oct-15 Admission on Day of Surgery a g worse gOct-15 CIP Delivery g g same g Oct-15 Theatre Efficiency g g same gOct-15 Capital Expenditure g g same g Oct-15 Average Length of Stay a g worse gOct-15 PSPP g g same g Oct-15 Bed Utilisation r r same aOct-15 Cash Balance a a same a Oct-15 Outpatient Productivity a a better a

Oct-15 New to Follow Up Ratio (Consultant Led Activity) r r same a

Resources EfficiencyOverall Performance Overall Performance

Patient Safety Patient ExperienceOverall Performance Overall Performance

VISION

To be the leading centre for high quality, sustainable Orthopaedic and related care, achieving excellence in both experience and outcomes for our

patients

Month Key Metric Actual YTD Change Forecast

Oct-15 Monitor Risk Rating - Finance g g same g

Oct-15 Monitor Risk Rating - Organisational Health a a same a

External PerceptionOverall Performance

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Patient Safety

Infection Control

Period Target Actual PerformanceApr-15 0.00 0.00 gMay-15 0.00 0.00 gJun-15 0.00 0.00 gJul-15 0.00 0.00 g

Aug-15 0.00 0.00 gSep-15 0.00 0.00 gOct-15 0.00 0.00 gNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Hospital Acquired MRSA Bacteraemia

0.00

1.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Safety

Infection Control



Hospital Acquired C.Difficile

0.00

1.00

2.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Safety

Period Target Actual PerformanceApr-15 0.00 0.00 gMay-15 0.00 2.00 aJun-15 0.00 0.00 gJul-15 0.00 1.00 a

Aug-15 0.00 4.00 rSep-15 0.00 0.00 gOct-15 0.00 1.00 aNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Serious Incidents

0.00

1.00

2.00

3.00

4.00

5.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Safety



Never Events

0.00

1.00

2.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

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Patient Safety



Never Events

0.00

1.00

2.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Safety

Period Target Actual PerformanceApr-15 0.00 1.00 rMay-15 0.00 0.00 gJun-15 0.00 1.00 rJul-15 0.00 0.00 g


Unexpected Deaths

0.00

1.00

2.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Safety

Clinical Quality



Hospital Acquired VTE (DVT or PE)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Mean UCL LCL Actual

Patient Safety

Clinical Quality



Inpatient Falls (Harms)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

11.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


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Patient Safety

Clinical Quality



Inpatient Falls (Harms)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

11.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


Patient Safety

Clinical Quality

Period Target Actual PerformanceApr-15 1.00 1.00 gMay-15 1.00 0.00 gJun-15 1.00 1.00 gJul-15 1.00 4.00 r

Aug-15 1.00 2.00 aSep-15 1.00 1.00 gOct-15 1.00 2.00 aNov-15 1.00Dec-15 1.00Jan-16 1.00Feb-16 1.00Mar-16 1.00

Hospital Acquired Pressure Ulcers - Grade 2 or Above

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


Patient Safety

Clinical Quality



Safety Thermometer - % with no new harms

92.00

93.00

94.00

95.00

96.00

97.00

98.00

99.00

100.00

101.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


92.00

93.00

94.00

95.00

96.00

97.00

98.00

99.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%


Patient Safety

Period Target Actual PerformanceApr-15 2.00 1.00 gMay-15 2.00 3.00 aJun-15 2.00 1.00 gJul-15 2.00 1.00 g


Medication Errors (Harms)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


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Patient Safety

Period Target Actual PerformanceApr-15 2.00 1.00 gMay-15 2.00 3.00 aJun-15 2.00 1.00 gJul-15 2.00 1.00 g


Medication Errors (Harms)

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


Patient Safety



Pressure Ulcer Assessments

98.40

98.60

98.80

99.00

99.20

99.40

99.60

99.80

100.00

100.20

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Safety

28 Day Emergency Readmission Rate

Period Target Actual PerformanceApr-15 1.00 0.87 gMay-15 1.00 0.63 gJun-15 1.00 1.03 aJul-15 1.00 1.06 a

Aug-15 1.00 0.64 gSep-15 1.00 1.00 gOct-15 1.00 No Data gNov-15 1.00Dec-15 1.00Jan-16 1.00Feb-16 1.00Mar-16 1.00

28 Days Emergency Readmissions to RJAH Following an

Overnight Stay

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%


Patient Safety

CQUIN



VTE Risk Assessments

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

102.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


13



Patient Safety

CQUIN



VTE Risk Assessments

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

102.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


14



Patient Experience

Friends & Family Test



Friends & Family - % Would Recommend (Inpatients and

Outpatients)

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

102.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience

Friends & Family Test

Period Target Actual PerformanceApr-15 0.00 0.74 aMay-15 0.00 0.14 aJun-15 0.00 0.37 aJul-15 0.00 0.17 a

Aug-15 0.00 0.00 gSep-15 0.00 0.63 aOct-15 0.00 0.19 aNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Friends & Family - % Would Not Recommend (Inpatients

and Outpatients)

0.00

0.20

0.40

0.60

0.80

1.00

1.20

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience



Number of Complaints

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er


Patient Experience

Theatre Cancellations



% Reportable Cancellations

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


15



Patient Experience




% Reportable Cancellations

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience



Aug-15 0.00 0.00 gSep-15 0.00 0.00 gOct-15 0.00 2.00 rNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Cancellations Not Rebooked within 28 Days

0.00

0.50

1.00

1.50

2.00

2.50

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Experience

Delayed Discharges

Period Target Actual PerformanceApr-15 3.50 3.62 aMay-15 3.50 0.83 gJun-15 3.50 0.71 gJul-15 3.50 3.55 a

Aug-15 3.50 4.42 aSep-15 3.50 7.30 rOct-15 3.50 4.10 aNov-15 3.50Dec-15 3.50Jan-16 3.50Feb-16 3.50Mar-16 3.50

% Delayed Discharges Against Occupied Beds on last

Thursday of Month

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%


Patient Experience

Access to Bone Tumour Services



Cancer Two Week Wait

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

102.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


16



Patient Experience




Cancer Two Week Wait

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

102.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience




31 Days First Treatment (Tumour)

94.00

95.00

96.00

97.00

98.00

99.00

100.00

101.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience



Aug-15 85.00 66.67 rSep-15 85.00 100.00 gOct-15 85.00 100.00 gNov-15 85.00Dec-15 85.00Jan-16 85.00Feb-16 85.00Mar-16 85.00

Cancer Plan 62 Days Standard (Tumour)

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience

Access to Services - English

Period Target Actual PerformanceApr-15 92.00 86.02 rMay-15 92.00 89.10 rJun-15 92.00 92.05 gJul-15 92.00 92.74 g


18 Weeks RTT Open Pathways

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


17



Patient Experience


Period Target Actual PerformanceApr-15 92.00 86.02 rMay-15 92.00 89.10 rJun-15 92.00 92.05 gJul-15 92.00 92.74 g


18 Weeks RTT Open Pathways

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience




6 Week Wait for Diagnostics - English Patients

98.40

98.60

98.80

99.00

99.20

99.40

99.60

99.80

100.00

100.20

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Patient Experience

Patients Waiting Over 52 Weeks

Period Target Actual PerformanceApr-15 0.00 1.00 rMay-15 0.00 0.00 gJun-15 0.00 0.00 gJul-15 0.00 3.00 r

Aug-15 0.00 3.00 rSep-15 0.00 2.00 rOct-15 0.00 25.00 rNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Patients Waiting Over 52 Weeks - English

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Patient Experience


Period Target Actual PerformanceApr-15 0.00 5.00 rMay-15 0.00 2.00 rJun-15 0.00 7.00 rJul-15 0.00 0.00 g

Aug-15 0.00 1.00 rSep-15 0.00 1.00 rOct-15 0.00 0.00 gNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Patients Waiting Over 52 Weeks - Welsh

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

200.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


18



Patient Experience


Period Target Actual PerformanceApr-15 0.00 5.00 rMay-15 0.00 2.00 rJun-15 0.00 7.00 rJul-15 0.00 0.00 g

Aug-15 0.00 1.00 rSep-15 0.00 1.00 rOct-15 0.00 0.00 gNov-15 0.00Dec-15 0.00Jan-16 0.00Feb-16 0.00Mar-16 0.00

Patients Waiting Over 52 Weeks - Welsh

0.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

180.00

200.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


19



Resources

Period Target Actual PerformanceApr-15 2.70 2.69 gMay-15 2.70 2.33 gJun-15 2.70 2.49 gJul-15 2.70 3.15 a


Sickness Absence

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%


Resources



Staff Stability Index

88.50

89.00

89.50

90.00

90.50

91.00

91.50

92.00

92.50

93.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Resources


Aug-15 90.00 85.41 aSep-15 90.00 88.30 aOct-15 90.00 88.44 aNov-15 90.00Dec-15 90.00Jan-16 90.00Feb-16 90.00Mar-16 90.00

Staff Appraisal

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Resources



Safe Staffing - % Shift Fill Rate

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

20.00

40.00

60.00

80.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


20



Resources



Safe Staffing - % Shift Fill Rate

0.00

20.00

40.00

60.00

80.00

100.00

120.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

20.00

40.00

60.00

80.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


21



Efficiency

Demand for Services

Period Target Actual PerformanceApr-15 8500.00 8829.00 gMay-15 8500.00 9029.00 gJun-15 8500.00 9216.00 aJul-15 8500.00 9474.00 a

Aug-15 8500.00 9340.00 aSep-15 8500.00 9756.00 rOct-15 8500.00 9814.00 rNov-15 8500.00Dec-15 8500.00Jan-16 8500.00Feb-16 8500.00Mar-16 8500.00

Total Open Pathways

0.00

2000.00

4000.00

6000.00

8000.00

10000.00

12000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.0

2000.0

4000.0

6000.0

8000.0

10000.0

12000.0

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Demand for Services

Period Target Actual PerformanceApr-15 2647.00 2642.00 aMay-15 2647.00 2840.00 gJun-15 2647.00 2878.00 gJul-15 2647.00 3184.00 g

Aug-15 2647.00 2695.00 gSep-15 2647.00 2995.00 gOct-15 2647.00 No Data gNov-15 2647.00Dec-15 2647.00Jan-16 2647.00Feb-16 2647.00Mar-16 2647.00

Referrals Received for Consultant Led Services

0.00

500.00

1000.00

1500.00

2000.00

2500.00

3000.00

3500.00

4000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

500.00

1000.00

1500.00

2000.00

2500.00

3000.00

3500.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Activity - Surgery

Period Target Actual PerformanceApr-15 990.00 968.00 aMay-15 995.00 1002.00 gJun-15 1123.00 1148.00 gJul-15 1146.00 1097.00 a

Aug-15 981.00 988.00 gSep-15 1121.00 1069.00 aOct-15 1125.00 1155.00 gNov-15 1045.00Dec-15 825.00Jan-16 1033.00Feb-16 1024.00Mar-16 1039.00

Surgical Division Activity - Inpatient Contract

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

1400.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Activity - Surgery

Period Target Actual PerformanceApr-15 6140.00 5951.00 aMay-15 6166.00 6141.00 aJun-15 6964.00 7490.00 gJul-15 7104.00 6845.00 a

Aug-15 6080.00 5736.00 aSep-15 6951.00 7566.00 gOct-15 6971.00 7348.00 gNov-15 6479.00Dec-15 5115.00Jan-16 6406.00Feb-16 6346.00Mar-16 6439.00

Surgical Division Activity - Outpatient Contract

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

8000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

8000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


22



Efficiency

Activity - Surgery

Period Target Actual PerformanceApr-15 6140.00 5951.00 aMay-15 6166.00 6141.00 aJun-15 6964.00 7490.00 gJul-15 7104.00 6845.00 a

Aug-15 6080.00 5736.00 aSep-15 6951.00 7566.00 gOct-15 6971.00 7348.00 gNov-15 6479.00Dec-15 5115.00Jan-16 6406.00Feb-16 6346.00Mar-16 6439.00

Surgical Division Activity - Outpatient Contract

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

8000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

8000.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Activity - Medicine

Period Target Actual PerformanceApr-15 188.00 208.00 gMay-15 189.00 167.00 rJun-15 214.00 224.00 gJul-15 218.00 200.00 a

Aug-15 187.00 176.00 aSep-15 213.00 258.00 gOct-15 214.00 182.00 rNov-15 199.00Dec-15 157.00Jan-16 197.00Feb-16 195.00Mar-16 198.00

Medicine Division Activity - Inpatient Contract

0.00

50.00

100.00

150.00

200.00

250.00

300.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

50.00

100.00

150.00

200.00

250.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Activity - Medicine



Medicine Division Activity - Outpatient Contract

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

1400.00

1600.00

1800.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

1400.00

1600.00

1800.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Daycase Performance


Aug-15 87.00 82.05 aSep-15 87.00 85.17 aOct-15 88.00 89.45 gNov-15 88.00Dec-15 88.00Jan-16 88.00Feb-16 88.00Mar-16 88.00

BADS Activity

72.00

74.00

76.00

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


23



Efficiency

Daycase Performance


Aug-15 87.00 82.05 aSep-15 87.00 85.17 aOct-15 88.00 89.45 gNov-15 88.00Dec-15 88.00Jan-16 88.00Feb-16 88.00Mar-16 88.00

BADS Activity

72.00

74.00

76.00

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Daycase Performance



Overall Daycase Rate

42.00

44.00

46.00

48.00

50.00

52.00

54.00

56.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

39.00

44.00

49.00

54.00

59.00

64.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Admission on Day of Surgery


Aug-15 92.00 92.77 gSep-15 92.00 93.30 gOct-15 94.00 93.74 aNov-15 94.00Dec-15 94.00Jan-16 95.00Feb-16 95.00Mar-16 95.00

% of Elective NHS Inpatients Admitted on Day of Surgery

78.00

80.00

82.00

84.00

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Theatre Efficiency



% Staffed Theatre Lists Utilised

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


24



Efficiency

Theatre Efficiency



% Staffed Theatre Lists Utilised

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

50.00

55.00

60.00

65.00

70.00

75.00

80.00

85.00

90.00

95.00

100.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Theatre Efficiency

Period Target Actual PerformanceApr-15 2.20 2.16 aMay-15 2.20 2.20 gJun-15 2.20 2.25 gJul-15 2.20 2.24 g

Aug-15 2.20 2.24 gSep-15 2.20 2.12 aOct-15 2.20 2.20 gNov-15 2.20Dec-15 2.20Jan-16 2.20Feb-16 2.20Mar-16 2.20

Theatre Cases Per Session

2.00

2.05

2.10

2.15

2.20

2.25

2.30

2.35

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Average Length of Stay


Aug-15 3.80 4.37 rSep-15 3.80 3.94 aOct-15 3.60 4.40 rNov-15 3.60Dec-15 3.60Jan-16 3.50Feb-16 3.50Mar-16 3.50

Average Length of Stay - Elective Excluding Daycase

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency




% of Primary Hip and Knee Patients Discharged in 3 days or

less

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

35.00

40.00

45.00

50.00

55.00

60.00

65.00

70.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Paper 03


25



Efficiency




% of Primary Hip and Knee Patients Discharged in 3 days or

less

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

35.00

40.00

45.00

50.00

55.00

60.00

65.00

70.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Bed Utilisation

Period Target Actual PerformanceApr-15 87.00 72.24 rMay-15 87.00 78.50 rJun-15 87.00 82.01 gJul-15 87.00 72.19 r

Aug-15 87.00 69.99 rSep-15 87.00 71.41 rOct-15 87.00 78.12 rNov-15 87.00Dec-15 87.00Jan-16 87.00Feb-16 87.00Mar-16 87.00

Bed Occupancy - Adult Orthopaedic Wards

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

%

Target Actual

Efficiency

Outpatient Productivity


Aug-15 5.50 5.60 aSep-15 5.50 5.81 rOct-15 5.25 5.22 aNov-15 5.25Dec-15 5.25Jan-16 5.00Feb-16 5.00Mar-16 5.00

Outpatient DNA Rate

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Efficiency

Period Target Actual PerformanceApr-15 2.10 2.23 rMay-15 2.10 2.12 aJun-15 2.10 2.35 rJul-15 2.05 2.15 a


New to Follow Up Ratio (Consultant Led Activity)

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


26



Efficiency

Period Target Actual PerformanceApr-15 2.10 2.23 rMay-15 2.10 2.12 aJun-15 2.10 2.35 rJul-15 2.05 2.15 a


New to Follow Up Ratio (Consultant Led Activity)

0.00

0.50

1.00

1.50

2.00

2.50

3.00

Apr

-14

May

-14

Jun

-14

Jul-

14

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Nu

mb

er

Target Actual

Paper 03


27

Finance Dashboard 31st October 2015Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

Commentary Commissioner affordability in relation to contract overperformance - Shropshire and BCU. Increased risk of contract penalities linked to RTT performance. Ongoing use of private sector and premium costs of delivery in excess of plan due to operational pressures. CIP Programme over identified and on plan, is being actively tracked through performance framework.

Category Sep-15 Oct-15 Movement Drivers

Fixed Assets 54,797 55,452 655 Capital investment above depreciation.

Non current receivables 641 704 64

Total Non Current Assets 55,438 56,157 718

Inventories (Stocks) 1,026 1,034 8

Receivables (Debtors) 8,356 8,663 307Increase in commissioner debt offset by interim settlement of

contract overperformance with Shropshire CCG.

Cash at Bank and in hand 4,252 4,835 583Interim settlement of contract overperformance with Shropshire

CCG.

Total Current Assets 13,634 14,532 899

Payables (Creditors) (8,628) (9,164) (536)Specific commissioner underperformance and post grad income

received for Q2 and deferred.

Borrowings (61) (57) 3

Current Provisions (246) (131) 115 VAT provision released.

Total Current Liabilities (8,935) (9,352) (418)

Total Assets less Current Liabilities 60,137 61,336 1,199

Non Current Borrowings (2,683) (3,682) (999) Further £1m loan drawdown.

Non Current Provisions (384) (396) (12)

Non Current Liabilities (> 1 year) (3,067) (4,078) (1,011)

Total Assets Employed 57,070 57,258 188

Public Dividend Capital (33,260) (33,260) 0

Revenue Position (71) (259) (188) In month surplus.

Retained Earnings (6,735) (6,735) 0

Revaluation Reserve (17,004) (17,004) 0

Total Taxpayers Equity (57,070) (57,258) (188)

Statement of Financial Position £'000s

Oct-15 YTD

Debtor Days 31 33

Creditor Days 35 36

Plan Actual Variance

Clinical Income from activity 83,908 49,667 50,208 541 193

Private Patient income 4,855 2,764 2,707 (57) (33)

Other income 5,756 3,377 3,618 241 54

Pay (53,424) (31,235) (31,511) (275) (133)

Non-pay (35,992) (21,424) (22,349) (925) (306)

EBITDA 5,104 3,148 2,673 (475) (225)

Finance Costs (4,101) (2,405) (2,388) 17 15

Operational Surplus 1,003 743 285 (458) (210)

EBITDA margin 5.4% 5.6% 4.7% -0.9%

Income and Expenditure £'000s

Movement In

Variance From

Prior Month

CategoryAnnual

Plan

Year To Date Position

Risks

Income Risk Red

Expenditure Risk Medium

CIP Risk Low

Debt Service Cover 4 I&E Margin 3

Liquidity (days) 4 Variance in I&E Margin 3

(£600)

(£400)

(£200)

£0

£200

£400

£600

£800

Clinical Income from activity Private Patient income Other income Pay Non-pay

V

a

r

i

a

n

c

e

Cumulative Variances £'000s

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

C

a

s

h

£

M


Monitor Plan £M 4.9 5.1 5.0 5.5 7.2 6.1 6.3 5.8 5.8 6.1 6.3 5.5

Actual £M 4.9 5.5 4.9 5.0 6.4 4.3 4.8

Forecast £M 4.9 5.5 4.9 5.0 6.4 4.3 4.8 4.4 4.3 4.6 4.7 5.0

Cash Flow

Overall FSRR 4

(£800)

(£600)

(£400)

(£200)

£0

£200

£400

£600

£800

£1,000

£1,200


S

u

r

p

l

i

u

s

/

(

D

e

f

i

c

i

t)

Period

Monthly Surplus/Deficit £'000s

Plan

Actual

Paper 03


28

RAG of Total Schemes Being Tracked

2,348 73% g

877 27% a

11 0% r

3,237 100%

Ca

pit

al

Co

mm

issio

ne

r P

erf

orm

an

ce

In Month CIP Achievement £000's Year To Date CIP Achievement £000's

CIP

by T

he

me

Year To Date Commissioner Income against Plan £m

CIP

by D

ivis

ion

Year to date capital programme £000's

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustFinance Dashboard 31st October 2015

Cost Improvement Programme

In Month CIP Achievement £000's Year To Date CIP Achievement £000's Trust YTD Achievement Against YTD Plan £000's

(50) 0 50 100 150 200

Bring Forward FYE

Capacity Alignment

Productivity

Procurement

Transformation

Workforce Redesign

Income

Miscellaneous

Oct Plan Oct Actual

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Total

YTD Plan YTD Actual

0 100 200 300 400 500 600 700

Bring Forward FYE

Capacity Alignment

Productivity

Procurement

Transformation

Workforce Redesign

Income

Miscellaneous

YTD Plan YTD Actual

0 50 100 150

Surgical Services

Medicine

Diagnostics

Estates & Facilities

Corporate

Oct Plan Oct Actual

0 100 200 300 400 500 600 700 800 900

Surgical Services

Medicine

Diagnostics

Estates & Facilities

Corporate

YTD Plan YTD Actual

- 5.00 10.00 15.00 20.00 25.00

Shropshire

BCU

Specialist

Other English Contracted

Powys

Telford

Other

Uncontracted

YTD actual YTD plan

ProjectAnnual

Plan

Year to

date Plan

Year to

date

Completed

Year to

date

Variance

In Month

Actual

Forecast

Outturn

Outturn

Variance

Backlog Maintenance 400 258 119 139 18 300 100

Medical equipment 400 178 215 -37 120 435 -35

IT 280 228 147 81 24 280 0

Project Management 150 88 81 7 12 150 0

Charitable Purchases TBC 200 89 84 5 -3 200 0

Contingency 300 100 0 100 0 68 232

Outpatients Refurbishment 400 320 10 310 6 10 390

Estates Rationalisation 100 100 9 91 6 100 0

Combined Heat and Pow er Plant 500 125 14 111 0 552 -52

Theatre and Tumour Development 11,821 5,369 3,086 2,283 677 11,821 0

Theatre Chillers 0 0 0 0 0 245 -245

NHS Capital Expenditure 14,551 6,855 3,765 3,090 860 14,161 390

Paper 03


29

Month 7

Achieved / Not Met

Referral to treatment time, 18 weeks in aggregate, incomplete pathways 92% 1.0 Yes Not met

Cancer 62 Day Waits for first treatment (from urgent GP referral) 85% 1.0 No Not relevant

Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service

referral)90% 1.0 No Not relevant

Cancer 31 day wait for second or subsequent treatment - surgery 94% 1.0 No Not relevant

Cancer 31 day wait for second or subsequent treatment - drug treatments 98% 1.0 No Not relevant

Cancer 31 day wait for second or subsequent treatment - radiotherapy 94% 1.0 No Not relevant

Cancer 31 day wait from diagnosis to first treatment 96% 0.5 No Achieved

Cancer 2 week (all cancers) 93% 0.5 No Achieved

Clostridium Difficile -meeting the C.Diff objective 2 1.0 No Achieved

Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No

CQC enforcement action within last 12 months (as at 31 Mar 2015) N/A No No

CQC enforcement action (including notices) currently in effect (as at 31 Mar 2015) N/A No No

CQC enforcement action (including notices) currently in effect N/A No No

Moderate CQC concerns or impacts regarding the safety of healthcare provision N/A No No

Major CQC concerns or impacts regarding the safety of healthcare provision N/A No No

Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in

place appropriate alternative arrangementsN/A No No

Score of 7 or less in standard 1 assessment at last NHSLA CNST inspection

(maternity or all services)N/A No No

Trust unable to declare ongoing compliance with minimum standards of CQC

registrationN/A No No

0

GREEN

Appendix 1

Indicative Risk Rating

Declaration of risks against healthcare targets and indicators for 2015/16

Target or Indicator (per Risk Assessment Framework)

Threshold

or target

YTD

Scoring

Risk

declared at

Annual Plan

Overall Score

Report by

Exception

Paper 03


30

Paper 04

U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Paper_04_RTT_Reporting_Process_Review.docx


NOVEMBER 2015

Executive Responsible Steven Vaughan, Interim Director of Operations








Executive Summary

This paper provides a more detailed summary of the Referral to Treatment performance, provides feedback from the operational reviews which have been carried out over the past month, their implications, outlines remedial actions and next steps.

Subject/Title Referral To Treatment (RTT) Reporting Process Review


For Discussion

For Approval

Received or approved by Board of Directors

Legal Implications

Recommendation The Board of Directors are asked to note the attached report.

Acronyms Included RTT – Referral to Treatment Targets IST - Intensive Support Team PAS – Patient Administration System CCG – Clinical Commissioning Group KPI – Key Performance Indicator SOP – Standard Operating Procedure

Paper 04



NOVEMBER 2015

REFERRAL TO TREATMENT (RTT) REPORTING PROCESS REVIEW

1. Introduction

1.1 The Board of Directors received a report in October which outlined that performance was deteriorating during the month and it was expected the core operational standard (92% open pathways <18weeks) would be missed. In addition, a number of reviews and/or diagnostic exercises into operational processes were taking place. These initial reviews have been completed, the findings have further exacerbated the deteriorating position. This report confirms the outstanding actions from the Deloitte LLP external review have been completed and provides a summary of current performance, findings from the operational reviews and details immediate next steps.

2. Access Policy – Recommendation from external review

2.1 Last month it was reported that the Access Policy development was behind plan, the Board is approving the Access Policy today. There will be a significant education process required to support the implementation, therefore it has been suggested the Board review this policy in 6 months, prior to an annual review cycle. Previously agreed monitoring and reporting is continuing.

3. Operational Review

3.1 As the operational review has taken place over the past month, issues regarding processes supporting application of the Trust’s access policy have been identified. In summary, there were three issues:

High numbers of patients were identified with the same ‘decision to treat’ (the date the consultant and patient agree they need their operation and add them to the waiting list) and ‘RTT clock start’ were identified.

Patients on planned pathways do not have expected treatment dates and some are waiting longer than their expected date. (A planned pathway is where a patient would be expecting to have regular procedures, say on an annual basis)

There is a backlog of follow-up outpatients

3.2 Within the Trust’s open pathways for English patients there were 1286 patients meeting this criteria; it is important to recognise this situation would be correct in some circumstances, such as patients who have been being ‘Actively Monitored’ or are now fit and ready for their second knee replacement. The waiting list has been reviewed and a significant number of errors in the recorded ‘clock starts’, which change the waiting list profile considerably, were found. In summary:

Date Correct

Date Incorrect

Insufficient information to confirm start date

Not RTT pathway patient

Total

885 312 63 26 1286

3.3 The incorrect clock starts are split between a cohort of 199 patients who had been removed/relisted

from the waiting list, mainly as the patients had been unavailable for periods of time or had requested dates in the future and 113, mainly being tertiary referred to the Trust, where the original start date had not been recorded. In addition, the ‘insufficient information’ data related to patients where the inter-provider transfer form/minimum data set information is missing; this missing information is being followed up.

Paper 04


3.4 In addition, a further 45 patients had deferred their treatment and did not have their waiting time recorded in the Patient Administration System.

3.5 With the exception of the ‘insufficient information’ patients, the start dates have all been corrected within the October monthly return.

3.6 Further work is being carried out on the planned and follow-up waiting lists to confirm and validate the position; in context the unvalidated total planned list has 1448 patients on it, 466 English patients either have no date or one in the past. The reported follow-up waiting list has 35413 patients on it in total and 8089 English patients should have had their outpatient appointment prior to the end of October. A formal report will be made to the next Board of Directors meeting.

4. Performance

4.1 The impact on the overall open pathways on the waiting list has been significant. The Total number of English patients waiting has not changed at 6020, however the number of breaches has increased by some 286, in addition an additional 23 patients who have waited longer than 52 weeks are now reported. This is detailed in the chart below.

Open Pathways

(target 92%)

No of Patients >18

weeks

No of Patients >52

weeks

April 86.0% 779

May 89.1% 615

June 92.1% 442

July 92.7% 421

August 92.4% 437

September 92.1% 473 2

October 87.3% 759 25

4.2 The tables below show how the number of patients waiting over 18 weeks has changed and the

split by sub-specialty.

Stage on Pathway September October

New Outpatients 11 25

Diagnostic/Follow up 70 110

Inpatient 356 624

Total Backlog 437 759

New Outpatient

Follow Up/ Diagnostic

Inpatient/ Daycase

Total 52+ weeks

Arthroplasty 3 17 132 152 4

Foot & Ankle 1 19 205 225 14

General Surgery 1 1 2

Gynaecology 1 1

Lower Limb 2 7 51 60

Metabolic Medicine 1 1 2

Neurology 2 1 3

Orthotics 3 3

Paediatric Medicine 1 1

Paediatric Orthopaedics 3 9 13 25

Pain 1 1

Professorial 2 11 13

Rheumatology 1 1

SOOS GPSI 1 1

Spinal Disorders 11 36 68 115 3

Sports Injuries 1 3 25 29 1

Tumour 1 1

Upper Limb 2 11 111 124 3

Total 29 112 618 759 25

Paper 04


4.3 The table below provides information about the Trust’s total waiting list. In overall terms this has

not changed significantly in the month, only the profiles. However, in light of the potential contractual changes, this situation may change in the coming months; the Board will receive information to demonstrate the impact.

English Welsh Total

Milestone 1 - New Outpatient 2998 1916 4914

Milestone 2 - Follow Up/Diagnostic 700 415 1115

Milestone 3 - Inpatient/Daycase 2323 1462 3785

Total 6021 3793 9814

5. Remedial actions

5.1 In respect of the access policy process issues, revised standard operating procedures have been

put in place. In addition the implementation of the revised access policy will re-enforce, provide further clarity and be supported by a training package.

5.2 As this situation has been emerging over recent weeks a multi-agency group have been overseeing outcomes of the reviews and immediate actions. This group meets weekly and consists of the Trust, Shropshire Clinical Commissioning Group, Monitor and NHS England. The initial focus is on managing any clinical risk for these patients; all of the >52 week wait patients are being telephoned by the clinical teams to check whether the delays have given rise to a potential worsening of their condition leading to harm. Lead clinicians from the Trust and Clinical Commissioning Group are reviewing the risk stratification to support prioritisation of further validation and potential treatment.

5.3 The priority is to focus on booking patients with highest potential risk and those waiting longest; in many cases patients have chosen to extend their wait, where dates had been agreed previously these will be honoured, meaning that some 52+ week patients will continue to be reported into the early part of 2016. Current capacity is being assessed both on-site and with other NHS and independent sector organisations. In addition, the bookings team are also reviewing processes and procedures to ensure the longest waiting patients are prioritised within the current available capacity across all aspects of care pathways.

5.4 A review of the whole waiting list of open pathways will need to be competed alongside a clinically prioritised administrative and clinical validation exercise is being put in place and where patients need a clinical review this will be arranged. The clinical review may not require patients to have a formal appointment with the Doctor, for example this could be on the telephone with one of the clinical team. The Trust is in ongoing discussions with Shropshire Clinical Commissioning Group about managing this in line with commissioning arrangements.

5.5 In addition to the internal activities, support will be provided through the NHS’s Elective Care Intensive Support team who will complete their formal review in December providing a report and recommendations to supplement the internal findings within ten working days. These combined findings will provide the basis for the formal operational recovery plan.

5.6 The Trust recognises that patients may have concerns about this and are putting in place arrangements to provide advice.

6. Conclusions and Recommendations

6.1 Despite the progress which has been made implementing recommendations from the Deloitte review, through the iterative nature of these remedial actions and other operational process reviews, further issues have been found. A process to formally manage the implications is being developed and will be overseen by the Business Risk and Investment Committee and reported back to the Board of Directors on an ongoing basis. At present it is not possible to confirm the timing of a full recovery and sustainability plan.

6.2 It is recommended that the Board note the report.

Steven Vaughan Interim Director of Operations

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NOVEMBER 2015

Executive Responsible Richard Clarke, Non Executive Director


Ann Ashworth, Head of Board Governance (Trust Secretary)







Executive Summary

This report highlights the key business undertaken by the Audit Committee at its meeting on 17

th July 2015 and 16

th October 2015.

Subject/Title Report by the Chair of the Audit Committee


For Discussion

For Approval


Legal Implications

Recommendation The Board of Directors are asked to note the Chairman’s Report.


Paper 05



NOVEMBER 2015

AUDIT COMMITTEE MEETING 17TH

JULY 2015 CHAIRMAN’S REPORT

Governance The Committee:

Received an update on Information Governance and Data Quality;

Received a copy of the Finance Governance pack;

Reviewed the section of the corporate risk register assigned to the Audit Committee;

Received a paper on the 2014/15 Trust reference cost submission; and

Reviewed the Whistleblowing Policy in reference to Freedom to Speak Up Report

Internal Audit Matters The Committee:

Noted KPMG’s progress against the 2015/16 internal audit plan

External Audit Matters The Committee:

Noted Deloitte LLP’s progress against the 2015/16 external audit plan Counter Fraud Matters

The Committee:

Received the LCFS progress report Routine Matters

The Committee received reports on:

Registers of Interests and Hospitality. In addition, the Committee reviewed its Work plan for 2015/16. Richard Clarke Non Executive Director

Paper 05



NOVEMBER 2015

AUDIT COMMITTEE MEETING 16TH

OCTOBER 2015 CHAIRMAN’S REPORT

Governance The Committee:

Received an update on Information Governance and Data Quality;

Received a copy of the Finance Governance pack;

Reviewed the section of the corporate risk register assigned to the Audit Committee;

Reviewed and approved updated Audit Terms of Reference;

Reviewed the Whistleblowing Policy in reference to Freedom to Speak Up Report;

Received a report on attendance at Risk Management Committee;

Received and recommended for approval the Policy for Engagement of External Auditors for Non-Audit Work; and

Received and recommended for approval the Standards of Business Conduct and Standards for Board Members

Internal Audit Matters The Committee:

Noted KPMG’s progress against the 2015/16 internal audit plan;

Received the Internal audit report on Orthotics Department Review; and Concluded the Trust had an effective internal audit service following a review of the

effectiveness of the service provided

External Audit Matters

The Committee:

Noted Deloitte LLP’s progress against the 2015/16 external audit plan; and

Concluded the Trust had an effective external audit service following a review of the effectiveness of the service provided

Counter Fraud Matters

The Committee:

Received the LCFS progress report; and

Received and recommended for approval the Anti Fraud, Bribery & Corruption Policy Routine Matters

The Committee received reports on:

Registers of Interests and Hospitality. In addition, the Committee reviewed its Work plan for 2015/16. Richard Clarke Non Executive Director

Paper 06

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1


NOVEMBER 2015

Executive Responsible Alastair Findlay, Non-Executive Director









Executive Summary

This report highlights the key business undertaken by the BRIC at its meeting on 7th July 2015 and 12

th October 2015.

Subject/Title Report from the Chairman of the Business Risk and Investment Committee (BRIC)


For Discussion

For Approval


Legal Implications

Recommendation The Trust Board are asked to note the BRIC Chairman’s Report.


Paper 06


2

Alastair Findlay Non-Executive Director

BOARD OF DIRECTORS

26TH NOVEMBER 2015

BUSINESS RISK AND INVESTMENT COMMITTEE CHAIRMAN’S REPORT OF THE MEETING OF 7TH

JULY 2015

Risk

The Committee reviewed the corporate risks which had been allocated to it, noting one new risk

o BCU being placed under special measures – following discussion this was then merged into the existing risk for financial challenges facing the Local Health Economy.

The reputational risk had been increased which had been triggered by the Monitor investigation.

Business Case Review

The Committee reviewed and made a recommendation to the Board of Directors to approve Option 2a in respect of the Combined Heat & Power business case.

The Committee reviewed and made a recommendation to the Board of Directors to approve an extension on the PAS system for 12 months from July 2016

Governance

The Committee received and noted an update on the progress against the RTT Recovery Plan

Regular Reports The Committee received the following reports:

Estates – Sustainability KPIs where it was noted the progress being made.

The IM&T report, noting progress on the key projects. o Integrated Health Care Records Programme – Digital Case notes – it was noted that

the ‘go-live’ date will be delayed o Electronic Prescribing and Medicine Administration (EPMA) system – it was noted that

the ‘go-live’ date will be delayed

Theatre/Tumour Unit progress update – request made to incorporate Capita/Kier summaries in future.

Capital update was noted

Procurement noted and a meeting will be held across the County of Non Executive Directors


Paper 06


3


BOARD OF DIRECTORS

26TH NOVEMBER 2015

BUSINESS RISK AND INVESTMENT COMMITTEE CHAIRMAN’S REPORT OF THE MEETING OF 12TH

OCTOBER 2015

Risk

The Committee reviewed the corporate risks which had been allocated to it.

The committee proposed that the Future Fit risk should be increased due to a delay statement being issued by Shropshire CCG.

The Committee requested a complete review of the wording on all risks and a change to the presentation of risk registers.

Strategy

The Committee recommended the Board of Director approve the Treasury Management Strategy revision; and

The Committee approved the Performance Management Strategy & Accountability Framework noting that this will need to be reviewed further following the Deloitte report findings.

Business Case Review

The Committee reviewed and made a recommendation to the Board of Directors to approve Option 2a in respect of the Combined Heat & Power business case.

The Committee reviewed and made a recommendation to the Board of Directors to approve an extension on the PAS system for 12 months from July 2016

Governance

The Committee reviewed the Partnership and SLA register – no new partnerships have been identified

The Committee received a presentation and an update on the progress against the RTT Recovery Plan – Board Development session to be arranged and an additional BRIC meeting to be held in November to monitor further progress against the recovery plan.

The Committee noted the change to financial risk rating metrics – 2 additional metrics will now be monitored

Regular Reports The Committee received the following reports:

The IM&T report, noting progress on the key projects. o Integrated Health Care Records Programme – Digital Case notes o Electronic Prescribing and Medicine Administration (EPMA) system

Theatre/Tumour Unit progress update

Capital update was noted

Review of Committee Work Plan


Paper 07

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NOVEMBER 2015

Executive Responsible Hilary Pepler, Non-Executive Director/Chairman of Quality and Safety Committee


Julia Palmer, Governance Manager







Executive Summary

The Quality and Safety Committee met on 16th July 2015 and 1

st

October 2015. A summary of the key issues discussed is given in the Chairman’s reports for the two meetings.

Subject/Title Quality and Safety Committee Chairman’s Report


For Discussion

For Approval


Legal Implications

Recommendation That the Trust Board note the Chairman’s report.

Acronyms Included Detail

PROM Patient Reported Outcome Measures

CQC Care Quality Commission

Paper 07



NOVEMBER 2015

CHAIRMAN’S REPORT FROM THE QUALITY AND SAFETY COMMITTEE MEETING 16TH

JULY 2015 Patient Story

A patient attended the meeting to present her story; she had been on the spinal injuries unit for a period of time after breaking her neck. She outlined how good her care had been and how well the staff had worked as a team. She described the hospital as being like a five-star hotel, where all she had to do was focus on getting better. She was very impressed with the ethos of the whole team.

Risk and Assurance

The Committee noted the Committee risk register.

The Committee received a six-monthly risk management report, which contained no areas of significant concerns

The Committee received the quarterly Health & Safety report

The Committee noted the annual security report which highlighted the work carried out in 2014/15 and reported that the Trust has progressed from amber to green in its self-assessment.

Clinical Effectiveness

The Committee discussed and noted the PROMS report.

The Committee received the annual clinical audit report and noted the progress that has been made on clinical audit.

Human Resources and Health & Safety

The Committee received the Human Resources report which showed work being done on staffing levels and sickness rates

Quality and Safety

The Committee received the quarterly claims report

The Committee noted the updated terms of reference for the Infection Control Committee and received the infection control report for quarter one which was very positive.

The Committee received an update on the wrong side nerve block incident from the Theatres Manager, who was able to answer the committee’s questions about the actions that had been taken, and confirm that a lot of learning had taken place as a result of this incident. The Committee also received a report on an unexpected death reported in March, which was initially reported as an SI but subsequently downgraded.

The Committee approved the following policies: o CQC Policy o Volunteer Policy

The Committee received the annual patient experience report.

The Committee approved the Trust self-assessment against the Monitor Quality Governance Framework

The Committee received a six-monthly update on current quality initiatives and noted the progress.

Paper 07


The Committee noted progress against the Francis recommendations.

The Committee noted that quality impact assessments for the Cost Improvement Plans for 2015/16

The Committee reviewed the most recent CQC intelligent monitoring report; the Trust is currently in the second highest banding.

Routine Matters

The Committee approved the current work plan for 2015/16. Any Other Business

The Committee discussed the forthcoming CQC inspection in October and the preparation work that is being done.

Paper 07


CHAIRMAN’S REPORT FROM THE QUALITY AND SAFETY COMMITTEE MEETING 1ST

OCTOBER 2015 Patient Story

The Committee heard a story from a patient on Alice Ward who had a very good experience on the ward, and felt that it had a good family atmosphere.

Clinical Effectiveness

The Committee received an update from the Infection Prevention & Control Nurse regarding the recent increase in infections and wound breakdowns. It was noted that Public Health England are now looking into this matter at the request of the Director of Nursing & Service Delivery.

The Committee received the PROMS report and noted that Quality Health will be providing a session at a future Board development day.

The Committee received the Clinical Effectiveness Committee terms of reference, as well as the workplan, which has been developed to cover the CQC Key Lines of Enquiry. The membership of the committee is currently under review.

The Committee received the Human Resources report. Quality and Safety

The Committee noted the claims report.

The Committee received a Serious Incident report on a fall that resulted in a fracture, and noted that although the fall was thought to be unavoidable, a number of actions had been put in place following the investigation.

The Committee received a Serious Incident Report on the deterioration, transfer out and subsequent death of a paediatric patient. They noted the actions had been put in place following the investigations and discussed whether an NMC referral was required in relation to the actions of a member of nursing staff.

The Committee received an update on the Freedom to Speak Up Guardian and agreed with the recommendation of the Director of Nursing & Service Delivery that it would be appropriate to wait until the National Officer in place and a clearer steer on the nature of the requirements was available. Contact is to be made with other local Trusts to review different models.

The Committee reviewed the Same Sex Accommodation policy and requested some amendments.

The Committee approved a report on medication errors. Risk and Assurance

The Committee received the WMQRS reports on care of critically ill children and transfers of care; action plans are in place and an update will be provided at the January meeting.

The Committee received reports from KPMG on compliance with CQC requirements and a review of medicines management. There are actions in place from both these reviews

The Committee reviewed the risk register and identified areas where further risk assessments may be required.

The Committee received the risk management report which gave an overview of incidents.

The Committee received the fire and security report. Routine Matters

The Committee noted the current work plan for 2015/16. Any Other Business

The Committee discussed the frequency and format of the meetings and noted that this needed further review. It was agreed that the Medical Director, Director of Nursing & Service Delivery and Associate Director of HR should identify options before the next meeting

Hilary Pepler Non-Executive Director / Chair of the Quality and Safety Committee

Paper 08

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NOVEMBER 2015

Executive Responsible









Executive Summary

The Draft Board Committee timetable for 2016/17 is attached.

Subject/Title 2016-17 Board Committee Timetable


For Discussion

For Approval


Legal Implications

Recommendation That the Board approves the Committee Timetable

Paper 08



NOVEMBER 2015

COMMITTEE TIMETABLE 2016/17

The three Board Committees meet on a quarterly basis. They normally meet in the month following the quarter end, ie April, July, October and January. This is to allow for timely reporting of the previous quarter’s performance and for the committees to review their sections of the corporate risk register in preparation for the Board consideration of the BAF. The timing of the committees within those months is influenced by a number of factors.

The Q&S committee receives a number of quarterly reports and sufficient time most be allowed for their preparation (eg CQIN performance, medical claims, safety thermometer, Infection control). This will be particularly important in April, when full year reports will be due and Easter falls over the first weekend.

There must be sufficient time for feedback on corporate risks to be reflected in the BAF

Consideration of workload on members attending the meetings and staff preparing the papers, given that there will also be a board meeting in those months.

Accommodation of NEDs commitments outside of the Trust where practical.

Avoidance of Audit Reports being considered by the Audit Committee (in summary) prior to them going to the responsible committee (in full)

For the April/May Committees the Audit Committee must be the final committee as it will receive reports from the other committees on their risk management for the year (now done through their annual reports) which feed into the annual risk assurance process.

The final timetable is inevitably a compromise, with not all of the factors noted above being able to be achieved.

RECOMMENDATION

That The Board approves the Committee Timetable

Paper 08


BOARD BUSINESS PROGRAMME 2016/17

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

2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017

FORMAL TRUST BOARD (monthly) 28th 24th 30th 28th - 29th 27th 24th - 26th 23rd 30th

ANNUAL GENERAL MEETING (annual) 28th

Council of Governors meeting dates (quarterly) TBC 24th 28th 24th 23rd

BOARD DEVELOPMENT SESSIONS TBC 28th 29th 26th

Board Strategy Day TBC TBC

Board Committees

Audit Committee - Regular (Friday) 6th 15th 14th 20th

Audit Committee - Extraordinary ( final accounts) 23rd

Quality & Safety - Regular (Thursday) 21st 16th 22nd 17th 19th 16th

Quality & Safety - Extraordinary (quality accounts ) 23rd

BRIC Tuesday 10th 12th 13th 8th 10th 4th

Charitable Funds 28th 27th 26th 30th

Nomination & Remuneration committee as & when required 30th

Paper 09

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NOVEMBER 2015

Executive Responsible Julie Roberts, Acting Director of Nursing








Executive Summary

The Open and Honest Care in your Local Hospital report is a transparent and consistent report in publishing safety, experience and improvement data with the overall aim of improving care, practice and culture within the hospital.

Subject/Title Open and Honest Care in your Local Hospital


For Discussion

For Approval


Legal Implications

Recommendation The Board are asked to approve and ratify the report

Open and Honest Care in your

Local Hospital

Open and Honest Care Report for:

The Robert Jones and Agnes Hunt Orthopaedic Hospital,

NHS Foundation Trust

Figure based on: August, 2015

‘The Open and Honest Care: Driving Improvement Programme aims to support organisations to

become more transparent and consistent in publishing safety, experience and improvement data; with

the overall aim of improving care, practice and culture’

Version number: 1.0

First published: October 2015

Prepared by: Amanda McFie, Quality Outcomes Facilitator

Contents

1 Safety ............................................................................................................................ 4

1.1 Safety Thermometer ............................................................................................... 4 1.2 Health Care Associated Infections (HCIs) ............................................................... 4 1.3 Pressure Ulcers ...................................................................................................... 5 1.4 Falls ........................................................................................................................ 5 1.5 Safe Staffing ........................................................................................................... 5

2 Experience .................................................................................................................... 6

2.1 Patient Experience ........................................................................................... 6 2.1.1 The Friends and Family Test ........................................................................... 6

2.2 A Patient’s Story .............................................................................................. 6 2.3 Staff Experience .............................................................................................. 6

2.3.1 The Friends and Family Test ........................................................................... 7

3 Improvement ................................................................................................................. 7

3.1 Improvement story: we are listening to our patients and making changes ............... 7 3.2 Supporting Information ............................................................................................ 7

1 Safety

1.1 Safety Thermometer

On one day each month we check to see how many of our patients suffered certain types of harm

whilst in our care. We call this the NHS Safety Thermometer. The Safety Thermometer looks at four

harms:

1. Pressure Ulcers

2. Falls

3. Blood Clots

4. Urine Infections (for those patients who have a urinary catheter in place)

This helps us to understand where we need to make improvements. The score below shows the

percentage of patients who did not experience any harm in the reported month.

98.06% of patients did not experience any of the four harms

For more information, including a breakdown by category, please visit:

http://www.safetythermometer.nhs.uk/

1.2 Health Care Associated Infections (HCIs)

HCAIs are infections acquired as a result of healthcare interventions. Clostridium difficile (C.difficile)

and methicillin-resistant staphylococcus aureus (MRSA) bacteraemia are nationally monitored as we

are trying to reduce the incidence of these infections. C.difficile is a type of bacterial infection that can

affect the digestive system, causing diarrhoea, fever and painful abdominal cramps - and sometimes

more serious complications. This bacteria does not normally affect healthy people, but because some

antibiotics remove the 'good bacteria' in the gut that protect against C.difficile, people on these

antibiotics are at greater risk.

The MRSA bacteria are often carried on the skin and inside the nose and throat. It is a particular

problem in hospitals because if it gets into a break in the skin it can cause serious infections and

blood poisoning. It is also more difficult to treat than other bacterial infections as it is resistant to a

number of widely-used antibiotics.

We have a zero tolerance policy to MRSA bacteraemia infections and are working towards reducing

C.difficile infections; part of this process is to set improvement targets. If the number of actual cases is

greater than the target then we have not improved enough.

The table below shows the number of infections we have had this month, plus the improvement target

and results for the year to date.

C.difficile MRSA

This month 0 0

Annual Target (April 15/16) 2 0

Actual to date 0 0

For more information please visit:

www.rjah.nhs.uk/Our-Services/Infection-Prevention-and-Control-at-RJAH.aspx

http://www.safetythermometer.nhs.uk/

http://www.rjah.nhs.uk/Our-Services/Infection-Prevention-and-Control-at-RJAH.aspx

1.3 Pressure Ulcers

Pressure ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They

are sometimes known as bedsores. They can be classified into four grades, with one being the least

severe and four being the most severe. The pressure ulcers reported include all validated

avoidable/unavoidable pressure ulcers that were obtained at any time during a hospital admission that

were not present on initial assessment.

This month 2 grade 2 - pressure ulcers were acquired during hospital stays and 0 grade 3 pressure

ulcer was acquired during hospital stay

1.4 Falls

This measure includes all falls in the hospital that resulted in injury, categorised as moderate, severe

or death, regardless of cause.

This includes avoidable and unavoidable falls sustained at any time during the hospital admission.

This month we reported 2 fall(s) that caused at least 'moderate' harm

Severity Number of falls

Moderate 3

Severe 0

Death 0

1.5 Safe Staffing

Guidelines recently produced by the National Institute for Health & Care Excellence (NICE) make

recommendations that focus on safe nursing for adult wards in acute hospitals and maternity settings.

As part of the guidance we are required to publish monthly reports showing the registered

nurses/midwives and unregistered nurses we have working in each area. The information included in

the report shows the monthly planned staffing hours in comparison with the monthly actual staffing

hours worked on each ward and/or the percentage of shifts meeting the safe staffing guidelines.

In order to view our reports please visit:

www.rjah.nhs.uk/About-Us/Publications/Corporate-Documents/Safe-Staffing-Levels.aspx

Severity Number of pressure ulcers

Grade 2 2

Grade 3 0

Grade 4 0

http://www.rjah.nhs.uk/About-Us/Publications/Corporate-Documents/Safe-Staffing-Levels.aspx

2 Experience

To measure patient and staff experience we use a variety of methods. The idea is simple: if you like

using a certain product or doing business with a particular company you like to share this experience

with others.

2.1 Patient Experience

2.1.1 The Friends and Family Test

The Friends and Family Test (FFT) requires all patients to be asked, at periodic points or following

discharge, ‘How likely are you to recommend our ward/ service/organisation to friends and family if

they needed similar care or treatment?’

This month 99 % of our patients said they would recommend our services. This is based on 1300

responses.

*This result may have changed since publication, for the latest score please visit:

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-

test-data/

We also asked 76 patients the following questions about their care:

% Patient Responses

1. Did you always receive the menu choice you requested

99%

2. Have you felt well cared for by nursing staff during your stay

97%

3. During your stay, have you ever been disturbed by noise at night

38%

4. Have you been kept informed and involved in the decisions about your care as much as you wanted to be, by health care professionals

97%

5. Percentage of call bells answered within 5 minutes 86%

6. Did a doctor spend enough time with you to answer all your questions after your operation

99%

2.2 A Patient’s Story –

Date: 9th October 2015 - Xray Atmosphere very calm organised and efficiently run from the meet and greet at reception and waiting area to the actual x-ray. As a patient I am impressed by the process of the radiographer meeting the patient at reception. This is a very valuable process as it allows the staff to make assessments of patients’ needs and build a trust and understanding of what is going to happen with the first point of contact. Good communication and empathy between staff and patient. Strong appreciation of the patient pathway ensuring that every patient receives the time required to get the best job done. thank you for excellent care

2.3 Staff Experience

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/


2.3.1 The Friends and Family Test

The Friends and Family Test (FFT) requires staff to be asked, at periodic points: How likely are you to

recommend our organisation to friends and family if they needed care or treatment?’ and ‘How likely

are you to recommend our organisation to friends and family as a place to work?’

For April – June 2015, 99% of staff said that they would recommend our organisation to friends and

family if they needed treatment. This is based on 124 responses.

*This result may have changed since publication, for the latest score please visit:

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-

test-data/

We also asked 134 staff the following questions

% Recommended

1. Would you recommend this ward/unit as a place to work?

77%

3 Improvement

3.1 Improvement story: we are listening to our patients and making changes

No patient likes to be kept waiting for an appointment – and their frustration can be increased further when they are kept in the dark as to what is happening. With staff busy and focused on their many other roles, this simple communication is something that can unfortunately fall by the wayside. But that is something the Main Outpatients Department are looking to put right, with a new Standard Operating Procedure (SOP) that commits to improving patient communication on waiting times. The Department have responded to feedback from PALS, complaints patient groups and on comment cards to create the new SOP. Commitments include: • All staff will inform patients/visitors if their appointment is delayed by 20 minutes (or longer) • All staff must inform receptionist of any delay • If appropriate, patients will be informed both visually and verbally when booking in at reception of any delay Apologies will be given by staff, and where possible/appropriate a reason given for the delay Responsibility for enforcing the SOP will lie with all members of staff managed as part of the Main Outpatient Department – whether permanent, temporary or Bank. This includes Health Care Assistants, Registered Nurses, Phlebotomists and Plaster Technicians. Alison Harper, Patient Experience Manager and PALS Lead, said: “This is a simple but effective improvement to the way we do things which has the potential to make a real and positive difference to the experience of our patients. “In our values we commit to providing a caring, professional and friendly service and this certainly fits in with that. With new leadership values having also been launched across the Trust in recent weeks, it is great to see the OPD taking the lead in this way. I hope it is something other departments across the Trust could eventually adopt as well.”

3.2 Supporting Information



Paper 10

U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Paper_10_Revision_to_Trust_Constitution.docx


NOVEMBER 2015

Executive Responsible Acting Chief Executive Officer









Executive Summary

The Constitution has been updated for the 2014 Election rules to enable electronic voting for future elections. Referral to initial Foundation Trust set up has been removed.

Subject/Title Revision to Trust Constitution


For Discussion

For Approval


Legal Implications

Recommendation The Board of Directors are asked to Approve the Trust Constitution

Acronyms Included

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Constitution

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Constitution

-------------------------------- TABLE OF CONTENTS --------------------------------

Core Constitution Paragraph 1. Interpretation and Definitions............................................................................... …….1 2. Name……………………………………………………………………………………… ........... 2 3. Principal Purpose ................................................................................................................ 3 4. Powers ................................................................................................................................ 4 5. Membership and Constituencies ......................................................................................... 5 6. Application for Membership ................................................................................................. 6 7. Public Constituency ............................................................................................................. 7 8. Staff Constituency ............................................................................................................... 8 9. Restriction on Membership ................................................................................................. 9 10. Council of Governors – Composition .................................................................................. 10 11. Council of Governors – Election of Governors .................................................................... 11 12. Council of Governors – Tenure ........................................................................................... 12 13. Council of Governors – Disqualification, Removal and Termination................................... 13 14 Council of Governors – Duties of Governors ...................................................................... 14 14. Council of Governors – Meetings of Governors .................................................................. 15 16. Council of Governors – Standing Orders ............................................................................ 16 17 Council of Governors – Referral to Panel ........................................................................... 17 18 Council of Governors – Conflicts of Interest of Governors ................................................. 18 19. Council of Governors – Travel Expenses ........................................................................... 19 20. Council of Governors – Further Provisions ......................................................................... 20 21. Board of Directors – Composition ....................................................................................... 21 22 Board of Directors –General Duty ....................................................................................... 22 23. Board of Directors – Qualification for Appointment as Non-Executive ............................... 23 24. Board of Directors – Appointment, Re-Appointment and Removal .................................... 24 25. Board of Directors – Appointment of Deputy Chairman ...................................................... 25 26. Board of Directors - Appointment of Senior Independent Director.................................26 27. Board of Directors - Tenure of Non-Executive Directors................................................27 28. Board of Directors – Appointment and Removal of the Chief Executive ............................ 28 29. Board of Directors – Disqualification ................................................................................... 29 30 Board of Directors – Meetings ............................................................................................. 30 31. Board of Directors – Standing Orders ................................................................................. 31 32 Board of Directors – Conflicts of Interest of Directors ......................................................... 32 33. Board of Directors – Remuneration and Terms of Office .................................................... 33 34. Registers ............................................................................................................................. 34 35. Admission to and Removal from the Registers ................................................................... 35 36 Registers – Inspection and Copies ..................................................................................... 36 37. Documents Available for Public Inspection …………………….………………………………37 38 Auditor …………………………………………………………………………..........................38 39. Audit Committee …………………………………………………………………………………..39 40 Accounts …………………………………………………………………………………………...40 41 Annual Report, Forward Plans and Non-NHS Work ........................................................... 41 42 Presentation of the annual accounts and reports to the Governors and Members ............ 42 43. Instruments .......................................................................................................................... 43 44 Amendment of the Constitution ........................................................................................... 43 45. Mergers etc and Significant Transactions ………………………………………………………45

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Annexes

Page

Annex 1 The Public Constituency

20

Annex 2 The Staff Constituency

22

Annex 3 Composition of Council of Governors

23

Annex 4 The Model Election Rules

25

Annex 5 Council of Governors: Additional Provisions

70

Appendix 5A Appointment, Re-Appointment and Removal of Non-Executive Directors (Including Chairman)

77

Appendix 5B Appendix 5C

Appointment and Removal of the External Auditor and other External Auditors Declaration of Eligibility to Service as Governor

77 82

Annex 6 Council of Governors: Standing Orders

83

Annex 7 Board of Directors: Standing Orders

97

Annex 8 Further Provisions

118

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1. Interpretation and Definitions

1.1 Unless otherwise stated, words or expressions contained in this Constitution shall bear the same meaning as in the National Health Service Act 2006 as amended by the Health and Social Care Act 2012 (the 2012 Act).

1.2 Words importing the singular shall import the plural and vice-versa.

1.3 In this Constitution:

2006 Act means the National Health Service Act 2006. 2012 Act is the Health and Social Care Act 2012.

Accounting Officer means the person who from time to time discharges the functions specified in paragraph 25(5) of Schedule 7 to the 2006 Act. For this Trust it shall be the Chief Executive.

Authorisation means the Terms of Authorisation provided by Monitor.

Board of Directors means the Board of Directors as constituted in accordance with the Constitution.

Chairman means the Chairman of the Trust appointed in accordance with the Constitution [to ensure that the Board of Directors and the Council of Governors discharge their respective responsibilities for the Trust as a whole].

Chief Executive means the Chief Executive of the Trust.

Clear Day means a day of the week not including a Saturday, Sunday or Public Holiday.

Constitution means the Constitution of the Trust, comprising this Core Constitution together with the Annexes and Appendices attached thereto as approved by Monitor,

August 2011 updated April 2013, [including any subsequent amendments approved by the Board of Directors and Council of Governors as set out in the 2012 Act]. Core Constitution means paragraphs 1 to 47 of this document prepared in accordance with the Model Core Constitution issued by Monitor in September 2008 updated April 2013.

Council of Governors means the Council of Governors as constituted in accordance with Annex 3 of the Constitution and has the same meaning as "Council of Governors" in the 2006 Act.

Deputy Chairman means one of the Non-Executive Directors of the Trust who is appointed by the Council of Governors to undertake the Chairman’s duties in the event that the Chairman is absent for any reason.

Director means a member of the Board of Directors appointed in accordance with the Constitution and includes both Executive and Non-Executive Directors.

Executive Director means a member of the Board of Directors who holds an executive office of the Trust.

FT Code means the NHS Foundation Trust Code of Governance published by Monitor in September 2006, updated in March 2010, July 2014 and any subsequent updates.

Funds held on trust means those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under

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powers derived under section 14 of Part 2, Schedule 4 of the 2006 Act. Such funds may or may not be charitable.

Governor means a member of the Council of Governors elected or appointed as provided by the Constitution.

Member means a member of the Trust.

Monitor is the body corporate known as Monitor, as provided by Section 61 of the 2012

Act.

Motion means a formal proposition to be discussed and voted on during the course of a meeting.

Nominated Officer means an officer charged with the responsibility for discharging specific tasks within the SOs and SFIs.

Non-Executive Director means a member of the Board of Directors who does not hold an executive office of the Trust.

Officer means an employee or any other person holding a paid appointment or office with the Trust.

Regulatory Framework means the 2006 Act, the Terms of Authorisation granted by Monitor and the Trust's Constitution.

Scheme of Delegation means the Schedule of Matters Reserved to the Board of Directors and the Delegation of Powers, as approved by the Board of Directors and reviewed from time to time.

Secretary means a person appointed by the Trust in accordance with the Constitution to be the Trust Secretary to act independently of the Board of Directors and the Council of Governors, to provide independent professional advice on matters relating to the governance of the Trust and to monitor the Trust’s compliance with the Regulatory Framework.

Significant Transaction means a transaction which relates to;

For UK healthcare: investments, divestments or other transactions comprising > 25% of the assets, income or capital of the NHS foundation Trust.

For non-healthcare related and/or international; investments, divestments or other transactions comprising > 25% of the assets, income or capital of the NHS Trust

or if a Trust is in significant breach, any investment/divestment comprising >10% of the assets, income or capital of the Trust.

SFIs mean the Standing Financial Instructions (including the Tendering and Contract Procedure) as approved by the Board of Directors and reviewed by it from time to time.

SOs means the Standing Orders of the Council of Governors set out in Annex 6 and the Standing Orders of the Board of Directors set out in Annex 7.

Terms of Authorisation means the Terms of authorisation issued by Monitor under Section 35 of the 2006 Act.

Trust means the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust.

Trust Headquarters means the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG.

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2. Name

The name of the foundation Trust is The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (the Trust).

3. Principal Purpose

3.1 The principal purpose of the Trust is the provision of goods and services for the purposes of the health service in England. 3.2 The Trust does not fulfill its principal purpose unless, in each financial year, its

total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.

3.3 The Trust may provide goods and services for any purposes related to:

the provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness, and

the promotion and protection of public health.

3.4 The Trust may also carry on activities other than those mentioned in the above paragraph for the purpose of making additional income available in order better to carry on its principal purpose

4. Powers 4.1 The powers of the Trust are set out in the 2006 Act, subject to any restrictions in the Terms of Authorisation.

4.2 All the powers of the Trust shall be exercised by the Board of Directors on behalf

of the Trust.

4.3 Any of these powers may be delegated to a Committee of Directors or to an Executive Director of the Trust. 5. Membership and Constituencies

The Trust shall have Members, each of whom shall be a member of one of the following constituencies:

5.1 a public constituency; or

5.2 a staff constituency.

6. Application for Membership

An individual who is eligible to become a member of the Trust may do so on application to the Trust.

7. Public Constituency 7.1 An individual who lives in an area specified in Annex 1 as an area for a public constituency may become or continue as a member of the Trust.

7.2 Those individuals who live in an area specified as an area for any public constituency are referred to collectively as the Public Constituency.

7.3 The minimum number of Members in each area for the Public Constituency is specified in Annex 1.

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8. Staff Constituency 8.1 An individual who is employed by the Trust under a contract of employment with the Trust may become or continue as a member of the Trust provided that:

8.1.1 he or she is employed by the Trust under a contract of employment which has no fixed term or has a fixed term of at least 12 months; or

8.1.2 he or she has been continuously employed by the Trust under a contract of employment for at least 12 months.

8.2 An individual who exercises functions for the purposes of the Trust, otherwise than under a contract of employment with the Trust, may become or continue as a member of the staff constituency provided that he or she has exercised these functions continuously for a period of at least 12 months.

8.3 Those individuals who are eligible for membership of the Trust by reason of the previous provisions are referred to collectively as the Staff Constituency.

8.4 The minimum number of Members in the Staff Constituency is specified in Annex 2.

8.5 An individual who is:

8.5.1 eligible to become a member of the Staff Constituency; and

8.5.2 invited by the Trust to become a member of the Staff Constituency shall become a member of the Trust as a member of the Staff Constituency without an application being made, unless he or she informs the Trust that he or she does not wish to do so. 9. Restriction on Membership 9.1 An individual who is a member of a constituency, or of a class within a constituency, may not while membership of that constituency or class continues, be a member of any other constituency or class. 9.2 An individual who satisfies the criteria for membership of the Staff Constituency may not become or continue as a member of any constituency other than the Staff Constituency.

9.3 An individual must be at least 14 years old to become a member of the Trust.

9.4 Further provisions as to the circumstances in which an individual may not become or continue as a member of the Trust are set out in paragraphs 3, 4 and 5 of Annex 8. 10. Council of Governors – Composition 10.1 The Trust is to have a Council of Governors, which shall comprise both elected and appointed Governors.

10.2 The composition of the Council of Governors is specified in Annex 3.

10.3 The Members of the Council of Governors, other than the appointed members, shall be chosen by election by their constituency or, where there are classes within a constituency, by their class within that constituency. The number of Governors to be elected by each constituency, or, where appropriate, by each class of each constituency, is specified in Annex 3.

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11. Council of Governors – Election of Governors 11.1 Elections for elected Members of the Council of Governors shall be conducted in accordance with the Model Election Rules.

11.2 The Model Election Rules as published from time to time by the Department of Health form part of this Constitution. The Model Election Rules current at the date of the Trust’s Authorisation are attached at Annex 4. 11.3 A subsequent variation of the Model Election Rules by the Department of Health shall not constitute a variation of the terms of the Constitution for the purposes of paragraph 48 of the Core Constitution.

11.4 An election, if contested, shall be by secret ballot.

12. Council of Governors - Tenure

12.1 An elected Governor may hold office for a period of up to three years.

12.2 An elected Governor shall cease to hold office if he or she ceases to be a member of the constituency or class by which he or she was elected.

12.3 An elected Governor shall be eligible for re-election at the end of his or her term, but shall not hold office for longer than nine consecutive years or three consecutive terms each of three years.

12.4 An appointed Governor may hold office for a period of up to three years.

12.5 An appointed Governor shall cease to hold office if the appointing organisation withdraws its sponsorship of him or her.

12.6 An appointed Governor shall be eligible for re-appointment at the end of his or her term, but shall not hold office for longer than nine consecutive years or three consecutive terms each of three years.

13. Council of Governors – Disqualification, Removal and Termination 13.1 The following may not become or continue as a member of the Council of Governors:

13.1.1 a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged;

13.1.2 a person who has made a composition or arrangement with, or granted a trust deed for, his or her creditors and has not been discharged in respect of it;

13.1.3 a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him or her.

13.2 Governors must be at least 16 years of age at the date they are nominated for election or appointment.

13.3 Further provisions as to the circumstances in which an individual may not become or continue as a member of the Council of Governors are set out in paragraph 6 of Annex 5.

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14. Council of Governors – Duties of Governors

14.1 The general duties of the Council of Governors are –

14.1.1 to hold the non-Executive Directors individually and collectively to account for the performance of the Board of Directors, and 14.1.2 to represent the interests of the Members of the Trust as a whole and the interests of the public.

14.2 The Trust must take steps to secure that the Governors are equipped with the skills and knowledge they require in their capacity as such. 15. Council of Governors – Meetings of Governors 15.1 The Chairman of the Trust (i.e. the Chairman of the Board of Directors, appointed in accordance with the provisions of paragraph 24.1 or paragraph 25.1 below) or, in his or her absence, the Deputy Chairman appointed in accordance with the provisions of paragraph 27 below), shall preside at meetings of the Council of Governors.

15.2 Meetings of the Council of Governors shall be open to members of the public. Members of the public may be excluded from a meeting for special reasons by resolution of the Council of Governors on the grounds that publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of the business or the proceedings.

15.3 For the purposes of obtaining information about the Trust’s performance of its functions or the Directors’ performance of their duties (and deciding whether to

propose a vote on the Trust’s or Directors’ performance), the Council of Governors may require one or more of the Directors to attend a meeting.

16. Council of Governors – Standing Orders

The Standing Orders of the Council of Governors are attached at Annex 6.

17. Council of Governors – Referral to the Panel

17.1 In this paragraph, the Panel means a panel of persons appointed by Monitor to which a governor of an NHS foundation Trust may refer a question as to whether the Trust has failed or is failing— -

17.1.1 to act in accordance with its Constitution, or

17.1.2 to act in accordance with provision made by or under Chapter 5 of the

2006 Act.

17.2 A governor may refer a question to the Panel only if more than half of the Members of the Council of Governors voting approve the referral. 18. Council of Governors - Conflicts of Interest of Governors 18.1 If a Governor has a pecuniary, personal or family interest, whether that interest is actual or potential and whether that interest is direct or indirect, in any proposed contract or other matter which is under consideration or is to be considered by the Council of Governors, the governor shall disclose that interest to the Members of the Council of Governors as soon as he or she becomes aware of it.

18.2 Further provisions on the disclosure of interests and arrangements for the exclusion of a Governor declaring any interest from any discussion or

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consideration of the matter in respect of which an interest has been disclosed are set out in paragraph 5 of Annex 6. 19. Council of Governors – Travel Expenses

The Trust may pay travelling and other expenses to Members of the Council of Governors at rates determined by the Trust.

20. Council of Governors – Further Provisions

Further provisions with respect to the Council of Governors are set out in Annex 5. 21. Board of Directors – Composition 21.1 The Trust is to have a Board of Directors, which shall comprise both Executive and Non-Executive Directors.

21.2 The Board of Directors is to comprise:

21.2.1 a Non-Executive Chairman;

21.2.2 no fewer than four and no more than six other Non-Executive Directors; and

21.2.3 no fewer than four and no more than six Executive Directors. such that at any time at least half the Board of Directors (excluding the Chairman) shall be Non-Executive Directors.

21.3 One of the Executive Directors shall be the Chief Executive.

21.4 The Chief Executive shall be the Accounting Officer.

21.5 One of the Executive Directors shall be the Finance Director.

21.6 One of the Executive Directors is to be a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984).

21.7 One of the Executive Directors is to be a registered nurse or a registered midwife.

22. Board of Directors – General Duty

The general duty of the Board of Directors and of each Director individually, is to act with a

view to promoting the success of the Trust so as to maximise the benefits for the Members

of the Trust as a whole and for the public.

23. Board of Directors – Qualification for Appointment as a Non-Executive Director

A person may be appointed as a Non-Executive Director only if:

23.1 he or she is a member of the Public Constituency; and

23.2 he or she is not disqualified by virtue of paragraph 31 below or paragraph 3.10 of Annex 7.

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24. Board of Directors – Appointment, Re-Appointment and Removal of Chairman and other Non-Executive Directors

24.1 The Council of Governors at a general meeting of the Council of Governors shall appoint, re-appoint or remove the Chairman of the Trust and the other Non- Executive Directors.

24.2 Removal of the Chairman or another Non-Executive Director shall require the approval of three-quarters of the Members of the Council of Governors. 24.3 Further provisions as to the process to be followed for the appointment, re- appointment and removal of Non-Executive Directors by the Council of Governors are set out in Appendix 5A of Annex 5.

24.4 The initial Chairman and the initial Non-Executive Directors are to be appointed in accordance with paragraph 25 below. 25. Board of Directors – Appointment of Deputy Chairman The Council of Governors at a general meeting of the Council of Governors shall appoint one of the Non-Executive Directors as Deputy Chairman. Further provisions on the appointment and powers of the Deputy Chairman are set out in paragraph 3.6 of Annex 7.

26. Board of Directors - Appointment of Senior Independent Director The Board of Directors shall in consultation with the Council of Governors appoint as Senior Independent Director one of the Non-Executive Directors who is deemed by the Board of Directors to be independent by reference to FT Code Provision B.1.1. Further provisions on the appointment and powers of the Senior Independent Director are set out in paragraph 3.7 of Annex 7.

27. Board of Directors - Tenure of Non-Executive Directors 27.1 A Non-Executive Director (including the Chairman) may hold office for a maximum period of up to three years.

27.2 A Non-Executive Director (including the Chairman) may be eligible for re- appointment at the end of his or her term, but shall not normally hold office for longer than six consecutive years or two consecutive terms each of three years. In accordance with FT Code Provision B.7.1, any term beyond six years (i.e. two consecutive terms each of three years) for a Non-Executive Director should be subject to rigorous review, which should take into account the need for progressive refreshing of the Board of Directors. A Non-Executive Director may, in exceptional circumstances, serve for longer than six years (i.e. two consecutive terms each of three-years), but this must be subject to annual re-appointment by the Council of Governors. 28. Board of Directors - Appointment and Removal of the Chief Executive and Other

Executive Directors 28.1 The Non-Executive Directors shall appoint or remove the Chief Executive.

28.2 The appointment of the Chief Executive shall require the approval of the Council of Governors. 28.3 A committee consisting of the Chairman, the Chief Executive and the other Non- Executive Directors shall appoint or remove the other Executive Directors.

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29. Board of Directors – Disqualification

29.1 The following may not become or continue as a member of the Board of Directors: 29.1.1 a person who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged.

29.1.2 a person who has made a composition or arrangement with, or granted a

Trust deed for, his or her creditors and has not been discharged in respect of it.

29.1.3 a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him or her.

29.2 Further provisions as to the circumstances in which an individual may not become

or continue as a member of the Board of Directors are set out in paragraph 3.10 of Annex 7.

30. Board of Directors – Meetings

30.1 Meetings of the Board of Directors shall be open to members of the public. Members of the public may be excluded from a meeting for special reasons.

30.2 Before holding a meeting, the Board of Directors must send a copy of the agenda of the meeting to the Council of Governors. As soon as practicable after holding a meeting, the Board of Directors must send a copy of the minutes of the meeting to the Council of Governors.

31. Board of Directors – Standing Orders The Standing Orders of the Board of Directors are attached at Annex 7.

32. Board of Directors - Conflicts of Interest of Directors 32.1 The duties that a Director of the Trust has by virtue of being a Director include in particular – 32.1.1 A duty to avoid a situation in which the Director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust. 32.1.2 A duty not to accept a benefit from a third party by reason of being a Director or doing (or not doing) anything in that capacity.

32.3 The duty referred to in sub-paragraph 34.1.1 is not infringed if –

32.2.1 The situation cannot reasonably be regarded as likely to give rise to a conflict of interest, or

32.2.2 The matter has been authorized in accordance with the Constitution.

32.3 The duty referred to in sub-paragraph 32.11 is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.

32.4 In sub-paragraph 34.1.2, “third party” means a person other than –

32.4.1 The Trust, or

32.4.2 A person acting on its behalf.

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32.5 If a Director of the Trust has in any way a direct or indirect interest in a proposed transaction or arrangement with the Trust, the Director must declare the nature and extent of that interest to the other Directors.

32.6 If a declaration under this paragraph proves to be, or becomes, inaccurate, incomplete, a further declaration must be made.

32.7 Any declaration required by this paragraph must be made before the Trust enters into the transaction or arrangement.

32.8 This paragraph does not require a declaration of an interest of which the Director is not aware or where the Director is not aware of the transaction or arrangement

in question.

32.9 A Director need not declare an interest –

32.9.1 If it cannot reasonably be regarded as likely to give rise to a conflict of interest;

32.9.2 If, or to the extent that, the Directors are already aware of it;

32.9.3 If, or to the extent that, it concerns terms of the Director’s appointment that have been or are to be considered –

32.9.3.1 By a meeting of the Board of Directors, or

32.9.3.2 By a committee of the Directors appointed for the purpose under the Constitution.

32.10 Further provisions on the disclosure of interests and arrangements for the exclusion of a Director declaring any interest from any discussion or consideration of the matter in respect of which an interest has been disclosed are set out in paragraph 9 of Annex 7.

33. Board of Directors – Remuneration and Terms of Office

33.1 The Council of Governors at a general meeting of the Council of Governors shall decide the remuneration and allowances, and the other terms and conditions of office, of the Chairman and the other Non-Executive Directors.

33.2 The Trust shall establish a committee of Non-Executive Directors to decide the remuneration and allowances, and the other terms and conditions of office, of the Chief Executive and other Executive Directors. 34. Registers

The Trust shall have:

34.1 a register of Members showing, in respect of each member, the constituency to which he or she belongs and, where there are classes within it, the class to which he or she belongs;

34.2 a register of Members of the Council of Governors;

34.3 a register of interests of Governors;

34.4 a register of Directors; and

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34.5 a register of interests of the Directors.

35. Admission to and Removal from the Registers

35.1 Register of Members

35.1.1 Subject to paragraph 8.5 above, applicants for membership of the Trust must complete and sign an application in the form prescribed by the Secretary.

35.1.2 The Secretary shall maintain the register of Members in two parts:

35.1.1.1 Part 1, which shall be the register referred to in the 2006 Act, shall include the name of each member and the constituency or class to which they belong, and shall be open to inspection by the public in accordance with paragraphs 38 and 39 below; and

35.1.1.2 Part 2, which shall contain all the information from the application form and shall not be open to inspection by the public nor may copies or extracts from it be made available to any third party.

35.1.3 Notwithstanding the provision in paragraph 37.1.1.2 above, the Trust shall extract such information as it needs in aggregate to satisfy itself that the actual membership of the Trust is representative of those eligible for membership and for the administration of the provisions of this Constitution.

35.2 Register of Governors The Register of Governors shall list the names of Governors, their category of membership of the Council of Governors and an address through which they may be contacted, which may be the Secretary.

35.3 Register of Governors’ Interests The Register of Governors’ interests shall contain the names of each governor, whether he or she has declared any interests and, if so, the interests declared in accordance with this Constitution and the Standing Orders of the Council of Governors set out in Annex 6. 35.4 Register of Directors The Register of Directors shall list the names of Directors, their capacity on the Board of Directors and an address through which they may be contacted, which may be the Secretary.

35.5 Register of Directors’ Interests The Register of Directors’ interests shall contain the names of each Director, whether he or she has declared any interests and, if so, the interests declared in accordance with this Constitution and the Standing Orders of the Board of Directors set out in Annex 7.

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36. Registers – Inspection and Copies

36.1 The Trust shall make the registers specified in paragraph 36 above available for inspection by members of the public, except in the circumstances set out below or as otherwise prescribed by regulations.

36.2 The Trust shall not make any part of its registers available for inspection by Members of the public which shows details of any member of the Trust, if the member so requests.

36.3 So far as the registers are required to be made available: 36.3.1 they are to be available for inspection free of charge at all reasonable times; and

36.3.2 a person who requests a copy of or extract from the registers is to be provided with a copy or extract.

36.4 If the person requesting a copy or extract is not a member of the Trust, the Trust may impose a reasonable charge for doing so.

37. Documents Available for Public Inspection

37.1 The Trust shall make the following documents available for inspection by members of the public free of charge at all reasonable times:

37.1.1 a copy of the current Constitution;

37.1.2 a copy of the latest annual accounts and of any report of the auditor on them;

37.13 a copy of the latest annual report;

37.14 a copy of the latest information as to its forward planning;

37.2 The trust shall also make the following documents relating to a special

administration of the Trust available for inspection by members of the public free of charge at all reasonable times:

37.2.1 a copy of any order made under section 65D (appointment of Trust

special administrator), 65J (power to extend time), 65KC (action following Secretary of State’s rejection of final report), 65L (Trusts coming out of administration) or 65LA (Trusts to be dissolved) of the 2006 Act.

37.2.2 a copy of any report laid under section 65D (appointment of Trust special

administrator) of the 2006 Act.

37.2.3 a copy of any information published under section 65D (appointment of

Trust special administrator) of the 2006 Act.

37.2.4 a copy of any draft report published under section 65F (administrator’s

draft report) of the 2006 Act.

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37.2.5 a copy of any statement provided under section 65F (administrator’s draft report) of the 2006 Act.

37.2.6 a copy of any notice published under section 65F (administrator’s draft

report), 65G (consultation plan), 65H (consultation requirements), 65J (power to extend time), 65KA (Monitor’s decision), 65KB (Secretary of State’s response to Monitor’s decision), 65KC (action following Secretary of State’s rejection of final report) or 65KD (Secretary of State’s response to re-submitted final report) of the 2006 Act.

37.2.7 a copy of any statement published or provided under section 65G

(consultation plan) of the 2006 Act.

37.2.8 a copy of any final report published under section 65I (administrator’s final report),

37.2.9 a copy of any statement published under section 65J (power to extend

time) or 65KC (action following Secretary of State’s rejection of final report) of the 2006 Act.

37.2.10 a copy of any information published under section 65M (replacement of

Trust special administrator) of the 2006 Act.

37.3 Any person who requests a copy of or extract from any of the above documents is to be provided with a copy.

37.4 If the person requesting a copy or extract is not a member of the Trust, the Trust

may impose a reasonable charge for doing so. 38. Auditor

38.1 The Trust shall have an auditor.

38.2 The Council of Governors shall appoint or remove the Auditor at a general meeting of the Council of Governors. 39. Audit Committee

The Trust shall establish a committee of Non-Executive Directors as an Audit Committee to perform such monitoring, reviewing and other functions as are appropriate.

40. Accounts

40.1 The Trust must keep proper accounts and proper records in relation to the accounts.

40.2 Monitor may with the approval of the Secretary of State give directions to the Trust

as to the content and form of its accounts.

40.3 The accounts are to be audited by the Trust’s Auditor. 40.4 The Trust shall prepare in respect of each financial year annual accounts in such form as Monitor may with the approval of the of the Secretary of State direct.

40.5 The functions of the Trust with respect to the preparation of the annual accounts shall be delegated to the Accounting Officer.

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41. Annual Report, Forward Plans and Non-NHS Work

41.1 The Trust shall prepare an Annual Report and send it to Monitor.

41.2 The Trust shall give information as to its forward planning in respect of each financial year to Monitor.

41.3 The document containing the information with respect to forward planning (referred to above) shall be prepared by the Directors.

41.4 In preparing the document, the Directors shall have regard to the views of the

Council of Governors.

41.4 Each forward plan must include information about –

41.4.1 the activities other than the provision of goods and services for the purposes of the health service in England that the Trust proposes to carry on, and

41.4.2 the income it expects to receive from doing so.

41.6 Where a forward plan contains a proposal that the Trust carry on an activity of a kind mentioned in sub-paragraph 43.5.1 the Council of Governors must –

41.6.1 determine whether it is satisfied that the carrying on of the activity will not

to any significant extent interfere with the fulfillment by the Trust of its

principal purpose or the performance of its other functions, and

41.6.2 notify the Directors of the Trust and its determination.

41.7 A Trust which proposes to increase by 5% or more the proportion of its total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England may implement the proposal only if more than half of the members of the Council of Governors of the Trust voting approve its implementation. 42. Presentation of the Annual Accounts and Reports to the Governors and Members

42.1 The following documents are to be presented to the Council of Governors at a general meeting of the Council of Governors:

42.1.1 the annual accounts

42.1.2 any report of the auditor on them

42.1.3 the annual report.

42.2 The documents shall also be presented to the Members of the Trust at the Annual Members’ Meeting by at least one member of the Board of Directors in attendance.

42.3 The Trust may combine a meeting of the Council of Governors convened for the purposes of sub-paragraph 44.1 with the Annual Members’ Meeting.

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43 Instruments

43.1 The Trust shall have a seal.

43.2 The seal shall not be affixed except under the authority of the Board of Directors.

43. Amendment of the Constitution

44.1 The Trust may make amendments of its Constitution only if –

44.1.1 More than half of the Members of the Council of Governors of the Trust

voting approve the amendments, and

44.1.2 More than half of the Members of the Board of Directors of the Trust voting approve the amendments.

44.2 Amendments made under paragraph 46.1 take effect as soon as the conditions in that paragraph are satisfied, but the amendment has no effect in so far as the Constitution would, as a result of the amendment, not accord with schedule 7 of the 2006 Act. 44.3 Where an amendment is made to the Constitution in relation the powers or duties of the Council of Governors (or otherwise with respect to the role that the Council of Governors has as part of the Trust) – 44.3.1 At least one member of the Council of Governors must attend the next Annual Members’ Meeting and present the amendment, and 44.3.2 The Trust must give the Members an opportunity to vote on whether they approve the amendment. 44.4 If more than half of the Members voting approve the amendment, the amendment continues to have effect; otherwise, it ceases to have effect and the Trust must take such steps as are necessary as a result. 44.5 Amendments by the Trust of its Constitution are to be notified to Monitor. For the avoidance of doubt, Monitor’s functions do not include a power or duty to determine whether or not the Constitution, as a result of the amendments, accords with Schedule 7 of the 2006 Act.

45 Mergers Etc. and Significant Transactions

45.1 The Trust may only apply for a merger, acquisition, separation or dissolution with

the approval of more than half of the Members of the Council of Governors.

The Trust may enter into a Significant Transaction only if more than half of the Members of the Council of Governors of the Trust voting approve entering into the

transaction. A Significant Transaction means a transaction which relates to;

For UK Healthcare: investments, divestments or other transactions comprising > 25% of the assets, income or capital of the NHS Foundation Trust.

For non-healthcare related and/or international; investments, divestments or other transactions comprising > 25% of the assets, income or capital of the NHS Trust

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or if a Trust is in significant breach, any investment/divestment comprising >10% of the assets, income or capital of the Trust.

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ANNEX 1:

THE PUBLIC CONSTITUENCY

(Paragraph 7)

Areas of the Public Constituency of the Trust

Name of area

Coverage Minimum number of Members

Shropshire (excluding Telford and Wrekin)

The electoral wards within the Shropshire Council area

[50]

(Total population 306,100)

North Wales

The electoral wards within the following areas:

Anglesey County Council

Conwy County Borough Council

Denbighshire County Council

Flintshire County Council

Gwynedd Council

Wrexham County Borough Council

[50]


Cheshire and Merseyside


Cheshire West and Chester Council

Cheshire East Council

Halton Borough Council

Knowsley Metropolitan Borough Council

Liverpool City Council

Sefton Council

St Helens Council

Warrington Borough Council

Wirral Metropolitan Borough Council

[10]

(Total population 2,408,900)

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West Midlands


Birmingham City Council

Coventry City Council

Dudley Metropolitan Borough Council

Sandwell Metropolitan Borough Council

Walsall Metropolitan Borough Council

Wolverhampton City Council

Herefordshire Council

Stoke-on-Trent City Council

Telford & Wrekin Council

Staffordshire County Council

Warwickshire County Council

Worcestershire County Council

[10]

(Total population 3,496,100)

Powys

The electoral wards within Powys County Council

[10]


Rest of England & Wales

All other electoral wards in England and Wales

[10] (Total

population 50,370,454)

Totals

Population

57,408,654

Minimum membership

140

Public Governors

10

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ANNEX 2:

THE STAFF CONSTITUENCY

(Paragraph 8)

There are no classes within the Staff Constituency. The minimum number of Members required in the Staff Constituency is 50.

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ANNEX 3:

COMPOSITION OF THE COUNCIL OF GOVERNORS

(Paragraph 10) 1. Principles

1.1. The composition of the Council of Governors shall, subject to the 2006 Act, seek to ensure that:

1.1.1. the interests of the community served by the Trust are appropriately

representative of the areas in which the Trust operates and the people using the services; and

1.1.2. the level of representation of the Public and Staff Constituencies and

Partnership Organisations provides an appropriate balance having regard to their respective interests in the Trust's affairs.

1.2. To this end, the Council of Governors shall:

1.2.1. maintain a policy for the composition of the Council of Governors which takes into account the Trust's membership strategy, the allocation of elected Governors across the Public and Staff Constituencies and the representation of Partnership Organisations;

1.2.2. from time to time, and not less than every three years, review the

policy for the composition of the Council of Governors; and

1.2.3. when necessary, propose amendments to this Constitution in accordance with paragraph 48 of the Core Constitution.

2. Composition of Council of Governors

2.1. The Council of Governors shall consist of 15 Members, to be composed as follows:

2.1.1 Nine Public Governors;

Shropshire (excluding Telford and Wrekin) – 3 Governors

North Wales – 2 Governors Cheshire and Merseyside – 1 Governor

West Midlands – 1 Governor Powys – 1 Governor Rest of England & Wales – 1 Governor

2.1.2 Three Staff Governors.

2.1.3 Three appointed Governors, comprising:

2.1.3.1 One local authority governor; and

2.1.3.3 Two further Governors appointed by Partnership Organisations as

defined in paragraph 2.3 below.

2.2 The number of Public Governors is to be more than half of the total membership

of the Council of Governors..

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2.3 The organisations specified as Partnership Organisations that may each appoint

one member of the Council of Governors are:

2.3.1 Keele University;

2.3.2 The Robert Jones and Agnes Hunt Orthopaedic Hospital Voluntary Services Committee. 3. Appointed Governors

3.1 Local Authority Governor

Shropshire Council or its successor organisation may appoint one local authority governor by notice in writing signed by the Chairman or Chief Executive of the Council and delivered to the Secretary.

3.2 Other Appointed Governors

3.2.1 Keele University of Keele, Staffordshire ST5 5BG or its successor organisation may appoint one governor by notice in writing signed by the Dean of the Faculty of Heath and delivered to the Secretary. 3.2.2 The Robert Jones and Agnes Hunt Orthopaedic Hospital Voluntary Services Committee or its successor organisation may appoint one governor by notice in writing signed by the Chairman of the Committee and delivered to the Secretary.

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ANNEX 4:

Election Rules

PART 1: INTERPRETATION 1. Interpretation PART 2: TIMETABLE FOR ELECTION 2. Timetable 3. Computation of time PART 3: RETURNING OFFICER 4. Returning officer 5. Staff 6. Expenditure 7. Duty of co-operation PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS 8. Notice of election 9. Nomination of candidates 10. Candidate’s particulars 11. Declaration of interests 12. Declaration of eligibility 13. Signature of candidate 14. Decisions as to validity of nomination forms 15. Publication of statement of nominated candidates 16. Inspection of statement of nominated candidates and nomination forms 17. Withdrawal of candidates 18. Method of election PART 5: CONTESTED ELECTIONS 19. Poll to be taken by ballot 20. The ballot paper 21. The declaration of identity (public and patient constituencies)

Action to be taken before the poll 22. List of eligible voters 23. Notice of poll 24. Issue of voting information by returning officer 25. Ballot paper envelope and covering envelope 26. E-voting systems The poll 27. Eligibility to vote 28. Voting by persons who require assistance 29. Spoilt ballot papers and spoilt text message votes 30. Lost voting information 31. Issue of replacement voting information 32. ID declaration form for replacement ballot papers (public and patient constituencies)

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33 Procedure for remote voting by internet 34. Procedure for remote voting by telephone 35. Procedure for remote voting by text message Procedure for receipt of envelopes, internet votes, telephone vote and text message votes 36. Receipt of voting documents 37. Validity of votes 38. Declaration of identity but no ballot (public and patient constituency) 39. De-duplication of votes 40. Sealing of packets PART 6: COUNTING THE VOTES STV41. Interpretation of Part 6 42. Arrangements for counting of the votes 43. The count STV44. Rejected ballot papers and rejected text voting records FPP44. Rejected ballot papers and rejected text voting records STV45. First stage STV46. The quota STV47 Transfer of votes STV48. Supplementary provisions on transfer STV49. Exclusion of candidates STV50. Filling of last vacancies STV51. Order of election of candidates FPP51. Equality of votes PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS FPP52. Declaration of result for contested elections STV52. Declaration of result for contested elections 53. Declaration of result for uncontested elections PART 8: DISPOSAL OF DOCUMENTS 54. Sealing up of documents relating to the poll 55. Delivery of documents 56. Forwarding of documents received after close of the poll 57. Retention and public inspection of documents 58. Application for inspection of certain documents relating to election

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PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION FPP59. Countermand or abandonment of poll on death of candidate STV59. Countermand or abandonment of poll on death of candidate PART 10: ELECTION EXPENSES AND PUBLICITY Expenses 60. Election expenses 61. Expenses and payments by candidates 62. Expenses incurred by other persons Publicity 63. Publicity about election by the corporation 64. Information about candidates for inclusion with voting information 65. Meaning of “for the purposes of an election” PART 11: QUESTIONING ELECTIONS AND IRREGULARITIES 66. Application to question an election PART 12: MISCELLANEOUS 67. Secrecy 68. Prohibition of disclosure of vote 69. Disqualification 70. Delay in postal service through industrial action or unforeseen event

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PART 1: INTERPRETATION

1. Interpretation 1.1 In these rules, unless the context otherwise requires:

“2006 Act” means the National Health Service Act 2006;

“corporation” means the public benefit corporation subject to this Constitution;

“council of Governors” means the council of Governors of the corporation;

“declaration of identity” has the meaning set out in rule 21.1;

“election” means an election by a constituency, or by a class within a constituency, to fill a vacancy among one or more posts on the council of Governors;

“e-voting” means voting using either the internet, telephone or text message;

“e-voting information” has the meaning set out in rule 24.2;

“ID declaration form” has the meaning set out in Rule 21.1; “internet voting record”

has the meaning set out in rule 26.4(d);

“internet voting system” means such computer hardware and software, data other equipment and services as may be provided by the returning officer for the purpose of enabling voters to cast their votes using the internet;

“lead governor” means the governor nominated by the corporation to fulfil the role described in Appendix B to The NHS Foundation Trust Code of Governance (Monitor, December 2013) or any later version of such code.

“list of eligible voters” means the list referred to in rule 22.1, containing the information in rule 22.2;

“method of polling” means a method of casting a vote in a poll, which may be by post, internet, text message or telephone;

“Monitor” means the corporate body known as Monitor as provided by section 61 of the 2012 Act; “numerical voting code” has the meaning set out in rule 64.2(b)

“polling website” has the meaning set out in rule 26.1;

“postal voting information” has the meaning set out in rule 24.1;

“telephone short code” means a short telephone number used for the purposes of

submitting a vote by text message;

“telephone voting facility” has the meaning set out in rule 26.2;

“telephone voting record” has the meaning set out in rule 26.5 (d);

“text message voting facility” has the meaning set out in rule 26.3;

“text voting record” has the meaning set out in rule 26.6 (d);

“the telephone voting system” means such telephone voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their

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votes by telephone;

“the text message voting system” means such text messaging voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their votes by text message;

“voter ID number” means a unique, randomly generated numeric identifier

allocated to each voter by the Returning Officer for the purpose of e-voting,

“voting information” means postal voting information and/or e-voting information

1.2 Other expressions used in these rules and in Schedule 7 to the NHS Act 2006

have the same meaning in these rules as in that Schedule.

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PART 2: TIMETABLE FOR ELECTIONS

2. Timetable 2.1 The proceedings at an election shall be conducted in accordance with the

following timetable:

Proceeding Time

Publication of notice of election Not later than the fortieth day before the day of the close of the poll.

Final day for delivery of nomination forms to returning officer

Not later than the twenty eighth day before the day of the close of the poll.

Publication of statement of nominated candidates

Not later than the twenty seventh day before the day of the close of the poll.

Final day for delivery of notices of withdrawals by candidates from election

Not later than twenty fifth day before the day of the close of the poll.

Notice of the poll Not later than the fifteenth day before the day of the close of the poll.

Close of the poll By 5.00pm on the final day of the election.

3. Computation of time 3.1 In computing any period of time for the purposes of the timetable:

(a) a Saturday or Sunday;

(b) Christmas day, Good Friday, or a bank holiday, or

(c) a day appointed for public thanksgiving or mourning,

shall be disregarded, and any such day shall not be treated as a day for the purpose of any proceedings up to the completion of the poll, nor shall the returning officer be obliged to proceed with the counting of votes on such a day.

3.2 In this rule, “bank holiday” means a day which is a bank holiday under the Banking

and Financial Dealings Act 1971 in England and Wales.

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PART 3: RETURNING OFFICER

4. Returning Officer 4.1 Subject to rule 69, the returning officer for an election is to be appointed by the

corporation. 4.2 Where two or more elections are to be held concurrently, the same returning

officer may be appointed for all those elections. 5. Staff 5.1 Subject to rule 69, the returning officer may appoint and pay such staff, including

such technical advisers, as he or she considers necessary for the purposes of the election.

6. Expenditure 6.1 The corporation is to pay the returning officer:

(a) any expenses incurred by that officer in the exercise of his or her functions under these rules,

(b) such remuneration and other expenses as the corporation may determine.

7. Duty of co-operation 7.1 The corporation is to co-operate with the returning officer in the exercise of his or

her functions under these rules.

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PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS

8. Notice of election 8.1 The returning officer is to publish a notice of the election stating:

(a) the constituency, or class within a constituency, for which the election is being held,

(b) the number of Members of the council of Governors to be elected from that constituency, or class within that constituency,

(c) the details of any nomination committee that has been established by the corporation,

(d) the address and times at which nomination forms may be obtained;

(e) the address for return of nomination forms (including, where the return of nomination forms in an electronic format will be permitted, the e-mail address for such return) and the date and time by which they must be received by the returning officer,

(f) the date and time by which any notice of withdrawal must be received by the returning officer

(g) the contact details of the returning officer

(h) the date and time of the close of the poll in the event of a contest.

9. Nomination of candidates 9.1 Subject to rule 9.2, each candidate must nominate themselves on a single

nomination form. 9.2 The returning officer:

(a) is to supply any member of the corporation with a nomination form, and

(b) is to prepare a nomination form for signature at the request of any member of the corporation,

but it is not necessary for a nomination to be on a form supplied by the returning officer and a nomination can, subject to rule 13, be in an electronic format.

10. Candidate’s particulars 10.1 The nomination form must state the candidate’s:

(a) full name,

(b) contact address in full (which should be a postal address although an e-mail address may also be provided for the purposes of electronic communication), and

(c) constituency, or class within a constituency, of which the candidate is a member.

11. Declaration of interests 11.1 The nomination form must state:

(a) any financial interest that the candidate has in the corporation, and

(b) whether the candidate is a member of a political party, and if so, which

33

party,

and if the candidate has no such interests, the paper must include a statement to that effect.

12. Declaration of eligibility 12.1 The nomination form must include a declaration made by the candidate:

(a) that he or she is not prevented from being a member of the council of Governors by paragraph 8 of Schedule 7 of the 2006 Act or by any provision of the Constitution; and,

(b) for a member of the public or patient constituency, of the particulars of his or her qualification to vote as a member of that constituency, or class within that constituency, for which the election is being held.

13. Signature of candidate 13.1 The nomination form must be signed and dated by the candidate, in a manner

prescribed by the returning officer, indicating that:

(a) they wish to stand as a candidate,

(b) their declaration of interests as required under rule 11, is true and correct, and

(c) their declaration of eligibility, as required under rule 12, is true and correct.

13.2 Where the return of nomination forms in an electronic format is permitted, the

returning officer shall specify the particular signature formalities (if any) that will need to be complied with by the candidate.

14. Decisions as to the validity of nomination 14.1 Where a nomination form is received by the returning officer in accordance with

these rules, the candidate is deemed to stand for election unless and until the returning officer:

(a) decides that the candidate is not eligible to stand,

(b) decides that the nomination form is invalid,

(c) receives satisfactory proof that the candidate has died, or

(d) receives a written request by the candidate of their withdrawal from candidacy.

14.2 The returning officer is entitled to decide that a nomination form is invalid only on

one of the following grounds:

(a) that the paper is not received on or before the final time and date for return of nomination forms, as specified in the notice of the election,

(b) that the paper does not contain the candidate’s particulars, as required by rule 10;

(c) that the paper does not contain a declaration of the interests of the candidate, as required by rule 11,

(d) that the paper does not include a declaration of eligibility as required by rule 12, or

(e) that the paper is not signed and dated by the candidate, if required by rule

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13.

14.3 The returning officer is to examine each nomination form as soon as is practicable

after he or she has received it, and decide whether the candidate has been validly nominated.

14.4 Where the returning officer decides that a nomination is invalid, the returning

officer must endorse this on the nomination form, stating the reasons for their decision.

14.5 The returning officer is to send notice of the decision as to whether a nomination is

valid or invalid to the candidate at the contact address given in the candidate’s nomination form. If an e-mail address has been given in the candidate’s nomination form (in addition to the candidate’s postal address), the returning officer may send notice of the decision to that address.

15. Publication of statement of candidates

15.1 The returning officer is to prepare and publish a statement showing the candidates who are standing for election.

15.2 The statement must show:

(a) the name, contact address (which shall be the candidate’s postal address),

and constituency or class within a constituency of each candidate standing, and

(b) the declared interests of each candidate standing,

as given in their nomination form.

15.3 The statement must list the candidates standing for election in alphabetical order

by surname.

15.4 The returning officer must send a copy of the statement of candidates and copies of the nomination forms to the corporation as soon as is practicable after publishing the statement.

16. Inspection of statement of nominated candidates and nomination forms

16.1 The corporation is to make the statement of the candidates and the nomination forms supplied by the returning officer under rule 15.4 available for inspection by members of the corporation free of charge at all reasonable times.

16.2 If a member of the corporation requests a copy or extract of the statement of

candidates or their nomination forms, the corporation is to provide that member with the copy or extract free of charge.

17. Withdrawal of candidates

17.1 A candidate may withdraw from election on or before the date and time for withdrawal by candidates, by providing to the returning officer a written notice of withdrawal which is signed by the candidate and attested by a witness.

18. Method of election

18.1 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is greater than the number of Members to be elected to the council of Governors, a poll is to be taken in accordance with Parts

35

5 and 6 of these rules. 18.2 If the number of candidates remaining validly nominated for an election after any

withdrawals under these rules is equal to the number of Members to be elected to the council of Governors, those candidates are to be declared elected in accordance with Part 7 of these rules.

18.3 If the number of candidates remaining validly nominated for an election after any

withdrawals under these rules is less than the number of Members to be elected to be council of Governors, then:

(a) the candidates who remain validly nominated are to be declared elected in

accordance with Part 7 of these rules, and

(b) the returning officer is to order a new election to fill any vacancy which remains unfilled, on a day appointed by him or her in consultation with the corporation.

36

PART 5: CONTESTED ELECTIONS

19. Poll to be taken by ballot 19.1 The votes at the poll must be given by secret ballot. 19.2 The votes are to be counted and the result of the poll determined in accordance

with Part 6 of these rules. 19.3 The corporation may decide that voters within a constituency or class within a

constituency, may, subject to rule 19.4, cast their votes at the poll using such different methods of polling in any combination as the corporation may determine.

19.4 The corporation may decide that voters within a constituency or class within a

constituency for whom an e-mail address is included in the list of eligible voters may only cast their votes at the poll using an e-voting method of polling.

19.5 Before the corporation decides, in accordance with rule 19.3 that one or more e-

voting methods of polling will be made available for the purposes of the poll, the corporation must satisfy itself that:

(a) if internet voting is to be a method of polling, the internet voting system to

be used for the purpose of the election is:

(i) configured in accordance with these rules; and

(ii) will create an accurate internet voting record in respect of any voter

who casts his or her vote using the internet voting system;

(b) if telephone voting to be a method of polling, the telephone voting system

to be used for the purpose of the election is:


(ii) will create an accurate telephone voting record in respect of any

voter who casts his or her vote using the telephone voting system;

(c) if text message voting is to be a method of polling, the text message voting

system to be used for the purpose of the election is:


(ii) will create an accurate text voting record in respect of any voter who

casts his or her vote using the text message voting system.

20. The ballot paper 20.1 The ballot of each voter (other than a voter who casts his or her ballot by an e-

voting method of polling) is to consist of a ballot paper with the persons remaining validly nominated for an election after any withdrawals under these rules, and no others, inserted in the paper.

20.2 Every ballot paper must specify:

(a) the name of the corporation,

(b) the constituency, or class within a constituency, for which the election is being held,

(c) the number of Members of the council of Governors to be elected from that

37

constituency, or class within that constituency,

(d) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates,

(e) instructions on how to vote by all available methods of polling, including the relevant voter’s voter ID number if one or more e-voting methods of polling are available,

(f) if the ballot paper is to be returned by post, the address for its return and the date and time of the close of the poll, and

(g) the contact details of the returning officer.

20.3 Each ballot paper must have a unique identifier. 20.4 Each ballot paper must have features incorporated into it to prevent it from being

reproduced. 21. The declaration of identity (public and patient constituencies) 21.1 The corporation shall require each voter who participates in an election for a public

or patient constituency to make a declaration confirming:

(a) that the voter is the person:

(i) to whom the ballot paper was addressed, and/or

(ii) to whom the voter ID number contained within the e-voting

information was allocated,

(b) that he or she has not marked or returned any other voting information in

the election, and

(c) the particulars of his or her qualification to vote as a member of the

constituency or class within the constituency for which the election is

being held,

(“declaration of identity”)

and the corporation shall make such arrangements as it considers appropriate to facilitate the making and the return of a declaration of identity by each voter, whether by the completion of a paper form (“ID declaration form”) or the use of an electronic method.

21.2 The voter must be required to return his or her declaration of identity with his or

her ballot. 21.3 The voting information shall caution the voter that if the declaration of identity is

not duly returned or is returned without having been made correctly, any vote cast by the voter may be declared invalid.

Action to be taken before the poll 22. List of eligible voters

22.1 The corporation is to provide the returning officer with a list of the Members of the constituency or class within a constituency for which the election is being held who are eligible to vote by virtue of rule 27 as soon as is reasonably practicable after the final date for the delivery of notices of withdrawals by candidates from an election.

38

22.2 The list is to include, for each member:

(a) a postal address; and, (b) the member’s e-mail address, if this has been provided to which his or her voting information may, subject to rule 22.3, be sent.

22.3 The corporation may decide that the e-voting information is to be sent only by e-

mail to those Members in the list of eligible voters for whom an e-mail address is included in that list.

23. Notice of poll 23.1 The returning officer is to publish a notice of the poll stating:

(a) the name of the corporation,

(b) the constituency, or class within a constituency, for which the election is being held,

(c) the number of Members of the council of Governors to be elected from that constituency, or class with that constituency,

(d) the names, contact addresses, and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates,

(e) that the ballot papers for the election are to be issued and returned, if appropriate, by post,

(f) the methods of polling by which votes may be cast at the election by voters in a constituency or class within a constituency, as determined by the corporation in accordance with rule 19.3,

(g) the address for return of the ballot papers,

(h) the uniform resource locator (url) where, if internet voting is a method of polling, the polling website is located;

(i) the telephone number where, if telephone voting is a method of polling, the telephone voting facility is located,

(j) the telephone number or telephone short code where, if text message voting is a method of polling, the text message voting facility is located,

(k) the date and time of the close of the poll,

(l) the address and final dates for applications for replacement voting information, and

(m) the contact details of the returning officer.

24. Issue of voting information by returning officer 24.1 Subject to rule 24.3, as soon as is reasonably practicable on or after the

publication of the notice of the poll, the returning officer is to send the following information by post to each member of the corporation named in the list of eligible voters: (a) a ballot paper and ballot paper envelope,

(b) the ID declaration form (if required),

(c) information about each candidate standing for election, pursuant to rule 61

39

of these rules, and

(d) a covering envelope;

(“postal voting information”).

24.2 Subject to rules 24.3 and 24.4, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by e-mail and/ or by post to each member of the corporation named in the list of eligible voters whom the corporation determines in accordance with rule 19.3 and/ or rule 19.4 may cast his or her vote by an e-voting method of polling: (a) instructions on how to vote and how to make a declaration of identity (if

required),

(b) the voter’s voter ID number,

(c) information about each candidate standing for election, pursuant to rule 64 of these rules, or details of where this information is readily available on the internet or available in such other formats as the Returning Officer thinks appropriate, (d) contact details of the returning officer,

(“e-voting information”).

24.3 The corporation may determine that any member of the corporation shall:

(a) only be sent postal voting information; or

(b) only be sent e-voting information; or

(c) be sent both postal voting information and e-voting information;

for the purposes of the poll.

24.4 If the corporation determines, in accordance with rule 22.3, that the e-voting information is to be sent only by e-mail to those Members in the list of eligible voters for whom an e-mail address is included in that list, then the returning officer shall only send that information by e-mail.

24.5 The voting information is to be sent to the postal address and/ or e-mail address

for each member, as specified in the list of eligible voters. 25. Ballot paper envelope and covering envelope 25.1 The ballot paper envelope must have clear instructions to the voter printed on it,

instructing the voter to seal the ballot paper inside the envelope once the ballot paper has been marked.

25.2 The covering envelope is to have:

(a) the address for return of the ballot paper printed on it, and

(b) pre-paid postage for return to that address.

25.3 There should be clear instructions, either printed on the covering envelope or elsewhere, instructing the voter to seal the following documents inside the covering envelope and return it to the returning officer –

(a) the completed ID declaration form if required, and

(b) the ballot paper envelope, with the ballot paper sealed inside it.

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26. E-voting systems

26.1 If internet voting is a method of polling for the relevant election then the returning officer must provide a website for the purpose of voting over the internet (in these rules referred to as "the polling website").

26.2 If telephone voting is a method of polling for the relevant election then the

returning officer must provide an automated telephone system for the purpose of voting by the use of a touch-tone telephone (in these rules referred to as “the telephone voting facility”).

26.3 If text message voting is a method of polling for the relevant election then the

returning officer must provide an automated text messaging system for the purpose of voting by text message (in these rules referred to as “the text message voting facility”).

26.4 The returning officer shall ensure that the polling website and internet voting

system provided will:

(a) require a voter to:

(i) enter his or her voter ID number; and

(ii) where the election is for a public or patient constituency, make a declaration of identity;

in order to be able to cast his or her vote;

(b) specify:

(i) the name of the corporation,

(ii) the constituency, or class within a constituency, for which the

election is being held,

(iii) the number of Members of the council of Governors to be elected

from that constituency, or class within that constituency,

(iv) the names and other particulars of the candidates standing for

election, with the details and order being the same as in the

statement of nominated candidates,

(v) instructions on how to vote and how to make a declaration of

identity,

(vi) the date and time of the close of the poll, and

(vii) the contact details of the returning officer;

(c) prevent a voter from voting for more candidates than he or she is entitled to

at the election;

(d) create a record ("internet voting record") that is stored in the internet voting system in respect of each vote cast by a voter using the internet that comprises of-

(i) the voter’s voter ID number;

(ii) the voter’s declaration of identity (where required);

(iii) the candidate or candidates for whom the voter has voted; and

(iv) the date and time of the voter’s vote,

(e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; and

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(f) prevent any voter from voting after the close of poll. 26.5 The returning officer shall ensure that the telephone voting facility and telephone

voting system provided will:

(a) require a voter to

(i) enter his or her voter ID number in order to be able to cast his or her

vote; and

(ii) where the election is for a public or patient constituency, make a

declaration of identity;

(b) specify:

(i) the name of the corporation,

(ii) the constituency, or class within a constituency, for which the election

is being held,

(iii) the number of Members of the council of Governors to be elected

from that constituency, or class within that constituency,

(iv) instructions on how to vote and how to make a declaration of identity,

(v) the date and time of the close of the poll, and

(vi) the contact details of the returning officer;

(c) prevent a voter from voting for more candidates than he or she is entitled to

at the election;

(d) create a record ("telephone voting record") that is stored in the telephone voting system in respect of each vote cast by a voter using the telephone that comprises of:



(iii) the candidate or candidates for whom the voter has voted; and

(iv) the date and time of the voter’s vote (e) if the voter’s vote has been duly cast and recorded, provide the voter with

confirmation of this;

(f) prevent any voter from voting after the close of poll. 26.6 The returning officer shall ensure that the text message voting facility and text

messaging voting system provided will:

(a) require a voter to:

(i) provide his or her voter ID number; and

(ii) where the election is for a public or patient constituency, make a

declaration of identity;

in order to be able to cast his or her vote;

(b) prevent a voter from voting for more candidates than he or she is entitled to at the election;

(d) create a record ("text voting record") that is stored in the text messaging voting system in respect of each vote cast by a voter by text message that comprises of:

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(ii) the candidate or candidates for whom the voter has voted; and

(iii) the date and time of the voter’s vote

(e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this;

(f) prevent any voter from voting after the close of poll. The poll 27. Eligibility to vote

27.1 An individual who becomes a member of the corporation on or before the closing date for the receipt of nominations by candidates for the election, is eligible to vote in that election.

28. Voting by persons who require assistance

28.1 The returning officer is to put in place arrangements to enable requests for assistance to vote to be made.

28.2 Where the returning officer receives a request from a voter who requires

assistance to vote, the returning officer is to make such arrangements as he or she considers necessary to enable that voter to vote.

29. Spoilt ballot papers and spoilt text message votes

29.1 If a voter has dealt with his or her ballot paper in such a manner that it cannot be accepted as a ballot paper (referred to as a “spoilt ballot paper”), that voter may apply to the returning officer for a replacement ballot paper.

29.2 On receiving an application, the returning officer is to obtain the details of the

unique identifier on the spoilt ballot paper, if he or she can obtain it. 29.3 The returning officer may not issue a replacement ballot paper for a spoilt ballot

paper unless he or she:

(a) is satisfied as to the voter’s identity; and (b) has ensured that the completed ID declaration form, if required, has not

been returned. 29.4 After issuing a replacement ballot paper for a spoilt ballot paper, the returning

officer shall enter in a list (“the list of spoilt ballot papers”):

(a) the name of the voter, and (b) the details of the unique identifier of the spoilt ballot paper (if that officer was

able to obtain it), and (c) the details of the unique identifier of the replacement ballot paper.

29.5 If a voter has dealt with his or her text message vote in such a manner that it

cannot be accepted as a vote (referred to as a “spoilt text message vote”), that voter may apply to the returning officer for a replacement voter ID number.

29.6 On receiving an application, the returning officer is to obtain the details of the voter

ID number on the spoilt text message vote, if he or she can obtain it.

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29.7 The returning officer may not issue a replacement voter ID number in respect of a

spoilt text message vote unless he or she is satisfied as to the voter’s identity. 29.8 After issuing a replacement voter ID number in respect of a spoilt text message

vote, the returning officer shall enter in a list (“the list of spoilt text message votes”):

(a) the name of the voter, and (b) the details of the voter ID number on the spoilt text message vote (if that

officer was able to obtain it), and (c) the details of the replacement voter ID number issued to the voter.

30. Lost voting information

30.1 Where a voter has not received his or her voting information by the tenth day before the close of the poll, that voter may apply to the returning officer for replacement voting information.

30.2 The returning officer may not issue replacement voting information in respect of lost voting information unless he or she:

(a) is satisfied as to the voter’s identity,

(b) has no reason to doubt that the voter did not receive the original voting information,

(c) has ensured that no declaration of identity, if required, has been returned.

30.3 After issuing replacement voting information in respect of lost voting information, the returning officer shall enter in a list (“the list of lost ballot documents”):

(a) the name of the voter

(b) the details of the unique identifier of the replacement ballot paper, if

applicable, and

(c) the voter ID number of the voter. 31. Issue of replacement voting information

31.1 If a person applies for replacement voting information under rule 29 or 30 and a declaration of identity has already been received by the returning officer in the name of that voter, the returning officer may not issue replacement voting information unless, in addition to the requirements imposed by rule 29.3 or 30.2, he or she is also satisfied that that person has not already voted in the election, notwithstanding the fact that a declaration of identity if required has already been received by the returning officer in the name of that voter.

31.2 After issuing replacement voting information under this rule, the returning officer

shall enter in a list (“the list of tendered voting information”): (a) the name of the voter,

(b) the unique identifier of any replacement ballot paper issued under this rule;

(c) the voter ID number of the voter.

32. ID declaration form for replacement ballot papers (public and patient constituencies)

32.1 In respect of an election for a public or patient constituency an ID declaration form

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must be issued with each replacement ballot paper requiring the voter to make a declaration of identity.

Polling by internet, telephone or text 33. Procedure for remote voting by internet

33.1 To cast his or her vote using the internet, a voter will need to gain access to the polling website by keying in the url of the polling website provided in the voting information.

33.2 When prompted to do so, the voter will need to enter his or her voter ID number.

33.3 If the internet voting system authenticates the voter ID number, the system will

give the voter access to the polling website for the election in which the voter is eligible to vote.

33.4 To cast his or her vote, the voter will need to key in a mark on the screen opposite

the particulars of the candidate or candidates for whom he or she wishes to cast his or her vote.

33.5 The voter will not be able to access the internet voting system for an election once

his or her vote at that election has been cast. 34. Voting procedure for remote voting by telephone

34.1 To cast his or her vote by telephone, the voter will need to gain access to the telephone voting facility by calling the designated telephone number provided in the voter information using a telephone with a touch-tone keypad.

34.2 When prompted to do so, the voter will need to enter his or her voter ID number

using the keypad.

34.3 If the telephone voting facility authenticates the voter ID number, the voter will be prompted to vote in the election.

34.4 When prompted to do so the voter may then cast his or her vote by keying in the

numerical voting code of the candidate or candidates, for whom he or she wishes to vote.

34.5 The voter will not be able to access the telephone voting facility for an election

once his or her vote at that election has been cast. 35. Voting procedure for remote voting by text message

35.1 To cast his or her vote by text message the voter will need to gain access to the text message voting facility by sending a text message to the designated telephone number or telephone short code provided in the voter information.

35.2 The text message sent by the voter must contain his or her voter ID number and

the numerical voting code for the candidate or candidates, for whom he or she wishes to vote.

35.3 The text message sent by the voter will need to be structured in accordance with

the instructions on how to vote contained in the voter information, otherwise the vote will not be cast.

Procedure for receipt of envelopes, internet votes, telephone votes and text message votes 36. Receipt of voting documents

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36.1 Where the returning officer receives:

(a) a covering envelope, or

(b) any other envelope containing an ID declaration form if required, a ballot paper envelope, or a ballot paper,

before the close of the poll, that officer is to open it as soon as is practicable; and rules 37 and 38 are to apply.

36.2 The returning officer may open any covering envelope or any ballot paper

envelope for the purposes of rules 37 and 38, but must make arrangements to ensure that no person obtains or communicates information as to:

(a) the candidate for whom a voter has voted, or

(b) the unique identifier on a ballot paper.

36.3 The returning officer must make arrangements to ensure the safety and security of the ballot papers and other documents.

37. Validity of votes

37.1 A ballot paper shall not be taken to be duly returned unless the returning officer is satisfied that it has been received by the returning officer before the close of the poll, with an ID declaration form if required that has been correctly completed, signed and dated.

37.2 Where the returning officer is satisfied that rule 37.1 has been fulfilled, he or she is

to:

(a) put the ID declaration form if required in a separate packet, and

(b) put the ballot paper aside for counting after the close of the poll.

37.3 Where the returning officer is not satisfied that rule 37.1 has been fulfilled, he or she is to:

(a) mark the ballot paper “disqualified”,

(b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper,

(c) record the unique identifier on the ballot paper in a list of disqualified documents (the “list of disqualified documents”); and

(d) place the document or documents in a separate packet.

37.4 An internet, telephone or text message vote shall not be taken to be duly returned unless the returning officer is satisfied that the internet voting record, telephone voting record or text voting record (as applicable) has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly made.

37.5 Where the returning officer is satisfied that rule 37.4 has been fulfilled, he or she is

to put the internet voting record, telephone voting record or text voting record (as applicable) aside for counting after the close of the poll.

37.6 Where the returning officer is not satisfied that rule 37.4 has been fulfilled, he or

she is to:

(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”,

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(b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents; and

(c) place the document or documents in a separate packet.

38. Declaration of identity but no ballot paper (public and patient constituency)1

38.1 Where the returning officer receives an ID declaration form if required but no ballot

paper, the returning officer is to: (a) mark the ID declaration form “disqualified”,

(b) record the name of the voter in the list of disqualified documents,

indicating that a declaration of identity was received from the voter without

a ballot paper, and

(c) place the ID declaration form in a separate packet.

39. De-duplication of votes

39.1 Where different methods of polling are being used in an election, the returning officer shall examine all votes cast to ascertain if a voter ID number has been used more than once to cast a vote in the election.

39.2 If the returning officer ascertains that a voter ID number has been used more than

once to cast a vote in the election he or she shall:

(a) only accept as duly returned the first vote received that was cast using the relevant voter ID number; and

(b) mark as “disqualified” all other votes that were cast using the relevant voter ID number

39.3 Where a ballot paper is disqualified under this rule the returning officer shall:

(a) mark the ballot paper “disqualified”,

(b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper,

(c) record the unique identifier and the voter ID number on the ballot paper in the list of disqualified documents;

(d) place the document or documents in a separate packet; and

(e) disregard the ballot paper when counting the votes in accordance with these rules.

39.4 Where an internet voting record, telephone voting record or text voting record is

disqualified under this rule the returning officer shall:

(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”,

(b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents;

(c) place the internet voting record, telephone voting record or text voting record (as applicable) in a separate packet, and

(d) disregard the internet voting record, telephone voting record or text voting

1 It should not be possible, technically, to make a declaration of identity electronically without also submitting a vote.

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record (as applicable) when counting the votes in accordance with these rules.

40. Sealing of packets

40.1 As soon as is possible after the close of the poll and after the completion of the procedure under rules 37 and 38, the returning officer is to seal the packets containing:

(a) the disqualified documents, together with the list of disqualified documents

inside it,

(b) the ID declaration forms, if required,

(c) the list of spoilt ballot papers and the list of spoilt text message votes,

(d) the list of lost ballot documents,

(e) the list of eligible voters, and

(f) the list of tendered voting information and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

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PART 6: COUNTING THE VOTES

STV41. Interpretation of Part 6 STV41.1 In Part 6 of these rules:

“ballot document” means a ballot paper, internet voting record, telephone voting record or text voting record.

“continuing candidate” means any candidate not deemed to be elected, and not excluded,

“count” means all the operations involved in counting of the first preferences recorded for candidates, the transfer of the surpluses of elected candidates, and the transfer of the votes of the excluded candidates,

“deemed to be elected” means deemed to be elected for the purposes of counting of votes but without prejudice to the declaration of the result of the poll,

“mark” means a figure, an identifiable written word, or a mark such as “X”,

“non-transferable vote” means a ballot document:

(a) on which no second or subsequent preference is recorded for a continuing

candidate,

or

(b) which is excluded by the returning officer under rule STV49,

“preference” as used in the following contexts has the meaning assigned below:

(a) “first preference” means the figure “1” or any mark or word which clearly

indicates a first (or only) preference,

(b) “next available preference” means a preference which is the second, or as

the case may be, subsequent preference recorded in consecutive order for a continuing candidate (any candidate who is deemed to be elected or is excluded thereby being ignored); and

(c) in this context, a “second preference” is shown by the figure “2” or any

mark or word which clearly indicates a second preference, and a third

preference by the figure “3” or any mark or word which clearly indicates a

third preference, and so on,

“quota” means the number calculated in accordance with rule STV46,

“surplus” means the number of votes by which the total number of votes for any candidate (whether first preference or transferred votes, or a combination of both) exceeds the quota; but references in these rules to the transfer of the surplus means the transfer (at a transfer value) of all transferable ballot documents from the candidate who has the surplus, “stage of the count” means:

(a) the determination of the first preference vote of each candidate, (b) the transfer of a surplus of a candidate deemed to be elected, or (c) the exclusion of one or more candidates at any given time,

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“transferable vote” means a ballot document on which, following a first preference, a second or subsequent preference is recorded in consecutive numerical order for a continuing candidate,

“transferred vote” means a vote derived from a ballot document on which a second or subsequent preference is recorded for the candidate to whom that ballot document has been transferred, and

“transfer value” means the value of a transferred vote calculated in accordance with rules STV47.4 or STV47.7.

42. Arrangements for counting of the votes 42.1 The returning officer is to make arrangements for counting the votes as soon as is

practicable after the close of the poll. 42.2 The returning officer may make arrangements for any votes to be counted using

vote counting software where:

(a) the board of Directors and the council of Governors of the corporation have approved:

(i) the use of such software for the purpose of counting votes in the

relevant election, and

(ii) a policy governing the use of such software, and

(b) the corporation and the returning officer are satisfied that the use of such software will produce an accurate result.

43. The count 43.1 The returning officer is to:

(a) count and record the number of:

(iii) ballot papers that have been returned; and

(iv) the number of internet voting records, telephone voting records

and/or text voting records that have been created, and

(b) count the votes according to the provisions in this Part of the rules and/or the provisions of any policy approved pursuant to rule 42.2(ii) where vote counting software is being used.

43.2 The returning officer, while counting and recording the number of ballot papers,

internet voting records, telephone voting records and/or text voting records and counting the votes, must make arrangements to ensure that no person obtains or communicates information as to the unique identifier on a ballot paper or the voter ID number on an internet voting record, telephone voting record or text voting record.

43.3 The returning officer is to proceed continuously with counting the votes as far as is

practicable. STV44. Rejected ballot papers and rejected text voting records STV44.1 Any ballot paper:

(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced,

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(b) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate,

(c) on which anything is written or marked by which the voter can be identified except the unique identifier, or

(d) which is unmarked or rejected because of uncertainty,

shall be rejected and not counted, but the ballot paper shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.

STV44.2 The returning officer is to endorse the word “rejected” on any ballot paper which

under this rule is not to be counted.

STV44.3 Any text voting record:

(a) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate,

(b) on which anything is written or marked by which the voter can be identified except the unique identifier, or

(c) which is unmarked or rejected because of uncertainty,

shall be rejected and not counted, but the text voting record shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.

STV44.4 The returning officer is to endorse the word “rejected” on any text voting record

which under this rule is not to be counted. STV44.5 The returning officer is to draw up a statement showing the number of ballot

papers rejected by him or her under each of the subparagraphs (a) to (d) of rule STV44.1 and the number of text voting records rejected by him or her under each of the sub-paragraphs (a) to (c) of rule STV44.3.

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FPP44. Rejected ballot papers and rejected text voting records FPP44.1 Any ballot paper:

(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced,

(b) on which votes are given for more candidates than the voter is entitled to vote,

(c) on which anything is written or marked by which the voter can be identified except the unique identifier, or

(d) which is unmarked or rejected because of uncertainty,

shall, subject to rules FPP44.2 and FPP44.3, be rejected and not counted. FPP44.2 Where the voter is entitled to vote for more than one candidate, a ballot paper is

not to be rejected because of uncertainty in respect of any vote where no uncertainty arises, and that vote is to be counted.

FPP44.3 A ballot paper on which a vote is marked:

(a) elsewhere than in the proper place,

(b) otherwise than by means of a clear mark,

(c) by more than one mark,

is not to be rejected for such reason (either wholly or in respect of that vote) if an intention that the vote shall be for one or other of the candidates clearly appears, and the way the paper is marked does not itself identify the voter and it is not shown that he or she can be identified by it.

FPP44.4 The returning officer is to:

(a) endorse the word “rejected” on any ballot paper which under this rule is not to be counted, and

(b) in the case of a ballot paper on which any vote is counted under rules FPP44.2 and FPP 44.3, endorse the words “rejected in part” on the ballot paper and indicate which vote or votes have been counted.

FPP44.5 The returning officer is to draw up a statement showing the number of rejected

ballot papers under the following headings:

(a) does not bear proper features that have been incorporated into the ballot paper,

(b) voting for more candidates than the voter is entitled to,

(c) writing or mark by which voter could be identified, and

(d) unmarked or rejected because of uncertainty,

and, where applicable, each heading must record the number of ballot papers rejected in part.

FPP44.6 Any text voting record: (a) on which votes are given for more candidates than the voter is entitled to

vote,

(b) on which anything is written or marked by which the voter can be identified except the voter ID number, or

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(c) which is unmarked or rejected because of uncertainty,

shall, subject to rules FPP44.7 and FPP44.8, be rejected and not counted. FPP44.7 Where the voter is entitled to vote for more than one candidate, a text voting

record is not to be rejected because of uncertainty in respect of any vote where no uncertainty arises, and that vote is to be counted.

FPP448 A text voting record on which a vote is marked:

(a) otherwise than by means of a clear mark,

(b) by more than one mark,

is not to be rejected for such reason (either wholly or in respect of that vote) if an intention that the vote shall be for one or other of the candidates clearly appears, and the way the text voting record is marked does not itself identify the voter and it is not shown that he or she can be identified by it.


(a) endorse the word “rejected” on any text voting record which under this rule is not to be counted, and

(b) in the case of a text voting record on which any vote is counted under rules FPP44.7 and FPP 44.8, endorse the words “rejected in part” on the text voting record and indicate which vote or votes have been counted.

FPP44.10 The returning officer is to draw up a statement showing the number of rejected text

voting records under the following headings:

(a) voting for more candidates than the voter is entitled to,

(b) writing or mark by which voter could be identified, and

(c) unmarked or rejected because of uncertainty,

and, where applicable, each heading must record the number of text voting records rejected in part.

STV45. First stage STV45.1 The returning officer is to sort the ballot documents into parcels according to the

candidates for whom the first preference votes are given. STV45.2 The returning officer is to then count the number of first preference votes given on

ballot documents for each candidate, and is to record those numbers. STV45.3 The returning officer is to also ascertain and record the number of valid ballot

documents. STV46. The quota STV46.1 The returning officer is to divide the number of valid ballot documents by a number

exceeding by one the number of Members to be elected. STV46.2 The result, increased by one, of the division under rule STV46.1 (any fraction

being disregarded) shall be the number of votes sufficient to secure the election of a candidate (in these rules referred to as “the quota”).

STV46.3 At any stage of the count a candidate whose total votes equals or exceeds the

quota shall be deemed to be elected, except that any election where there is only

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one vacancy a candidate shall not be deemed to be elected until the procedure set out in rules STV47.1 to STV47.3 has been complied with.

STV47. Transfer of votes STV47.1 Where the number of first preference votes for any candidate exceeds the quota,

the returning officer is to sort all the ballot documents on which first preference votes are given for that candidate into sub- parcels so that they are grouped:

(a) according to next available preference given on those ballot documents for

any continuing candidate, or

(b) where no such preference is given, as the sub-parcel of non-transferable votes.

STV47.2 The returning officer is to count the number of ballot documents in each parcel

referred to in rule STV47.1. STV47.3 The returning officer is, in accordance with this rule and rule STV48, to transfer

each sub-parcel of ballot documents referred to in rule STV47.1(a) to the candidate for whom the next available preference is given on those ballot documents.

STV47.4 The vote on each ballot document transferred under rule STV47.3 shall be at a

value (“the transfer value”) which:

(a) reduces the value of each vote transferred so that the total value of all such votes does not exceed the surplus, and

(b) is calculated by dividing the surplus of the candidate from whom the votes are being transferred by the total number of the ballot documents on which those votes are given, the calculation being made to two decimal places (ignoring the remainder if any).

STV47.5 Where at the end of any stage of the count involving the transfer of ballot

documents, the number of votes for any candidate exceeds the quota, the returning officer is to sort the ballot documents in the sub-parcel of transferred votes which was last received by that candidate into separate sub-parcels so that they are grouped:

(a) according to the next available preference given on those ballot documents

for any continuing candidate, or

(b) where no such preference is given, as the sub-parcel of non-transferable votes.

STV47.6 The returning officer is, in accordance with this rule and rule STV48, to transfer

each sub-parcel of ballot documents referred to in rule STV47.5(a) to the candidate for whom the next available preference is given on those ballot documents.

STV47.7 The vote on each ballot document transferred under rule STV47.6 shall be at:

(a) a transfer value calculated as set out in rule STV47.4(b), or

(b) at the value at which that vote was received by the candidate from whom it is now being transferred,

whichever is the less.

STV47.8 Each transfer of a surplus constitutes a stage in the count.

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STV47.9 Subject to rule STV47.10, the returning officer shall proceed to transfer transferable ballot documents until no candidate who is deemed to be elected has a surplus or all the vacancies have been filled.

STV47.10 Transferable ballot documents shall not be liable to be transferred where any

surplus or surpluses which, at a particular stage of the count, have not already been transferred, are:

(a) less than the difference between the total vote then credited to the

continuing candidate with the lowest recorded vote and the vote of the candidate with the next lowest recorded vote, or

(b) less than the difference between the total votes of the two or more continuing candidates, credited at that stage of the count with the lowest recorded total numbers of votes and the candidate next above such candidates.

STV47.11 This rule does not apply at an election where there is only one vacancy. STV48. Supplementary provisions on transfer STV48.1 If, at any stage of the count, two or more candidates have surpluses, the

transferable ballot documents of the candidate with the highest surplus shall be transferred first, and if:

(a) The surpluses determined in respect of two or more candidates are equal,

the transferable ballot documents of the candidate who had the highest recorded vote at the earliest preceding stage at which they had unequal votes shall be transferred first, and

(b) the votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between those candidates by lot, and the transferable ballot documents of the candidate on whom the lot falls shall be transferred first.

STV48.2 The returning officer shall, on each transfer of transferable ballot documents under rule STV47:

(a) record the total value of the votes transferred to each candidate,

(b) add that value to the previous total of votes recorded for each candidate and record the new total,

(c) record as non-transferable votes the difference between the surplus and the total transfer value of the transferred votes and add that difference to the previously recorded total of non-transferable votes, and

(d) compare:

(i) the total number of votes then recorded for all of the candidates, together with the total number of non-transferable votes, with

(ii) the recorded total of valid first preference votes. STV48.3 All ballot documents transferred under rule STV47 or STV49 shall be clearly

marked, either individually or as a sub-parcel, so as to indicate the transfer value recorded at that time to each vote on that ballot document or, as the case may be, all the ballot documents in that sub-parcel.

STV48.4 Where a ballot document is so marked that it is unclear to the returning officer at

any stage of the count under rule STV47 or STV49 for which candidate the next preference is recorded, the returning officer shall treat any vote on that ballot document as a non-transferable vote; and votes on a ballot document shall be so treated where, for example, the names of two or more candidates (whether continuing candidates or not) are so marked that, in the opinion of the returning

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officer, the same order of preference is indicated or the numerical sequence is broken.

STV49. Exclusion of candidates STV49.1 If:

(a) all transferable ballot documents which under the provisions of rule STV47 (including that rule as applied by rule STV49.11) and this rule are required to be transferred, have been transferred, and

(b) subject to rule STV50, one or more vacancies remain to be filled, the returning officer shall exclude from the election at that stage the candidate with the then lowest vote (or, where rule STV49.12 applies, the candidates with the then lowest votes).

STV9.2 The returning officer shall sort all the ballot documents on which first preference

votes are given for the candidate or candidates excluded under rule STV49.1 into two sub-parcels so that they are grouped as:

(a) ballot documents on which a next available preference is given, and

(b) ballot documents on which no such preference is given (thereby including ballot documents on which preferences are given only for candidates who are deemed to be elected or are excluded).

STV49.3 The returning officer shall, in accordance with this rule and rule STV48, transfer each sub-parcel of ballot documents referred to in rule STV49.2 to the candidate for whom the next available preference is given on those ballot documents.

STV49.4 The exclusion of a candidate, or of two or more candidates together, constitutes a

further stage of the count. STV49.5 If, subject to rule STV50, one or more vacancies still remain to be filled, the

returning officer shall then sort the transferable ballot documents, if any, which had been transferred to any candidate excluded under rule STV49.1 into sub- parcels according to their transfer value.

STV49.6 The returning officer shall transfer those ballot documents in the sub-parcel of

transferable ballot documents with the highest transfer value to the continuing candidates in accordance with the next available preferences given on those ballot documents (thereby passing over candidates who are deemed to be elected or are excluded).

STV49.7 The vote on each transferable ballot document transferred under rule STV49.6

shall be at the value at which that vote was received by the candidate excluded under rule STV49.1.

STV9.8 Any ballot documents on which no next available preferences have been

expressed shall be set aside as non-transferable votes. STV49.9 After the returning officer has completed the transfer of the ballot documents in the

sub-parcel of ballot documents with the highest transfer value he or she shall proceed to transfer in the same way the sub-parcel of ballot documents with the next highest value and so on until he has dealt with each sub-parcel of a candidate excluded under rule STV49.1.

STV49.10 The returning officer shall after each stage of the count completed under this rule:

(a) record:

(i) the total value of votes, or

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(ii) the total transfer value of votes transferred to each candidate,

(b) add that total to the previous total of votes recorded for each candidate and record the new total,

(c) record the value of non-transferable votes and add that value to the previous non-transferable votes total, and

(d) compare:

(i) the total number of votes then recorded for each candidate together with the total number of non-transferable votes, with

(ii) the recorded total of valid first preference votes. STV49.11 If after a transfer of votes under any provision of this rule, a candidate has a

surplus, that surplus shall be dealt with in accordance with rules STV47.5 to STV47.10 and rule STV48.

STV49.12 Where the total of the votes of the two or more lowest candidates, together with

any surpluses not transferred, is less than the number of votes credited to the next lowest candidate, the returning officer shall in one operation exclude such two or more candidates.

STV49.13 If when a candidate has to be excluded under this rule, two or more candidates

each have the same number of votes and are lowest:

(a) regard shall be had to the total number of votes credited to those candidates at the earliest stage of the count at which they had an unequal number of votes and the candidate with the lowest number of votes at that stage shall be excluded, and

(b) where the number of votes credited to those candidates was equal at all stages, the returning officer shall decide between the candidates by lot and the candidate on whom the lot falls shall be excluded.

STV50. Filling of last vacancies STV50.1 Where the number of continuing candidates is equal to the number of vacancies

remaining unfilled the continuing candidates shall thereupon be deemed to be elected.

STV50.2 Where only one vacancy remains unfilled and the votes of any one continuing

candidate are equal to or greater than the total of votes credited to other continuing candidates together with any surplus not transferred, the candidate shall thereupon be deemed to be elected.

STV50.3 Where the last vacancies can be filled under this rule, no further transfer of votes

shall be made. STV51. Order of election of candidates STV51.1 The order in which candidates whose votes equal or exceed the quota are

deemed to be elected shall be the order in which their respective surpluses were transferred, or would have been transferred but for rule STV47.10.

STV51.2 A candidate credited with a number of votes equal to, and not greater than, the

quota shall, for the purposes of this rule, be regarded as having had the smallest surplus at the stage of the count at which he obtained the quota.

STV51.3 Where the surpluses of two or more candidates are equal and are not required to

be transferred, regard shall be had to the total number of votes credited to such candidates at the earliest stage of the count at which they had an unequal number

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of votes and the surplus of the candidate who had the greatest number of votes at that stage shall be deemed to be the largest.

STV51.4 Where the number of votes credited to two or more candidates were equal at all

stages of the count, the returning officer shall decide between them by lot and the candidate on whom the lot falls shall be deemed to have been elected first.

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FPP51. Equality of votes FPP51.1 Where, after the counting of votes is completed, an equality of votes is found to

exist between any candidates and the addition of a vote would entitle any of those candidates to be declared elected, the returning officer is to decide between those candidates by a lot, and proceed as if the candidate on whom the lot falls had received an additional vote.

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PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS

FPP52. Declaration of result for contested elections FPP52.1 In a contested election, when the result of the poll has been ascertained, the

returning officer is to:

(a) declare the candidate or candidates whom more votes have been given than for the other candidates, up to the number of vacancies to be filled on the council of Governors from the constituency, or class within a constituency, for which the election is being held to be elected,

(b) give notice of the name of each candidate who he or she has declared elected:

(i) where the election is held under a proposed Constitution pursuant to powers conferred on the [insert name] NHS Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Trust, or

(ii) in any other case, to the chairman of the corporation; and

(c) give public notice of the name of each candidate whom he or she has declared elected.

FPP52.2 The returning officer is to make:

(a) the total number of votes given for each candidate (whether elected or not), and

(b) the number of rejected ballot papers under each of the headings in rule FPP44.5,

(c) the number of rejected text voting records under each of the headings in rule FPP44.10,

available on request.

STV52. Declaration of result for contested elections STV52.1 In a contested election, when the result of the poll has been ascertained, the

returning officer is to:

(a) declare the candidates who are deemed to be elected under Part 6 of these rules as elected,

(b) give notice of the name of each candidate who he or she has declared elected –

(i) where the election is held under a proposed Constitution pursuant to powers conferred on the [insert name] NHS Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Trust, or

(ii) in any other case, to the chairman of the corporation, and

(c) give public notice of the name of each candidate who he or she has declared elected.

STV52.2 The returning officer is to make:

(a) the number of first preference votes for each candidate whether elected or not,

(b) any transfer of votes,

(c) the total number of votes for each candidate at each stage of the count at

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which such transfer took place,

(d) the order in which the successful candidates were elected, and

(e) the number of rejected ballot papers under each of the headings in rule STV44.1,

(f) the number of rejected text voting records under each of the headings in rule STV44.3,

available on request.

53. Declaration of result for uncontested elections

53.1 In an uncontested election, the returning officer is to as soon as is practicable after final day for the delivery of notices of withdrawals by candidates from the election:

(a) declare the candidate or candidates remaining validly nominated to be

elected, (b) give notice of the name of each candidate who he or she has declared

elected to the chairman of the corporation, and (c) give public notice of the name of each candidate who he or she has

declared elected.

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PART 8: DISPOSAL OF DOCUMENTS

54. Sealing up of documents relating to the poll 54.1 On completion of the counting at a contested election, the returning officer is to

seal up the following documents in separate packets:

(a) the counted ballot papers, internet voting records, telephone voting records and text voting records,

(b) the ballot papers and text voting records endorsed with “rejected in part”,

(c) the rejected ballot papers and text voting records, and

(d) the statement of rejected ballot papers and the statement of rejected text voting records,

and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

54.2 The returning officer must not open the sealed packets of:

(a) the disqualified documents, with the list of disqualified documents inside it,

(b) the list of spoilt ballot papers and the list of spoilt text message votes,

(c) the list of lost ballot documents, and

(d) the list of eligible voters, or access the complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 and held in a device suitable for the purpose of storage.

54.3 The returning officer must endorse on each packet a description of:

(a) its contents,

(b) the date of the publication of notice of the election,

(c) the name of the corporation to which the election relates, and

(d) the constituency, or class within a constituency, to which the election relates.

55. Delivery of documents 55.1 Once the documents relating to the poll have been sealed up and endorsed

pursuant to rule 56, the returning officer is to forward them to the chair of the corporation.

56. Forwarding of documents received after close of the poll 56.1 Where:

(a) any voting documents are received by the returning officer after the close of the poll, or

(b) any envelopes addressed to eligible voters are returned as undelivered too late to be resent, or

(c) any applications for replacement voting information are made too late to

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enable new voting information to be issued,

the returning officer is to put them in a separate packet, seal it up, and endorse and forward it to the chairman of the corporation.

57. Retention and public inspection of documents 57.1 The corporation is to retain the documents relating to an election that are

forwarded to the chair by the returning officer under these rules for one year, and then, unless otherwise directed by the board of Directors of the corporation, cause them to be destroyed.

57.2 With the exception of the documents listed in rule 58.1, the documents relating to

an election that are held by the corporation shall be available for inspection by Members of the public at all reasonable times.

57.3 A person may request a copy or extract from the documents relating to an election

that are held by the corporation, and the corporation is to provide it, and may impose a reasonable charge for doing so.

58. Application for inspection of certain documents relating to an election 58.1 The corporation may not allow:

(a) the inspection of, or the opening of any sealed packet containing –

(i) any rejected ballot papers, including ballot papers rejected in part,

(ii) any rejected text voting records, including text voting records

rejected in part,

(iii) any disqualified documents, or the list of disqualified documents,

(iv) any counted ballot papers, internet voting records, telephone

voting records or text voting records, or

(v) the list of eligible voters, or

(b) access to or the inspection of the complete electronic copies of the internet

voting records, telephone voting records and text voting records created in

accordance with rule 26 and held in a device suitable for the purpose of

storage,

by any person without the consent of the board of Directors of the corporation. 58.2 A person may apply to the board of Directors of the corporation to inspect any of

the documents listed in rule 58.1, and the board of Directors of the corporation may only consent to such inspection if it is satisfied that it is necessary for the purpose of questioning an election pursuant to Part 11.

58.3 The board of Directors of the corporation’s consent may be on any terms or

conditions that it thinks necessary, including conditions as to –

(a) persons,

(b) time,

(c) place and mode of inspection,

(d) production or opening,

and the corporation must only make the documents available for inspection in accordance with those terms and conditions.

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58.4 On an application to inspect any of the documents listed in rule 58.1 the board of

Directors of the corporation must:

(a) in giving its consent, and

(b) in making the documents available for inspection ensure that the way in which the vote of any particular member has been given shall not be disclosed, until it has been established –

(i) that his or her vote was given, and

(ii) that Monitor has declared that the vote was invalid.

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PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION

FPP59. Countermand or abandonment of poll on death of candidate FPP59.1 If at a contested election, proof is given to the returning officer’s satisfaction

before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to:

(a) countermand notice of the poll, or, if voting information has been issued,

direct that the poll be abandoned within that constituency or class, and

(b) order a new election, on a date to be appointed by him or her in consultation with the corporation, within the period of 40 days, computed in accordance with rule 3 of these rules, beginning with the day that the poll was countermanded or abandoned.

FPP59.2 Where a new election is ordered under rule FPP59.1, no fresh nomination is

necessary for any candidate who was validly nominated for the election where the poll was countermanded or abandoned but further candidates shall be invited for that constituency or class.

FPP59.3 Where a poll is abandoned under rule FPP59.1(a), rules FPP59.4 to FPP59.7 are

to apply. FPP59.4 The returning officer shall not take any step or further step to open envelopes or

deal with their contents in accordance with rules 38 and 39, and is to make up separate sealed packets in accordance with rule 40.


(a) count and record the number of ballot papers, internet voting records, telephone voting records and text voting records that have been received,

(b) seal up the ballot papers, internet voting records, telephone voting records and text voting records into packets, along with the records of the number of ballot papers, internet voting records, telephone voting records and text voting records and

ensure that complete electronic copies of the internet voting records telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.

FPP59.6 The returning officer is to endorse on each packet a description of:

(a) its contents,

(b) the date of the publication of notice of the election,

(c) the name of the corporation to which the election relates, and

(d) the constituency, or class within a constituency, to which the election relates.

FPP59.7 Once the documents relating to the poll have been sealed up and endorsed

pursuant to rules FPP59.4 to FPP59.6, the returning officer is to deliver them to the chairman of the corporation, and rules 57 and 58 are to apply.

STV59. Countermand or abandonment of poll on death of candidate STV59.1 If, at a contested election, proof is given to the returning officer’s satisfaction

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before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to:

(a) publish a notice stating that the candidate has died, and

(b) proceed with the counting of the votes as if that candidate had been excluded from the count so that –

(i) ballot documents which only have a first preference recorded for the candidate that has died, and no preferences for any other candidates, are not to be counted, and

(ii) ballot documents which have preferences recorded for other candidates are to be counted according to the consecutive order of those preferences, passing over preferences marked for the candidate who has died.

STV59.2 The ballot documents which have preferences recorded for the candidate who has

died are to be sealed with the other counted ballot documents pursuant to rule 54.1(a).

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PART 10: ELECTION EXPENSES AND PUBLICITY

Election expenses 60. Election expenses 60.1 Any expenses incurred, or payments made, for the purposes of an election which

contravene this Part are an electoral irregularity, which may only be questioned in an application made to Monitor under Part 11 of these rules.

61. Expenses and payments by candidates 61.1 A candidate may not incur any expenses or make a payment (of whatever nature)

for the purposes of an election, other than expenses or payments that relate to:

(a) personal expenses,

(b) travelling expenses, and expenses incurred while living away from home, and

(c) expenses for stationery, postage, telephone, internet(or any similar means of communication) and other petty expenses, to a limit of £100.

62. Election expenses incurred by other persons 62.1 No person may:

(a) incur any expenses or make a payment (of whatever nature) for the purposes of a candidate’s election, whether on that candidate’s behalf or otherwise, or

(b) give a candidate or his or her family any money or property (whether as a gift, donation, loan, or otherwise) to meet or contribute to expenses incurred by or on behalf of the candidate for the purposes of an election.

62.2 Nothing in this rule is to prevent the corporation from incurring such expenses,

and making such payments, as it considers necessary pursuant to rules 63 and 64.

Publicity 63. Publicity about election by the corporation 63.1 The corporation may:

(a) compile and distribute such information about the candidates, and

(b) organise and hold such meetings to enable the candidates to speak and respond to questions,

as it considers necessary.

63.2 Any information provided by the corporation about the candidates, including

information compiled by the corporation under rule 64, must be:

(a) objective, balanced and fair,

(b) equivalent in size and content for all candidates,

(c) compiled and distributed in consultation with all of the candidates standing for election, and

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(d) must not seek to promote or procure the election of a specific candidate or candidates, at the expense of the electoral prospects of one or more other candidates.

63.3 Where the corporation proposes to hold a meeting to enable the candidates to

speak, the corporation must ensure that all of the candidates are invited to attend, and in organising and holding such a meeting, the corporation must not seek to promote or procure the election of a specific candidate or candidates at the expense of the electoral prospects of one or more other candidates.

64. Information about candidates for inclusion with voting information 64.1 The corporation must compile information about the candidates standing for

election, to be distributed by the returning officer pursuant to rule 24 of these rules.

64.2 The information must consist of:

(a) a statement submitted by the candidate of no more than 250 words,

(b) if voting by telephone or text message is a method of polling for the

election, the numerical voting code allocated by the returning officer to

each candidate, for the purpose of recording votes using the telephone

voting facility or the text message voting facility (“numerical voting code”),

and

(c) a photograph of the candidate. 65. Meaning of “for the purposes of an election” 65.1 In this Part, the phrase “for the purposes of an election” means with a view to, or

otherwise in connection with, promoting or procuring a candidate’s election, including the prejudicing of another candidate’s electoral prospects; and the phrase “for the purposes of a candidate’s election” is to be construed accordingly.

65.2 The provision by any individual of his or her own services voluntarily, on his or her

own time, and free of charge is not to be considered an expense for the purposes of this Part.

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PART 11: QUESTIONING ELECTIONS AND THE CONSEQUENCE OF IRREGULARITIES

66. Application to question an election 66.1 An application alleging a breach of these rules, including an electoral irregularity

under Part 10, may be made to Monitor for the purpose of seeking a referral to the independent election arbitration panel ( IEAP).

66.2 An application may only be made once the outcome of the election has been

declared by the returning officer. 66.3 An application may only be made to Monitor by:

(a) a person who voted at the election or who claimed to have had the right to

vote, or

(b) a candidate, or a person claiming to have had a right to be elected at the election.

66.4 The application must:

(a) describe the alleged breach of the rules or electoral irregularity, and

(b) be in such a form as the independent panel may require. 66.5 The application must be presented in writing within 21 days of the declaration of

the result of the election. Monitor will refer the application to the independent election arbitration panel appointed by Monitor.

66.6 If the independent election arbitration panel requests further information from the

applicant, then that person must provide it as soon as is reasonably practicable. 66.7 Monitor shall delegate the determination of an application to a person or panel of

persons to be nominated for the purpose. 66.8 The determination by the IEAP shall be binding on and shall be given effect by the

corporation, the applicant and the Members of the constituency (or class within a constituency) including all the candidates for the election to which the application relates.

66.9 The IEAP may prescribe rules of procedure for the determination of an application

including costs.

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PART 12: MISCELLANEOUS

67. Secrecy 67.1 The following persons:

(a) the returning officer,

(b) the returning officer’s staff,

must maintain and aid in maintaining the secrecy of the voting and the counting of the votes, and must not, except for some purpose authorised by law, communicate to any person any information as to:

(i) the name of any member of the corporation who has or has not been given

voting information or who has or has not voted,

(ii) the unique identifier on any ballot paper,

(iii) the voter ID number allocated to any voter,

(iv) the candidate(s) for whom any member has voted. 67.2 No person may obtain or attempt to obtain information as to the candidate(s) for

whom a voter is about to vote or has voted, or communicate such information to any person at any time, including the unique identifier on a ballot paper given to a voter or the voter ID number allocated to a voter.

67.3 The returning officer is to make such arrangements as he or she thinks fit to

ensure that the individuals who are affected by this provision are aware of the duties it imposes.

68. Prohibition of disclosure of vote 68.1 No person who has voted at an election shall, in any legal or other proceedings to

question the election, be required to state for whom he or she has voted. 69. Disqualification 69.1 A person may not be appointed as a returning officer, or as staff of the returning

officer pursuant to these rules, if that person is:

(a) a member of the corporation,

(b) an employee of the corporation,

(c) a Director of the corporation, or

(d) employed by or on behalf of a person who has been nominated for election. 70. Delay in postal service through industrial action or unforeseen event 70.1 If industrial action, or some other unforeseen event, results in a delay in:

(a) the delivery of the documents in rule 24, or

(b) the return of the ballot papers,

the returning officer may extend the time between the publication of the notice of the poll and the close of the poll by such period as he or she considers appropriate.

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ANNEX 5

COUNCIL OF GOVERNORS: ADDITIONAL PROVISIONS

(Paragraphs 13 and 20) 1. Council of Governors – duties of Governors

1.1. The general duties of the Council of Governors are –

1.1.1. to hold the non-Executive Directors individually and collectively to account for the performance of the Board of Directors, and

1.1.2. to represent the interests of the Members of the Trust as a whole and the interests of the public.

2. Role and Responsibilities of the Council of Governors

2.1. The roles and responsibilities of the Council of Governors to be exercised at a general meeting are:

2.1.1. subject to paragraph 28 of the Core Constitution, to appoint, re-appoint

or remove the Chairman and the other Non-Executive Directors in accordance with the processes set out in Appendix 5A to this Annex 5;

2.1.2. to decide the remuneration and allowances, and the other terms and

conditions of office, of the Non-Executive Directors as provided in paragraph 37 of the Core Constitution;

2.1.3. to appoint or remove the Auditor as provided in paragraph 42 of the

Constitution in accordance with the process set out in Appendix 5B to this Annex 5;

2.1.4. to be presented with the annual accounts, any report of the Auditor on

them and the annual report as provided in paragraph 46 of the Core Constitution;

2.1.5. to consider disputes as to membership referred to it pursuant to

paragraph 7 of Annex 8; and 2.1.6. to consider resolutions to remove a governor pursuant to paragraph 17

of the Core Constitution and paragraph 7 below.

2.1.7. approve Significant Transactions being undertaken by the Trust. Approval will require the approval of more than half of the Members of the Council of Governors of the Trust voting.

2.1.8. approve the application for a merger acquisition, separation or dissolution. Approval will require the approval of more than half of the Members of the Council of Governors of the Trust voting.

2.1.9. approve amendments to the Constitution as set out in paragraph 48 of

the core Constitution.

2.1.10. approve a proposal to increase by 5% or more the proportion of the Trusts’ total income in any financial year attributable to activities other than the provision of goods and services for the purposes of health service in England.. Approval will require more than half of the Members

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of the Council of Governors of the Trust voting.

2.1.11. utilise the Panel if the Trust is at significant risk of breaching the regulatory framework in this paragraph, the Panel means a panel of persons appointed by Monitor to which a governor of an NHS foundation Trust may refer a question as to whether the Trust has failed or is failing. 2.1.11.1. to act in accordance with its Constitution, or

2.1.11.2. to act in accordance with provision made by or under Chapter 5 of the 2006 Act.

2.1.12. A governor may refer a question to the Panel only if more than half of the Members of the Council of Governors voting approve the referral.

2.2. The roles and responsibilities of the Council of Governors, to be exercised at a

general meeting or otherwise, are:

2.2.1. to approve (by a majority of the Governors present and voting) an appointment by the Non-Executive Directors of the Chief Executive other than the initial Chief Executive appointed in accordance with paragraph 19 (5) of schedule 7 to the 2006 Act;

2.2.2. to be consulted by the Board of Directors regarding the information to be

given to Monitor as to the Trust’s forward planning in respect of each financial year and to give its views to the Board of Directors for the purposes of the preparation by the Board of Directors of any document containing such information which is to be given to Monitor;

2.2.3. to consider the annual accounts, any report of the Auditor on them and

the annual report as provided in paragraph 46 of the Core Constitution 2.2.4. to respond as appropriate when consulted by the Directors; and

2.2.5. to communicate directly with Monitor, through a nominated lead

governor, if the Trust is at risk of significantly breaching its Terms of its authorisation and concerns cannot be resolved.

2.3. Governors also have the specific role and functions of:

2.3.1. reviewing annually the extent to which the Trust is meeting its objective

of delivering high-quality services; 2.3.2. working with the Board of Directors on such other matters for the benefit

of the Trust as may be agreed between them; 2.3.3. developing membership in accordance with the Trust's membership

strategy; 2.3.4. representing the interests of the Members of the Trust as a whole and

the interests of the public; 2.3.5. holding the Non-Executive Directors individually and collectively to

account for the performance of the Board of Directors; and

2.3.6. take steps to be appropriately equipped with the skills and knowledge to perform the duties required.

2.4. Notwithstanding the provisions of paragraphs 1 and 2 above, the Governors may

exercise other functions at the request of the Board of Directors.

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3. Elected Governors

Public Governors are to be elected by Members of the area of the Public Constituency to which they belong and Staff Governors are to be elected by Members of the Staff Constituency.

4. Tenure of Elected Governors

4.1. An elected governor,:

4.1.1. shall normally hold office for a period of three years commencing immediately after the conclusion of the general meeting of the Council of Governors at which his or her election is announced;

4.1.2. shall be eligible for re-election at the end of his or her first and second

terms of office;

4.1.3. may not hold office for longer than nine consecutive years or three consecutive terms each of three years.

4.2. For the purposes of these provisions concerning the terms of office of elected

Governors, “year” means a period of twelve months commencing immediately after the conclusion of a general meeting of the Council of Governors.

5. Appointed Governors

The Secretary shall agree with each of the Partnership Organisations identified in Annex 3 a process for the appointment of one Governor by each such organisation.

6. Tenure of Appointed Governors

An appointed governor:

6.1. shall normally hold office for a period of up to three years commencing

immediately after the conclusion of the general meeting of the Council of Governors at which his or her appointment is announced;

6.2. shall cease to hold office if the appointing organisation withdraws its appointment

of him or her; 6.3. shall be eligible for re-election at the end of his or her first and second terms of

office; 6.4. may not hold office for longer than nine consecutive years or three consecutive

terms each of three years. 7. Further Provisions as to Disqualification, Termination and Removal

7.1. Disqualification

A person may not become or continue as a governor of the Trust in the circumstances set out in paragraph 17 of the Core Constitution or if:

7.1.1. in the case of an elected governor:

7.1.1.1. he or she is not or ceases to be a member of the

constituency by which he or she was elected; or

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7.1.1.2. he or she fails to sign a declaration in the form set out in

Appendix 5C to this Annex 5 setting out the particulars of his or her qualification to vote as a member of the Trust and confirming that he or she is not prevented from being a member of the Council of Governors;

7.1.2. in the case of an Appointed Governor, the appointing Partnership

Organisation withdraws their appointment of him or her;

7.1.3. he or she is under 16 years of age at the time he or she is nominated for election or appointment;

7.1.4. he or she has failed or refused to sign and deliver to the Secretary a

statement confirming his or her agreement to comply with the Governors' Code of Conduct;

7.1.5. he or she has refused without reasonable cause to undertake any

training which the Trust and/or the Council of Governors requires all Governors to undertake;

7.1.6. he or she is an Executive or Non-Executive Director or the Secretary of

the Trust, or a governor, Non-Executive Director, chairman, chief Executive officer or secretary of another NHS Foundation Trust, or of a body corporate whose business competes with the mandatory services of the Trust as defined in Schedule 2 of the Trust’s Terms of Authorisation;

7.1.7. he or she is a member of a local authority’s Overview and Scrutiny

Committee covering health matters; 7.1.8. he or she is incapable by reason of mental disorder, illness or injury of

managing or administering his or her property and affairs; 7.1.9. he or she has within the preceding two years been dismissed, otherwise

than by reason of redundancy, from any paid employment with a health service body;

7.1.10. he or she is a person whose tenure of office as the Chairman or as a

member or Director of a health service body has been terminated on the grounds that his or her appointment is not in the interests of the NHS, including for non-attendance at meetings or for non-disclosure of a pecuniary interest;

7.1.11. Monitor has exercised its powers to remove him or her as a member of

the Council of Governors of the Trust or has suspended him or her from office or has disqualified him or her from holding office as a governor of the Trust for a specified period or has exercised any of those powers in relation to him or her at any time, whether in relation to the Trust or to any other NHS Foundation Trust;

7.1.12. he or she has had his or her name removed from any list maintained by

any Primary Care Trust pursuant to Parts 4, 5, 6 or 7 of the NHS Act 2006 and/or Regulations made under those Parts and has not subsequently had his or her name included on such a list and in view of the reason or reasons for such removal he or she is not considered by the Chairman to be a fit and proper person to hold the office of governor;

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7.1.13. on the basis of disclosures obtained through an application to the Disclosures and Barring Service, he or she is not considered by the Chairman to be a fit and proper person to hold the office of governor; or

7.1.14. he or she is or has been subject to a Sexual Offences Prevention Order,

a Foreign Travel Order or a Risk of Sexual Harm Order made under the provisions of the Sexual Offences Act 2003.

7.1.15. he or she is the subject of a disqualification order made under the

Company Directors Disqualification Act 1986;

7.2. Duty of Governor to Notify Trust on Becoming Disqualified

7.2.1. Where a person elected or appointed to be a governor becomes disqualified from office under the provisions of paragraph 17 of the Core Constitution or of paragraph 7.1 above, he or she shall notify the Secretary in writing of such disqualification as soon as practicable and in any event within 14 days of becoming aware of those matters which render him or her disqualified. The Secretary shall then remove him or her from the register of Governors.

7.2.2. If it comes to the attention of the Secretary that a governor is disqualified

otherwise than by notification in accordance with paragraph 7.2.1 above (whether at the time of the governor’s election or appointment or subsequently), the Secretary shall immediately declare that the individual in question is disqualified and give notice to him or her in writing to that effect as soon as practicable and in any event within 14 days of the date of the declaration.

7.2.3. In the event of any dispute as to whether a governor is disqualified, the

governor concerned may refer the matter to the dispute resolution procedure set out in paragraph 7 of Annex 8 within 28 days of the date upon which notice in writing is given to the governor.

7.3. Termination of Office

7.3.1. A governor may resign from that office at any time during the term of that

office by giving notice to the Secretary in writing, upon which he or she shall cease to hold office.

7.3.2. A governor shall cease to hold office on his or her death.

7.4. Removal of a Governor from Office

7.4.1. The Chairman shall be authorised to take such action as may be immediately required, including but not limited to exclusion of the governor concerned from Council meetings, so that any allegation made against a governor on the following grounds can be investigated:

7.4.1.1. non-compliance with the Regulatory Framework, the

Governors' Code of Conduct, the Standing Orders of the Council of Governors set out in Annex 6 and/or the Standing Financial Instructions of the Trust; or

7.4.1.2. misconduct detrimental to the Trust; or 7.4.1.3. failure to attend any meeting of the Council of Governors

for a consecutive period of six months or alternatively two consecutive meetings of the Council of Governors unless

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the Council of Governors is satisfied by a two-thirds majority that:

7.4.1.3.1. the absence was due to reasonable

cause; and 7.4.1.3.2. the governor concerned will be able and

intends to start attending meetings of the Council of Governors again within such period as the Council of Governors considers reasonable.

7.4.2. Where any grounds within paragraph 7.4.1 are alleged, it shall be open

to the Council of Governors to decide, by two-thirds majority of those present and voting, to lay a formal charge of non-compliance or misconduct.

7.4.3. The governor in question will be notified in writing of the allegations,

detailing the specific behavior which is considered to be detrimental to the Trust, and inviting and considering his or her response within a defined appropriate and reasonable timescale.

7.4.4. The governor may be invited to address the Council of Governors in

person if the matter cannot be resolved satisfactorily through correspondence.

7.4.5. The Council of Governors, by a two-thirds majority of those present and

voting and a majority of Governors who are Members of the Public Constituency of the Trust, can decide whether to uphold the charge of non-compliance or misconduct detrimental to the Trust.

7.4.6. The Council of Governors can impose such sanctions as shall be

deemed appropriate. Such sanctions may be the issuing of a written warning as to the governor’s future conduct; non-payment of expenses; and/or removal of the governor from office.

7.4.7. Upon disqualification, removal or termination of a governor's office in

accordance with this paragraph 7, the Secretary shall cause his or her name to be removed immediately from the register of Governors.

7.4.8. Any decision of the Council of Governors to terminate a governor’s

tenure of office may be referred by the governor concerned to the dispute resolution procedure under paragraph 7 of Annex 8 within 28 days of the date upon which notice in writing of the Council of Governors' decision made in accordance with this paragraph 7.4 is communicated to the governor concerned.

7.4.9. A governor who resigns under paragraph 7.3.1 above or whose office is

terminated under this paragraph 7.4 shall not be eligible to stand for re-election to the Council of Governors for a period of three years from the date of his or her resignation or removal from office or the date upon which any appeal against his or her removal from office is disposed of whichever is later.

7.4.10. In the event that an elected governor’s seat falls vacant before the end of

the term of office, the provisions as set out at paragraph 9 below shall apply.

8. Suspension from Duties of Staff Governors

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A Staff governor who is suspended from duties for any reason will also be suspended from his or her role as governor for the duration of his or her suspension and may not attend meetings of the Council of Governors in his or her capacity as a governor. Absence from meetings of the Council of Governors during a period of suspension from duties shall not count as failure to attend for the purposes of paragraph 7.4.1.3 above.

9. Vacancies Amongst Governors

9.1. Where a vacancy arises on the Council of Governors for any reason other than expiry of term of office, the following provisions shall apply.

9.2. Where the vacancy arises amongst the appointed Governors, the Secretary shall

request the appointing Partnership Organisation to appoint a replacement. 9.3. Where the vacancy arises amongst the elected Governors, the Council of

Governors shall be at liberty to:

9.3.1. call an election within three months to fill the seat; or

9.3.2. invite the next highest polling candidate for that seat at the most recent election, who is willing to take office, to fill the seat for the unexpired period of the term of office; or

9.3.3. leave the vacancy outstanding until the next scheduled general election

of Governors, provided that the vacancy shall not be for more than nine months.

10. Remuneration of Governors

Governors are not to receive remuneration, provided that this shall not prevent the remuneration of Governors by their employer or the reimbursement in accordance with paragraph 23 of the Core Constitution of travelling and other expenses reasonably incurred by Governors in carrying out their responsibilities as Members of the Council of Governors.

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APPENDIX 5A

APPOINTMENT, RE-APPOINTMENT AND REMOVAL OF

NON-EXECUTIVE DIRECTORS (INCLUDING CHAIRMAN)

(Paragraph 24)

1. Power of Council of Governors

As provided by paragraph 24 of the Constitution, the power to appoint, re-appoint and remove Non-Executive Directors (including the Chairman) shall lie with the Council of Governors.

2. Appointment of Nomination Committee

2.1. The Council of Governors shall appoint an ad hoc Nomination Committee for the purpose of making recommendations to it on each exercise of its powers to appoint and re-appoint the Chairman and other Non-Executive Directors and to remove a Non-Executive Director (including the Chairman).

2.2. The members of a Nomination Committee appointed by the Council of Governors

shall comprise:

2.2.1. two Public Governors; 2.2.2. one Staff governor; 2.2.3. one appointed governor; and 2.2.4. a chairman who shall be:

2.2.4.1. the Chairman of the Trust; or 2.2.4.2. (where the Nomination Committee has been appointed to

make recommendations to the Council of Governors on the exercise of its powers to appoint, re-appoint or remove the Chairman) the Senior Independent Director; or

2.2.4.3. (where the Senior Independent Director has expressed

an interest in applying for the post of Chairman in the event of a vacancy) a Non-Executive Director who has declared that he or she does not intend to apply for appointment as Chairman.

2.3. Each of the members of a Nomination Committee appointed by the Council of

Governors shall have one vote. 2.4. The quorum required for the transaction of business at any meeting of a

Nomination Committee appointed by the Council of Governors shall be three Members, of whom two must be elected Governors.

2.5. A Nomination Committee appointed by the Council of Governors may:

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2.5.1. call upon the advice and support of the Chief Executive, the Secretary and any other Director or officer of the Trust as it sees fit;

2.5.2. invite the Chairman of another NHS Foundation Trust to act as an

independent assessor to advise the Committee as required; and 2.5.3. appoint external search consultants to assist it in identifying suitable

candidates for appointment, subject to the advance agreement of the Board of Directors. Any conflict arising between the Council of Governors and the Board of Directors under this provision shall be determined in accordance with the dispute resolution procedure set out in paragraph 7 of Appendix 8.

3. Re-appointment of Serving Non-Executive Director (including Chairman)

3.1. Not less than six months before the end of the current term of office of a Non-Executive Director (including a Chairman) who has served no more than one term of office as a Non-Executive Director of the Trust and who is willing to continue to serve in that capacity, the Council of Governors shall appoint an ad hoc Nomination Committee composed in accordance with paragraph 3.2 above.

3.2. The responsibilities of the Nomination Committee appointed by the Council of

Governors shall be to:

3.2.1. seek assurance on behalf of the Council of Governors that, following formal performance evaluation, the performance of the non-Executive Director proposed for re-appointment continues to be effective and to demonstrate commitment to the role;

3.2.2. consider whether the re-appointment of the Non-Executive Director

concerned would be in the continuing best interests of the Trust having regard to the qualifications, skills and experience required for the position and to the membership qualification set out in paragraph 27 of the Core Constitution;

3.2.3. report to the Council of Governors on its proceedings in formulating its

recommendations; and 3.2.4. make recommendations to the Council of Governors as to whether:

3.2.4.1. the Non-Executive Director concerned should be re-appointed for a further term of office; or

3.2.4.2. a process of open competition should be initiated for the

appointment of a new Non-Executive Director (including a new Chairman).

3.3. Having considered the recommendations of the Nomination Committee, the

Council of Governors shall, subject to the approval of a simple majority of the Members present and voting at a general meeting of the Council of Governors, either:

3.3.1. re-appoint the Non-Executive Director concerned for a single further term

of office of not more than three years; or 3.3.2. determine to initiate a process of open competition for the appointment

of a new Non-Executive Director (including a new Chairman), in which event the current Non-Executive Director may stand for re-appointment provided that he or she has served no more than one term of office as a Non-Executive Director of the Trust.

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3.4. On completion of the process set out in paragraphs 4.1 - 4.3 above, the

Nomination Committee appointed by the Council of Governors shall be dissolved and a fresh Nomination Committee shall be appointed as and when the need arises.

4. Appointment of New Non-Executive Director (including new Chairman)

4.1. On a determination by the Council of Governors to initiate a process of open competition for the appointment of a new Non-Executive Director or a new Chairman, the Council of Governors shall appoint an ad hoc Nomination Committee composed in accordance with paragraph 3.2 above.



4.2.1. prepare a job description and person specification for the appointment of a new Non-Executive Director or a new Chairman, having regard to the views of the Board of Directors on the qualifications, skills and experience required for the position and to the membership qualification set out in paragraph 27of the Core Constitution;

4.2.2. arrange for the post to be advertised in local, regional and national

media as appropriate and agree with the Board of Directors any use to be made of external search consultants;

4.2.3. agree selection criteria and apply them in shortlisting and conducting

formal interviews with candidates;

4.2.4. report to the Council of Governors on its proceedings in formulating its recommendations; and

4.2.5. recommend to the Council of Governors no fewer than three and no

more than five candidates whom it considers suitable for appointment to the vacant post or posts.

4.3. Having considered the recommendations of the Nomination Committee, the

Council of Governors shall, subject to the approval of a simple majority of the Members present and voting at a general meeting of the Council of Governors, either appoint an new Non-Executive Director or a new Chairman from amongst the candidates recommended by the Nomination Committee or shall invite the Nomination Committee to make an alternative recommendation.

4.4. On completion of the appointment process set out in paragraphs 5.1 - 5.3 above,

the Nomination Committee appointed by the Council of Governors shall be dissolved and a fresh Nomination Committee shall be appointed as and when the need arises.

5. Removal of Non-Executive Director (including Chairman)

5.1. In accordance with paragraph 4.6.2 of Annex 6, a governor wishing to propose a formal motion for the removal of a Non-Executive Director (including the Chairman) for consideration by the Council of Governors must make a request in writing to the Chairman at least 10 Clear Days (as defined in Annex 6) before the meeting of the Council of Governors at which he or she wishes the matter to be considered. The request should be accompanied by a written statement of the reasons for the proposal to remove the Non-Executive Director concerned and should state whether the business is proposed to be transacted in private.

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5.2. On receipt of a formal motion in accordance with paragraph 6.1 above for the removal of a Non-Executive Director, the Council of Governors shall appoint an ad hoc Nomination Committee composed in accordance with paragraph 3 above.



5.3.1. consider the written statement of the reasons for the proposal to remove the Non-Executive Director and request from the proposer of the motion such further information or clarification as the Nomination Committee sees fit;

5.3.2. notify the Non-Executive Director concerned of the reasons given for the

proposed removal, including any specific allegations, and invite his or her written response within a defined and reasonable timescale;

5.3.3. consider the response received from the Non-Executive Director whose

removal has been proposed and request from the Non-Executive Director concerned such further information or clarification as the Nomination Committee sees fit;

5.3.4. take into account the annual appraisal carried out by the Chairman (in

the case of a Non-Executive Director) or the Senior Independent Director (in the case of the Chairman);

5.3.5. report to the Council of Governors on its proceedings in formulating its

recommendations; and 5.3.6. make recommendations to the Council of Governors as to whether the

formal motion for the removal of a Non-Executive Director should be approved or rejected.

5.4. The Council of Governors shall consider the recommendations of the Nomination

Committee and shall, subject to the approval of three-quarters of the Members of the Council of Governors, determine whether the Non-Executive Director concerned should be removed in accordance with the original motion.

5.5. If the motion to remove the Non-Executive Director is rejected by the Members of

the Council of Governors, no further proposal can be put forward to remove the same Non-Executive Director based upon the same reasons within twelve months of the meeting.

5.6. If the motion to remove the Non-Executive Director is carried, the Non-Executive

Director concerned shall cease to be a member of the Board of Directors and the Secretary shall his or her name to be removed immediately from the register of Directors.

5.7. Any decision of the Council of Governors to remove a Director may be referred by

the Director concerned to the dispute resolution procedure under paragraph 7 of Annex 8 within 28 days of the date upon which notice in writing of the Council of Governors' decision is communicated to the Director.

5.8. On completion of the process set out in paragraphs 6.2 - 6.4 above, the

Nomination Committee appointed by the Council of Governors shall be dissolved and a fresh Nomination Committee shall be appointed as and when the need arises.

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APPENDIX 5B:

APPOINTMENT AND REMOVAL OF THE EXTERNAL AUDITOR AND OTHER EXTERNAL AUDITORS

(Paragraph 40)

1. Process for Appointment of the External Auditor and Other External Auditor

The Audit Committee shall nominate the External Auditor to be appointed by the Council of Governors and may also resolve that an external auditor other than the External Auditor be appointed to review and publish a report on any other aspect of the Trust’s performance. Any such external auditor is to be appointed by the Council of Governors.

2. Qualification for Appointment as the External Auditor and Other External Auditor

2.1 A person may only be appointed as the auditor if he or she (or in the case of a firm each of its Members) is a member of one or more of the bodies referred to in paragraph 23 (4) of Schedule 7 to the 2006 Act.

2.2 The External Auditor is to carry out his or her duties in accordance with Schedule 10 to the 2006 Act and in accordance with any directions given by Monitor on standards, procedures and techniques to be adopted. 3. Process for the Removal of the External Auditor

The Audit Committee shall investigate the reasons surrounding the proposed removal of the Auditors, including, where appropriate, any allegations made against the Auditor. The Audit Committee will report the findings of these investigations to the Council of Governors and, if supported by the conclusions of the report, recommend the removal of the Auditor.

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APPENDIX 5C:

DECLARATION OF ELIGIBILITY TO SERVE AS GOVERNOR

To: The Secretary Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust Oswestry Shropshire SY10 7AG I name...................................................................................................................... hereby declare that I am a member of the

Public Constituency / Staff Constituency delete where not applicable

and that I am not prevented from being a member of the Council of Governors by reason of any provisions of paragraph 8 of Schedule 7 to the National Health Service Act 2006 or of the Trust's Constitution. Signed....................................................................................................................... Date............................................................................................................................

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ANNEX 6

COUNCIL OF GOVERNORS: STANDING ORDERS

(Paragraph 20) CONTENTS 1. Introduction 2. Interpretation 3. The Council of Governors 4. Meetings of the Council of Governors

Frequency of meetings

Annual meeting

Admission of the public

Calling meetings

Notice of meetings

Setting the agenda

Petitions

Chairman of meeting

Chairman's ruling

Quorum

Discussion on motion requested by a governor

Voting

Suspension of Standing Orders

Minutes

Record of attendance

Committees 5. Declaration of interests and register of governors' interests 6. Standards of business conduct 7. Interface between Board of Directors and Council of Governors 8. Status of Standing Orders

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1. Introduction

1.1 The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust became a Public Benefit Corporation on its authorisation by Monitor pursuant to the National Health Service Act 2006 as amended by the Health and Social Care Act 2012 (the 2012 Act). 1.2 The principal place of business of the Trust is currently at Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG. 1.3 The Trust is governed by the 2006 Act as amended by the Health and SociaCare

Act 2012, its Constitution and its Terms of Authorisation granted by Monitor or subsequent license conditions issued by Monitor (the Regulatory Framework). The functions of the Trust are defined by the Regulatory Framework. The Regulatory Framework requires the Council of Governors of the Trust to adopt Standing Orders for the regulation of its proceedings and business and to adhere at all times to the Governors' Code of Conduct.

2. Interpretation

Save as otherwise permitted by law, at any meeting the Chairman shall be the final authority on the interpretation of Standing Orders on which he or she shall be advised by the Chief Executive and the Secretary.

3. The Council of Governors

The roles and responsibilities of the Council of Governors are set out in paragraph 1 and 2 of Annex 5 of the Constitution and have effect as if incorporated into these Standing Orders.

4. Meetings of the Council of Governors

4.1. Frequency of Meetings Meetings of the Council of Governors shall be held at such times and places as the Council of Governors may determine and there shall be at least four meetings in any year including:

4.1.1. an annual meeting no later than 30 September in each year apart from the first year, when the Council of Governors is to receive and consider the annual accounts, any report by the Auditor and the annual report; and

4.1.2. any other meetings required of the Governors in order to fulfill their

functions in accordance with the Constitution.

4.2. Annual Meeting

4.2.1. The Council of Governors shall present to each annual meeting:

4.2.1.1. a report on the proceedings of its meetings held since the last annual meeting;

4.2.1.2. a report on progress since the last annual meeting in

developing the membership strategy including the steps taken to ensure that the actual membership is fully representative of the persons who are eligible to be Members under the Constitution;

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4.2.1.3. a report on any change to the membership of the Council of Governors which has taken place since the last annual meeting; and

4.2.1.4. a report containing such comments as it wishes to make

regarding the Trust's performance, its accounts for the preceding financial year and its future service development plans.

4.2.1.5. This meeting may be combined with the Trust’s Annual

Members meeting.

4.3. Admission of the Public

4.3.1. The public and representatives of the press shall be afforded facilities to attend all formal meetings of the Council of Governors except where it resolves that members of the public and representatives of the press be excluded from all or part of a meeting on the grounds that:

4.3.1.1. any publicity would be prejudicial to the public interest by

reason of the confidential nature of the business to be transacted; or

4.3.1.2. for other reasons stated in the resolution and arising from the

nature of the business or the proceedings that the Council of Governors believes are special reasons for excluding the public from the meeting in accordance with the Constitution.

4.3.2. Nothing in these Standing Orders shall require the Council of Governors

to allow members of the public and representatives of the press to record proceedings in any manner whatsoever, other than writing, or to make any oral report of proceedings as they take place, without the prior agreement of the Council of Governors.

4.4. Calling Meetings

4.4.1. The Secretary may call a meeting of the Council of Governors at any time.

4.4.2. If the Secretary refuses to call a meeting after a requisition for that

purpose, signed by at least one-third of the whole number of the Governors and specifying the business to be transacted at the meeting, has been presented to him or her, or if, without so refusing, the Secretary does not call a meeting within five Clear Days after such requisition has been presented to him or her at the Trust’s Headquarters, one-third or more of the Governors may forthwith call a meeting for the purpose of conducting that business.

4.5. Notice of Meetings

4.5.1. Before each meeting of the Council of Governors, a notice of the meeting, specifying the business proposed to be transacted at it, shall be delivered to, or sent by post to the usual place of residence of every governor, so as to be available to him or her at least six Clear Days before the meeting save in the case where the Chairman (or Deputy Chairman) consider that an emergency situation prevails.

4.5.2. Before each meeting of the Council of Governors a public notice of the

time and place of the meeting, and the public part of the agenda, shall,

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insofar as it is available, be displayed at the Trust's Headquarters at least three Clear Days before the meeting.

4.5.3. Want of service of the notice on any governor shall not affect the validity

of a meeting, but failure to serve the notice on more than three Governors shall invalidate the meeting. A notice shall be presumed to have been served at the time at which the notice would be delivered in the ordinary course of posting.

4.5.4. In the case of a meeting called by Governors in accordance with

paragraph 4.4.2 above, the notice shall be signed by those Governors and no business shall be transacted at the meeting other than that specified in the requisition.

4.5.5. Agendas will be sent to Governors before the meeting and supporting

papers, whenever possible, shall accompany the agenda, but will certainly be dispatched no later than three Clear Days before the meeting, save when the Chairman (or Deputy Chairman) considers that emergency circumstances prevail.

4.6. Setting the Agenda

4.6.1. The Council of Governors may determine that certain matters shall appear on every agenda for a meeting and shall be addressed prior to any other business being conducted.

4.6.2. A governor who desires a matter to be included on an agenda, including

a formal motion for discussion and voting on at a meeting, shall make his or her request in writing to the Chairman at least ten Clear Days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than ten Clear Days before a meeting may be included on the agenda at the discretion of the Chairman.

4.7. Petitions

Where a petition has been received by the Trust, the Chairman shall include the petition as an item for the agenda of the next meeting of the Council of Governors.

4.8. Chairman of Meeting

4.8.1. At any meeting of the Council of Governors, the Chairman, if present, shall preside.

4.8.2. If the Chairman is absent from the meeting or is absent temporarily on

the grounds of a declared conflict of interest the Deputy Chairman shall preside.

4.8.3. If the Deputy Chairman is absent from the meeting or is absent

temporarily on the grounds of a declared conflict of interest, another Non-Executive Director shall be appointed by the Council of Governors to preside at that meeting.

4.9. Chairman’s Ruling

Statements made by Governors at meetings of the Council of Governors shall be relevant to the matter under discussion at the time and the decision of the Chairman of the meeting on questions of order, relevancy, regularity and any other matters shall be final.

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4.10. Quorum

No business shall be transacted at a meeting of the Council of Governors unless at least six Governors, consisting of four Governors who are members of the Public Constituency, and two from the other constituencies. 4.10.1. If at any meeting of the Council of Governors there is no quorum present

within 30 minutes of the time fixed for the start of the meeting, the meeting shall stand adjourned for five Clear Days and upon reconvening, those present shall constitute a quorum.

4.10.2. A governor who has been disqualified from participating in the discussion

on any matter shall not count towards the quorum. 4.10.3. A governor who has not been disqualified but who is excluded from

voting on a particular matter by reason of the declaration of a conflict of interest as provided in paragraph 5 below shall not count towards the quorum for the discussion on that matter. If as a result a quorum is not available for the discussion and/or the passing of a motion on that matter, the matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

4.11. Discussion on Motion Requested by a Governor

Where a governor has requested inclusion of a motion on the agenda in accordance with paragraph 4.6.2 above, the process for discussion and voting on the motion shall be as follows: 4.11.1. the governor who requested its inclusion shall have the right to move the

motion, subject to a time limit of five minutes;

4.11.2. the governor proposing the motion shall have a right of reply at the close of any discussion on the motion or any amendment thereto, subject to a time limit of three minutes;

4.11.3. once a motion has been moved, no governor shall speak more than once or for more than three minutes;

4.11.4. when a motion is under discussion or immediately prior to discussion it shall be open to a governor to move: 4.11.4.1. an amendment to the motion;

4.11.4.2. the adjournment of the discussion or of the meeting;

4.11.4.3. that the meeting proceed to the next business;

4.11.4.4. the appointment of an ad hoc committee to deal with the

specific item of business to which the motion refers;

4.11.4.5. that the motion be now put; 4.11.4.6. that as provided by paragraph 4.3.1 the public be

excluded from the meeting in relation to the discussion concerning the motion.

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4.11.5. In the case of sub-paragraphs 4.11.4.3 and 4.11.4.5 above, to ensure objectivity these matters may only be put by a governor who has not previously taken part in the debate and who is eligible to vote.

4.11.6. No amendment to the motion shall be admitted if, in the opinion of the

Chairman of the meeting, the amendment negates the substance of the motion.

4.12. Voting

4.12.1. A governor may not vote at a meeting of the Council of Governors unless (at the beginning of his or her tenure or at another time agreed by the Secretary) he or she has made a declaration in the form specified in Appendix 5C to Annex 5 confirming that he or she is a member of the constituency which elected him or her and is not prevented from being a member of the Council of Governors by paragraph 8 of Schedule 7 to the 2006 Act or this Constitution. Where a governor's circumstances in respect of his or her declaration have changed, he or she shall make a new declaration in the form specified in Appendix 5C to Annex 5 within seven days.

4.12.2. Except where this Constitution expressly provides that the approval of

three-quarters of the Governors present and voting is required, every question at a meeting of the Council of Governors shall be determined by a simple majority of the votes of the Chairman of the meeting and the Governors present and voting on the question.

4.12.3. The Chairman of the meeting of the Council of Governors shall in the

case of an equality of votes on any question or proposal have a casting vote.

4.12.4. All questions put to the vote shall, at the discretion of the Chairman of

the meeting, be determined by oral expression or by a show of hands. A paper ballot may be used if a majority of the Governors present so request.

4.12.5. If at least one-third of the Governors present so request, the voting

(other than by paper ballot) on any question may be recorded to show how each governor present voted or abstained.

4.12.6. If a governor so requests, his or her vote shall be recorded by name

upon any vote (other than by paper ballot). 4.12.7. In no circumstances may an absent governor vote by proxy. Absence is

defined as being absent at the time of the vote. 4.12.8. In circumstances which must be approved in advance by the Council of

Governors and which may be included in a Schedule to these Standing Orders, the Chairman may specify in a notice of a meeting any matter which requires approval by a written resolution and such a matter may be approved in writing provided that at least three-quarters of the Governors, and a majority of Governors who are Members of the Public Constituency of the Trust, approve the resolution in writing within the timescale imposed in such a notice.

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4.13. Suspension of Standing Orders

4.13.1. Except where this would contravene any statutory provision, any one or more of these Standing Orders may be suspended at any meeting, provided that:

4.13.1.1. at least two-thirds of the Governors are present; 4.13.1.2. there is a majority of Governors present who are

Members of the Public Constituency of the Trust; and 4.13.1.3. a majority of those present vote in favor of suspension.

4.13.2. A decision to suspend the Standing Orders shall be recorded in the

minutes of the meeting. 4.13.3. A separate record of matters discussed during the suspension of

Standing Orders shall be made and shall be available to the Chairman and Governors.

4.13.4. No formal business may be transacted while Standing Orders are

suspended.

4.14. Minutes

4.14.1. The minutes of the proceedings of every meeting of the Council of Governors and of any committee appointed by the Council of Governors in accordance with paragraph 4.16 below shall be drawn up by the Secretary and submitted for agreement at the next ensuing meeting of the Council of Governors.

4.14.2. No discussion shall take place upon the minutes except upon their

accuracy or where the Chairman considers discussion appropriate. Any amendment to the minutes shall be agreed at the next ensuing meeting of the Council of Governors and recorded in manuscript on the minutes, which shall be signed by the person presiding at the meeting. Signed minutes shall be retained by the Secretary.

4.14.3. The signed minutes shall be conclusive evidence of the events of the

meeting to which they relate. 4.14.4. Minutes of meetings of the Council of Governors shall be circulated in

accordance with Governors' wishes.

4.15. Record of Attendance

The names of the Chairman and Governors present at the meeting shall be recorded in the minutes.

4.16. Committees

4.16.1. The Council of Governors shall not delegate to any committee or individual governor any of the powers or responsibilities which are to be exercised by it at a general meeting. However, the Council of Governors may appoint committees to assist it in the proper performance of its functions under the Regulatory Framework.

4.16.2. These Standing Orders, as far as they are applicable, shall apply with

appropriate alteration to meetings of any committees established by the Council of Governors, with the terms “Chairman” to be read as a

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reference to the Chairman of the committee and the term “governor” to be read as a reference to a member of the committee as the context permits.

4.16.3. Each such committee shall have such terms of reference and powers

and be subject to such conditions as the Council of Governors shall decide and shall be in accordance with the Regulatory Framework. Such terms of reference shall have effect as if incorporated into these Standing Orders.

4.16.4. Any committee established under this paragraph 4.16 may call upon

outside advisers to assist it with its tasks, subject to the advance agreement of the Board of Directors. Any conflict arising between the Council of Governors and the Board of Directors under this paragraph shall be determined in accordance with the dispute resolution procedure set out in paragraph 7 of Annex 8.

4.16.5. The Council of Governors shall approve the appointment of Members to

each of the committees which it has formally constituted. 4.16.6. Where the Council of Governors is to appoint persons to a committee to

undertake statutory functions, and where such appointments are to operate independently of the Council of Governors, such appointments shall be made in accordance with applicable statute and regulations and with guidance issued by Monitor.

4.16.7. Where the Council of Governors determines that persons other than

Governors, Directors or officers of the Trust shall be appointed to a committee, the terms of such appointment shall be determined by the Council of Governors subject to the payment of travelling expenses and other allowances being in accordance with such sum as may be determined by the Board of Directors.

4.16.8. The Council of Governors may appoint Members to serve on joint

committees with the Board of Directors or committees of the Board of Director if requested by the Board of Directors.

5. Declarations of Interests and Register of Governors' Interests

5.1. Declaration of Interests

5.1.1. The Regulatory Framework requires each governor to declare to the Secretary:

5.1.1.1. any actual or potential interest, direct or indirect, which is

relevant and material to the business of the Trust, as described in paragraph 5.2.2 below; and

5.1.1.2. any actual or potential pecuniary interest, direct or indirect, in

any contract, proposed contract or other matter concerning the Trust, as described in paragraph 5.2.3 below; and

5.1.1.3. any actual or potential family interest, direct or indirect, of

which the governor is aware, as described in paragraph 5.2.6 below.

5.1.2. Such a declaration shall be made either at the time of the governor’s

election or appointment or as soon thereafter as the interest arises, but within five Clear Days of the governor becoming aware of the existence

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of that interest, and shall be made in such manner as the Secretary may prescribe from time to time.

5.1.3. In addition, if a governor is present at a meeting of the Council of

Governors and has an interest of any sort in any matter which is the subject of consideration, he or she shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter. At the time that the interests are declared, they should be recorded in the minutes of the meeting.

5.1.4. Subject to paragraph 5.2.4 below, if a governor has declared a pecuniary

interest (as described in paragraphs 5.2.2 and 5.2.3) in any matter which is the subject of consideration, he or she shall not take part in the consideration or discussion of that matter.

5.1.5. A governor who is aware of an alteration in his or her circumstances

which gives rise to any changes in the interests he or she has previously declared should declare the changes at the next meeting of the Council of Governors following the change occurring.

5.1.6. This paragraph 5 applies to any committee, sub-committee or joint

committee of the Council of Governors and to any member of any such committee, sub-committee, or joint committee (whether or not he or she is also a governor).

5.1.7. The interests of Governors in companies likely or possibly seeking to do

business with the NHS should be published in the Trust’s Annual Report. The information should be kept up to date for inclusion in succeeding Annual Reports.

5.2. Nature of Interests

5.2.1. Definitions of the terms "relevant and material", "pecuniary interest" and

"family interest" are set out below. If having considered these definitions a governor is in doubt as to the relevance or materiality of an interest, he or she should discuss the matter with the Chairman or the Secretary.

"Relevant and Material"

5.2.2. Interests which should be regarded as "relevant and material" are as

follows:

5.2.2.1. Directorships, including Non-Executive Directorships held in private companies or public limited companies (with the exception of those of dormant companies); or

5.2.2.2. ownership, part-ownership or Directorship of private

companies, businesses or consultancies likely or possibly seeking to do business with the NHS; or

5.2.2.3. majority or controlling share holdings in organisations likely or

possibly seeking to do business with the NHS; or 5.2.2.4. a position of authority in a charity or voluntary organisation in

the field of health and social care; or

5.2.2.5. an affliction to a health or social care related campaigning special interest group

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5.2.2.6. any connection with a voluntary or other organisation contracting for NHS services or commissioning NHS services; or

5.2.2.7. any connection with an organisation, entity or company

considering entering into or having entered into a financial agreement with the Trust, including but not limited to, lenders or banks.

"Pecuniary Interest"

5.2.3. A governor shall be treated as having indirectly a pecuniary interest in a

contract, proposed contract or other matter, if:

5.2.3.1. he or she, or a nominee of his or hers, is a director of a company or other body, not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or

5.2.3.2. he or she is a partner of, or is in the employment of a person

with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration.

5.2.4. A governor shall not be treated as having a pecuniary interest in any

contract, proposed contract or other matter by reason only of:

5.2.4.1. his or her membership of a company or other body, if he or she has no beneficial interest in any securities of that company or other body; or

5.2.4.2. an interest in any company, body or person with which he or

she is connected which is so remote or insignificant that it cannot reasonably be regarded as likely to influence the governor in the consideration or discussion of or in voting on, any question with respect to that contract or matter; or

5.2.4.3. any travelling or other expenses or allowances payable to the

governor in accordance with paragraph 23 of the Core Constitution.

5.2.5. Where a governor has an indirect pecuniary interest in a contract,

proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body and 5.2.5.1. the total nominal value of those securities does not exceed

£5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less; and

5.2.5.2. if the share capital is of more than one class, the total nominal

value of shares of any one class in which he or she has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class, the governor shall not be prohibited from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it, without prejudice however to his or her duty to disclose the interest.

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“Family Interest”

5.2.6. A "family interest" is an interest of the spouse or partner or any parent, child, brother or sister of a governor which if it were the interest of that governor would be a personal interest or a pecuniary interest of his or hers.

5.3. Register of Governors’ Interests

5.3.1. The Secretary shall keep a register of Governors' interests which shall contain the names of each governor, whether he or she has declared any interest, and if so, the interest declared.

5.3.2. It is the obligation of the governor to inform the Secretary in writing within

7 Clear Days of becoming aware of the existence of a relevant or material interest. The Secretary must amend the appropriate register of interests upon receipt within 3 Clear Days.

5.3.3. The register of Governors' interests will be available to the public and the

Chairman will take reasonable steps to bring the existence of the register of interests to the attention of the local population and to publicise arrangements for viewing it. Copies or extracts of the register of interests must be provided to Members of the Trust free of charge and within a reasonable time period of the request. A reasonable charge may be imposed on non-members for copies or extracts of the register of interests.

5.3.4. In establishing, maintaining, updating and publicising the register of

interests, the Trust shall comply with all guidance issued from time to time by Monitor. The details of Governors’ interests recorded in the register of interests will be kept up to date by means of a regular review as necessary by the Chief Executive or Secretary during which any changes of interests recently declared will be incorporated.

6. Standards of Business Conduct

6.1. Governors' Code of Conduct

A Governor shall sign and deliver to the Secretary a statement confirming his or her agreement to comply with the Governors' Code of Conduct and shall at all times comply with its provisions and with the provisions of the Trust's policies, procedures and Standing Financial Instructions.

6.2. Interest of Governors in Contracts

6.2.1. If it comes to the knowledge of a governor that a contract in which he or

she has any pecuniary interest not being a contract to which the governor is a party, has been, or is proposed to be, entered into by the Trust he or she shall at once give notice in writing to the Chairman or Secretary of the fact that he or she is interested therein. In the case of persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

6.2.2. A governor must also declare to the Chairman or Secretary any other

employment or business or other relationship of his or hers, or of a cohabiting spouse or partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust. The Trust shall require such interests to be recorded in the register of Governors' interests.

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6.3. Canvassing and Recommendations in Relation to Appointments

6.3.1. Canvassing of Governors directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph 6.3.1 shall be included in application forms or otherwise brought to the attention of candidates.

6.3.2. A governor shall not solicit for any person any appointment under the

Trust or recommend any person for such appointment, but this shall not preclude a governor from giving written testimonial of a candidate's ability, experience or character for submission to the Trust in relation to any appointment.

6.3.3. Informal discussions outside appointment panels or committees, whether

solicited or unsolicited, should be declared to the panel or committee.

6.4. Relatives of Governors

6.4.1. Candidates for any staff appointment shall when making an application disclose in writing whether they are related to any governor. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him or her liable to instant dismissal.

6.4.2. A governor shall disclose to the Chairman any relationship between

himself or herself and a candidate of whose candidature that governor is aware. It shall be the duty of the Chairman to report to the Council of Governors any such disclosure made.

6.4.3. On appointment, Governors should disclose to the Council of Governors

whether they are related to any other governor, any member of the Board of Directors or any holder of an office in the Trust.

6.5. External Consultants

This paragraph 6 will apply equally to all external consultants or other agents acting on behalf of the Trust. The Trust's Scheme of Delegation should be adhered to at all times.

7. Interface Between the Board of Directors and the Council of Governors

7.1. The Board of Directors will co-operate with the Council of Governors in order to comply with the Regulatory Framework in all respects and in particular in relation to the following matters which are set out specifically within the Constitution:

7.1.1. The Directors, having regard to the views of the Council of Governors,

are to prepare the information as to the Trust’s forward planning in respect of each financial year to be given to Monitor.

7.1.2. The Directors are to present to the Council of Governors at a general

meeting the annual accounts, any report of the Auditor on them, and the annual report.

7.1.3. Before holding a meeting, the Board of Directors must send a copy of the agenda of the meeting to the Council of Governors. As soon as

practicable after holding a meeting, the Board of Directors must send a

copy of the minutes of the meeting to the Council of Governors.

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7.2. For the purposes of obtaining information about the Trust’s performance of its functions or the Directors’ performance of their duties (and deciding whether to propose a vote on the Trust’s or Directors’ performance), the Council of Governors may require one or more of the Directors to attend a meeting.

7.3. The Trust will take steps to ensure that the Governors are equipped with the skills and knowledge they require in their capacity as such.

7.4. The Council of Governors may request that any matter which relates to the Trust's compliance with the Regulatory Framework is included on the agenda for a meeting of the Board of Directors.

7.5. If the Council of Governors desires that a matter as described in paragraph 7.2 be

included on an agenda for discussion by the Board of Directors, it shall make its request in writing to the Chairman at least 14 Clear Days before the meeting of the Board of Directors. The Chairman shall decide whether the matter is appropriate to be included on the agenda. Requests made less than 14 Clear Days before a meeting may be included on the agenda at the discretion of the Chairman.

8. Status of Standing Orders

8.1. Standing Orders to be Given to Governors

The Secretary shall provide a copy of these Standing Orders to each governor and shall endeavor to ensure that each governor understands his or her responsibilities within these Standing Orders.

8.2. Documents Having the Standing of Standing Orders

The Trust's Scheme of Delegation (incorporating the Schedule of Matters reserved to the Board of Directors) and Standing Financial Instructions (incorporating the Tendering and Contract Procedure) shall have effect as if incorporated into these Standing Orders.

8.3. Duty to Report Non-Compliance with Standing Order

All Governors have a duty to disclose any non-compliance with these Standing Orders to the Secretary as soon as possible. Full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Council of Governors for action or ratification.

8.4. Review, Variation and Amendment of Standing Orders

8.4.1. These Standing Orders, including all documents having effect as if incorporated in them, shall be subject to regular review by the Council of Governors at intervals not exceeding every three years.

8.4.2. As prescribed by paragraph 48 of the Core Constitution, amendment by

the Trust of its Constitution, including these Standing Orders, are to be made with the approval of the Board of Directors and the Council of Governors.

8.4.3. No amendment of these Standing Orders shall be made unless:

8.4.3.1. relevant notice of a meeting of the Council of Governors has been served in accordance with paragraph 4.5 above;

8.4.3.2. a notice of motion under paragraph 4.6.2 has been given;

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8.4.3.3. the proposed amendment has been discussed at a meeting of the Council of Governors at which at least one-half of the Governors were present;

8.4.3.4. at least 50% of the Governors present and voting voted in

favour of the proposed amendment; 8.4.3.5. the proposed amendment does not contravene the Regulatory

Framework, any statutory provisions or any guidance issued by Monitor; and

8.4.3.6. the change has been approved by the Board of Directors.

8.4.4. Amendments made under paragraph 46.1 take effect as soon as the

conditions in that paragraph are satisfied, but the amendment has no effect in so far as the Constitution would, as a result of the amendment, not accord with schedule 7 of the 2006 Act.

8.5. Where an amendment is made to the Constitution in relation the powers or duties of the Council of Governors (or otherwise with respect to the role that the Council of Governors has as part of the Trust) –

8.5.1. At least one member of the Council of Governors must attend the next Annual Members’ Meeting and present the amendment, and

8.5.2. The trust must give the Members an opportunity to vote on whether they approve the amendment.

8.5.3. If more than half of the Members voting approve the amendment, the amendment continues to have effect; otherwise, it ceases to have effect and the Trust must take such steps as are necessary as a result.

8.5.4 Amendments by the Trust of its Constitution are to be notified to Monitor. For the avoidance of doubt, Monitor’s functions do not include a power or duty to determine whether or not the Constitution, as a result of the amendments, accords with Schedule 7 of the 2006 Act.

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ANNEX 7

BOARD OF DIRECTORS: STANDING ORDERS

(Paragraph 33) CONTENTS 1. Introduction 2. Interpretation 3. The Board of Directors

Authority

Composition

Appointment, re-appointment and removal of Chairman and other Non-Executive Directors

Remuneration and terms of office of Chairman and Non-Executive Directors

Appointment and powers of Deputy Chairman

Appointment and powers of Senior Independent Director

Appointment and removal of Chief Executive and other Executive Directors

Remuneration and terms of office of Chief Executive and other Executive Directors

Disqualification of Directors 4. Secretary 5. Meetings of the Board of Directors

Calling meetings

Notice of meetings

Setting the agenda

Petitions

Chairman of meeting

Chairman's ruling

Quorum

Discussion on motion requested by a Director

Written motions

Voting

Suspension of Standing Orders

Minutes

Record of attendance

Meetings: electronic communication 6. Exercise of functions by delegation

Emergency powers

Delegation to committees

Delegation to officers 7. Committees 8. Interface between the Board of Directors and the Council of Governors 9. Declaration of interests and register of Directors' interests 10. Standards of business conduct

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11. Instruments 12. Status of Standing Orders

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1. Introduction

1.1. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust became a Public Benefit Corporation on its authorisation by Monitor pursuant to the National Health Service Act 2006, as amended by the 2012 Act.

1.2. The principal place of business of the Trust is the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG.

1.3. The Trust is governed by the 2006 Act, the 2012 Act, its Constitution and the Term of Authorisation granted by Monitor or subsequent license conditions issued by Monitor (together the Regulatory Framework). The functions of the Trust are conferred by the Regulatory Framework.

1.4. The Regulatory Framework requires the Board of Directors to adopt Standing

Orders for the regulation of its proceedings and business. The Standing Orders set out below, together with the Scheme of Delegation and the Standing Financial Instructions (which documents have effect as if incorporated into these Standing Orders), provide a comprehensive operating framework for the business conduct of the Trust.

1.5. As a Public Benefit Corporation the Trust has specific powers to contract in its own

name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable. The Trust also has a common law duty as a bailee for patients' property held by the Trust on behalf of patients.

2. Interpretation

Save as otherwise permitted by law, at any meeting the Chairman shall be the final authority on the interpretation of Standing Orders, on which he or she shall be advised by the Chief Executive and the Secretary.

3. The Board of Directors

3.1. Authority

3.2. As a Foundation Trust, the Trust shall have all the powers set out in the Constitution and in the 2006 Act, as amended the 2012 Act

3.2.1. The powers of the Trust established under statute shall be exercised by

the Board of Directors.

3.2.2. The Trust has resolved that certain powers and decisions may only be exercised or made by the Board of Directors in formal session. These powers and decisions are set out in the Schedule of Matters Reserved to the Board, which has effect as if incorporated into these Standing Orders.

3.3. Composition of the Board of Directors

3.3.1. In accordance with paragraph 25 of the Core Constitution the Board of

the Trust is to comprise:

3.3.1.1. a Non-Executive Chairman; 3.3.1.2. no fewer than four and no more than six other Non-Executive

Directors; and

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3.3.1.3. no fewer than four and no more than six Executive Directors such that at any time at least half the Board of Directors (excluding the Chairman) shall be Non-Executive Directors.

3.3.2. One of the Executive Directors shall be the Chief Executive.

3.3.3. The Chief Executive shall be the Accounting Officer.

3.3.4. One of the Executive Directors shall be the finance Director.

3.3.5. One of the Executive Directors is to be a registered medical practitioner

or a registered dentist (within the meaning of the Dentists Act 1984).

3.3.6. One of the Executive Directors is to be a registered nurse or a registered midwife.

3.3.7. The validity of any act is not affected by any vacancy among the

Directors or defect in the appointment of a Director.

3.4. Appointment, Re-Appointment and Removal of the Chairman and Other Non-Executive Directors

3.4.1. As provided by paragraph 28 of the Core Constitution, the Council of

Governors at a general meeting of the Council of Governors shall appoint, re-appoint or remove the Chairman of the Trust and the other Non-Executive Directors.

3.4.2. The process for the appointment, re-appointment or removal of Non-

Executive Directors (including the Chairman) shall be as provided in Appendix 5A to Annexe 5 of this Constitution.

3.5. Remuneration and Terms of Office of the Chairman and Non-Executive

Directors

3.5.1. The Chairman and the Non-Executive Directors are to be appointed by the Council of Governors at a general meeting at which the Council of Governors shall decide:

3.5.1.1. the period of office; 3.5.1.2. the remuneration and allowances; and 3.5.1.3. the other terms and conditions of office of the Chairman and

other Non-Executive Directors.

3.6. Appointment and Powers of Deputy Chairman

3.6.1. As provided by paragraph 30 of the Core Constitution, the Council of Governors shall appoint a Non-Executive Director to be Deputy Chairman for such period, not exceeding the remainder of his or her term as a Non-Executive Director, as the Council of Governors may specify on appointing him or her.

3.6.2. Where the Chairman of the Trust has died or has ceased to hold office,

or where he or she has been unable to perform his or her duties as Chairman owing to illness, conflict of interest or any other cause, the Deputy Chairman shall act as Chairman until a new Chairman is appointed or the existing Chairman resumes his or her duties, as the case may be. References to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform his duties, be

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taken to include references to the Deputy Chairman. Where both the Chairman and Deputy Chairman are unable to perform their duties owing to illness, conflict of interest or any other cause, another Non-Executive Director may be appointed by the Council of Governors to act as Chairman.

3.6.3. A Non-Executive Director so appointed may at any time resign from the

office of Deputy Chairman by giving notice in writing to the Council of Governors. The Council of Governors may thereupon appoint another Non-Executive Director as Deputy Chairman in accordance with the provisions of paragraph 3.6.1 above.

3.7. Appointment and Powers of Senior Independent Director

3.7.1. The Board of Directors shall in consultation with the Council of

Governors appoint as the Senior Independent Director one of the Non-Executive Directors who is deemed by the Board of Directors to be independent by reference to FT Code Provision A.4.1. The term of office of the Senior Independent Director shall be specified by the Board of Directors on appointing him or her but shall not exceed the remainder of his or her term as a Non-Executive Director.

3.7.2. The Senior Independent Director shall perform the role set out in FT

Code Provisions A4.1 and otherwise as summarised in a role description agreed between the Board of Directors and the Council of Governors which shall as a minimum include:

3.7.2.1. leading the Non-Executive Directors in the evaluation of the

Chairman as part of process agreed with the Council of Governors;

3.7.2.2. being available to Members and Governors if they have

concerns which contact through the normal channels of Chairman, Chief Executive or Finance Director has failed to resolve or for which such contact is inappropriate; and

3.7.2.3. attending sufficient meetings with Governors to listen to their

views in order to help develop a balanced understanding of the issues and concerns of Governors.

3.7.3. As provided by FT Code Provision A.4.1, the Deputy Chairman

appointed in accordance with paragraph 3.6 above may also be appointed as the Senior Independent Director, provided that he or she is deemed by the Board of Directors to be independent by reference to FT Code Provision A.3.1.

3.7.4. If a Deputy Chairman who is also the Senior Independent Director is

required to act in the capacity of Chairman in accordance with paragraph 3.6.2 above, the Board of Directors in consultation with the Council of Governors shall appoint another independent Non-Executive Director to serve as Senior Independent Director on a temporary basis. Where the Deputy Chairman is required to act in the capacity of the Chairman for a period exceeding one calendar month, the Board of Directors in consultation with the Council of Governors shall appoint a new permanent Senior Independent Director from amongst the other independent Non-Executive Directors.

3.7.5. A Non-Executive Director so appointed may at any time resign from the

office of Senior Independent Director by giving notice in writing to the Chairman. The Board of Directors in consultation with the Council of

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Governors may thereupon appoint another Non-Executive Director as Senior Independent Director in accordance with the provisions of paragraph 3.7.1 above.

3.8. Appointment and Removal of Chief Executive and other Executive Directors

3.8.1. The initial Chief Executive is to be appointed in accordance with paragraph 32 of the Core Constitution.

3.8.2. As provided by paragraph 28 of the Core Constitution, the Non-

Executive Directors shall appoint or remove the Chief Executive, save that the appointment of the Chief Executive (other than the initial Chief Executive) shall require the approval of a majority of the Governors present and voting at a general meeting of the Council of Governors.

3.8.3. A committee consisting of the Chairman, the other Non-Executive

Directors and the Chief Executive shall appoint or remove the other Executive Directors.

3.9. Remuneration and Terms of Office of the Chief Executive and Executive

Directors

3.9.1. The Trust shall establish a committee of Non-Executive Directors in accordance with paragraph 7.1 below to decide:

3.9.1.1. the period of office; 3.9.1.2. the remuneration and allowances; and 3.9.1.3. the other terms and conditions of office of the Chief Executive

and other Executive Directors.

3.9.2. The Trust may reimburse Directors' travelling and other costs and

expenses incurred in carrying out their duties at rates determined by the committee of Non-Executive Directors referred to in paragraph 3.9.1 above. These are to be disclosed in the annual report.

3.9.3. The remuneration and allowances for Directors are to be disclosed in

bands in the annual report.

3.10. Disqualification of Directors

A person may not become or continue as a Director of the Trust if: 3.10.1. he or she has refused to sign and deliver to the Secretary a statement

confirming acceptance of the Directors' Code of Conduct. 3.10.2. he or she is a member of a Local Involvement Network covering the

Trust; 3.10.3. he or she is a member of a local authority’s Overview and Scrutiny

Committee covering health matters; 3.10.4. he or she is the subject of a disqualification order made under the

Company Directors Disqualification Act 1986; 3.10.5. he or she is a person whose tenure of office as a Chairman or as a

member or Director of an NHS body has been terminated on the grounds that his or her appointment is not in the interests of the health service,

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including for non-attendance at meetings or for non-disclosure of a pecuniary interest;

3.10.6. he or she has within the preceding two years been dismissed, otherwise

than by reason of redundancy, from any paid employment with an NHS body;

3.10.7. in the case of a Non-Executive Director, he or she has refused without

reasonable cause to fulfill any training requirement established by the Board of Directors;

3.10.8. he or she is incapable by reason of mental disorder, illness or injury of

managing or administering his or her property and affairs; 3.10.9. Monitor has exercised its powers to remove him or her as a member of

the Board of Directors of the Trust or has suspended him or her from office or has disqualified him or her from holding office as a Director of the Trust for a specified period or has exercised any of those powers in relation to him or her at any time, whether in relation to the Trust or to any other NHS Foundation Trust;

3.10.10. he or she has had his or her name removed from any list maintained by

any Clinical Commissionong Group pursuant to Parts 4, 5, 6 or 7 of the NHS Act 2006 and/or Regulations made under those Parts and has not subsequently had his or her name included on such a list and in view of the reason or reasons for such removal he or she is not considered by the Chairman to be a fit and proper person to hold the office of Director;

3.10.11. on the basis of disclosures obtained through an application to the

Disclosure Barring Service, he or she is not considered by the Chairman to be a fit and proper person to hold the office of Director; or

3.10.12. he or she is or has been subject to a Sexual Offences Prevention Order,

a Foreign Travel Order or a Risk of Sexual Harm Order made under the provisions of the Sexual Offences Act 2003.

4. Secretary

4.1. The Trust shall have a Secretary who may be an employee. The Secretary may not be a Governor, or the Chief Executive or the Finance Director.

4.2. The Secretary’s functions shall include:

4.2.1. acting as the Secretary to the Council of Governors and the Board of Directors, and to any committees, sub-committee or joint committees of the Council of Governors and the Board of Directors;

4.2.2. calling and attending all meetings of the Council of Governors and the

Board of Directors and of any committees, sub-committee or joint committees of the Council of Governors and the Board of Directors and ensuring that minutes are kept of those meetings;

4.2.3. keeping the register of Governors, the register of Governors’ interests,

the register of Directors, the register of Directors’ interests and the other registers and books required by this Constitution to be kept;

4.2.4. having custody of the Trust’s seal; 4.2.5. publishing to Members in an appropriate form information which they

should have about the Trust’s affairs; and

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4.2.6. preparing and sending to Monitor and to any other statutory body all

returns which are required to be made.

4.3. The Secretary is to be appointed and removed by the Chairman and the Chief Executive acting jointly.

5. Meetings of the Board of Directors

5.1. Calling Meetings

5.1.1. Ordinary meetings of the Board of Directors shall be held at such times and places as the Board of Directors may determine.

5.1.2. Meetings of the Board of Directors shall be open to Members of the public. Members of the public may be excluded from a meeting for

special reasons.

5.1.3. The Chairman may call a meeting of the Board of Directors at any time. If the Chairman refuses to call a meeting after a requisition for that purpose, signed by at least one-third of the whole number of Members of the Board of the Directors, and this has been presented to him or her, or if, without so refusing, the Chairman does not call a meeting within five Clear Days after such requisition has been presented to him or her at the Trust’s Headquarters, one-third or more Members of the Board of Directors may forthwith call a meeting.

5.2. Notice of Meetings

5.2.1. Before each meeting of the Board of Directors a notice of the meeting,

specifying the business proposed to be transacted at it, shall be delivered to every Director, or sent by post to the usual place of residence of every Director, so as to be available to him or her at least six Clear Days before the meeting save in the case where the Chairman (or Deputy Chairman) consider that an emergency situation prevails.

5.2.2. Want of service of the notice on any member of the Board of Directors shall not affect the validity of a meeting, but failure to serve the notice on more than three Directors shall invalidate the meeting. A notice shall be presumed to have been served at the time at which the notice would be delivered in the ordinary course of the post.

5.2.3. In the case of a meeting called by Directors in default of the Chairman in accordance with paragraph 5.1.3 above, the notice shall be signed by those Directors and no business shall be transacted at the meeting other than that specified in the notice.

5.2.4. In the event of an emergency giving rise to the need for an immediate meeting, paragraph 5.2.1 shall not prevent the calling of such a meeting without the requisite six Clear Days' notice provided that every effort is made to make personal contact with every Director who is not absent from the United Kingdom and the agenda for the meeting is restricted to matters arising in that emergency.

5.2.5. Agendas will be sent to Directors before the meeting and supporting

papers, whenever possible, shall accompany the agenda, but will certainly be dispatched no later than three Clear Days before the meeting, save in the case where the Chairman or Deputy Chairman consider that an emergency situation prevails.

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5.2.6. Agendas will be sent to the Council of Governors prior to the meeting .

5.3. Setting the Agenda

5.3.1. The Board of Directors may determine that certain matters shall appear on every agenda for a meeting and shall be addressed prior to any other business being conducted.

5.3.2. A Director who desires a matter to be included on an agenda, including a

motion for discussion and voting at a meeting, shall make his or her request in writing to the Chairman at least ten Clear Days before the meeting. The request should include appropriate supporting information. Requests made less than ten Clear Days before a meeting may be included on the agenda at the discretion of the Chairman.

5.4. Petitions

Where a petition has been received by the Trust the Chairman shall include the petition as an item for the agenda of the next Board of Directors meeting.

5.5. Chairman of Meeting

5.5.1. At any meeting of the Board of Directors, the Chairman, if present, shall preside.

5.5.2. If the Chairman is absent from the meeting or is absent temporarily on

the grounds of a declared conflict of interest, the Deputy Chairman shall preside.

5.5.3. If both the Chairman and Deputy Chairman are absent from the meeting

or are absent temporarily on the grounds of declared conflicts of interest, another Non-Executive Director shall be appointed by the Board of Directors to preside at that meeting.

5.6. Chairman’s Ruling

Statements made by Directors at meetings of the Board of Directors shall be relevant to the matter under discussion at the time and the decision of the Chairman of the meeting on questions of order, relevancy, regularity and any other matters shall be final.

5.7. Quorum

5.7.1. No business shall be transacted at a meeting of the Board of Directors unless at least one-third of the whole number of the Directors are present, including at least one Executive Director and one Non-Executive Director.

5.7.2. The above requirement for at least one Executive Director to form part of

the quorum shall not apply where the Executive Directors are excluded from a meeting (for example when the Board of Directors considers recommendations in relation to the remuneration or other terms of service of the Executive Directors).

5.7.3. An officer who has been appointed formally by the Board of Directors to

act-up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy shall count towards the quorum. An officer attending a meeting of the Board of Directors to represent an Executive Director during a period of incapacity or temporary absence without formal acting-up status shall not count

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towards the quorum. An officer’s status when attending a meeting of the Board of Directors shall be recorded in the minutes.

5.7.4. A Director who has been disqualified from participating in the discussion

on any matter shall not count towards the quorum. 5.7.5. A Director who has not been disqualified but who is excluded from voting

on a particular matter on the grounds of a declared conflict of interest shall not count towards the quorum for the discussion on that matter. If as a result a quorum is not available for the discussion and/or the passing of a motion on any matter, the matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

5.8. Discussion on Motion Requested by a Director

Where a Director has requested the inclusion of a motion on the agenda in accordance with paragraph 5.3.2 above, the process for discussion and voting on the motion shall be as follows:

5.8.1. the Director who requested its inclusion shall have the right to propose

the motion, subject to a time limit of five minutes; 5.8.2. the Director proposing the motion shall have a right of reply at the close

of any discussion on the motion or any amendment thereto, subject to a time limit of three minutes;

5.8.3. once a motion has been proposed, no Director shall speak more than

once or for more than three minutes; 5.8.4. when a motion is under discussion or immediately prior to discussion it

shall be open to Director to move:

5.8.4.1. an amendment to the motion; 5.8.4.2. the adjournment of the discussion or the meeting; 5.8.4.3. that the meeting proceed to the next business; 5.8.4.4. the appointment of an ad hoc committee to deal with the

specific item of business to which the motion refers; or 5.8.4.5. that the motion be now put.

5.8.5. In the case of 5.8.4.3 and 5.8.4.5 above, to ensure objectivity these matters may only be put by a Director who has not previously taken part in the debate and who is eligible to vote.

5.8.6. No amendment to the motion shall be admitted if, in the opinion of the

Chairman of the meeting, the amendment negates the substance of the motion.

5.9. Written Motions

5.9.1. In urgent situations and with the consent of the Chairman, a written motion may be used to transact business otherwise required to be conducted at a general meeting of the Board of Directors.

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5.9.2. If all Directors have been notified of the motion and a simple majority of Directors entitled to attend and vote at a general meeting of the Board of Directors sign and return a copy of a written motion within five Clear Days of dispatch, then the motion will be deemed to have been resolved notwithstanding that the Directors have not gathered in one place.

5.9.3. The effective date of the resolution shall be the date that the last copy is

signed and, until that date, a Director who has previously indicated acceptance can withdraw and the motion shall fail.

5.9.4. Once the resolution is passed, a copy certified by the Secretary shall be

recorded in the minutes of the next ensuring meeting of the Board of Directors where it will be signed by the person presiding at it.

5.10. Voting

5.10.1. Every question at a meeting of the Board of Directors shall be determined by a majority of the votes of the Directors present and voting on the question.

5.10.2. In the case of the number of votes for and against a motion being equal,

the Chairman of the meeting shall have a second or casting vote. 5.10.3. All questions put to the vote shall, at the discretion of the Chairman of

the meeting, be determined by oral expression or by a show of hands. A paper ballot may be used if a majority of the Directors present so request.

5.10.4. If at least one-third of the Members of the Board of Directors present so

request, the voting (other than by paper ballot), on any question may be recorded to show how each Director present voted or abstained.

5.10.5. If a Director so requests, his or her vote shall be recorded by name upon

any vote (other than by paper ballot). 5.10.6. In no circumstances may an absent Director vote by proxy. Absence is

defined as being absent at the time of the vote. 5.10.7. An officer who has been appointed formally by the Board of Directors to

act-up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Executive Director. An officer attending a meeting of the Board of Directors to represent an Executive Director during a period of incapacity or temporary absence without formal acting-up status may not exercise the voting rights of the Executive Director. An officer’s status when attending a meeting of the Board of Directors shall be recorded in the minutes.

5.11. Suspension of Standing Orders

5.11.1. Except where this would contravene any statutory provision or any direction made by Monitor, any one or more of the Standing Orders may be suspended at any meeting, provided that:

5.11.1.1. at least two-thirds of the Directors are present, including

one Executive Director and one Non-Executive Director; and

5.11.1.2. a majority of those present vote in favour of suspension.

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5.11.2. A decision to suspend the Standing Orders shall be recorded in the minutes of the meeting.

5.11.3. A separate record of matters discussed during the suspension of

Standing Orders shall be made and shall be available to the Directors. 5.11.4. No formal business may be transacted while Standing Orders are

suspended. 5.11.5. The Audit Committee shall review every decision to suspend Standing

Orders.

5.12. Minutes

5.12.1. The minutes of the proceedings of every meeting of the Board of Directors and of any committee appointed by the Board of Directors in accordance with paragraph 7 below shall be drawn up by the Secretary and submitted for agreement at the next ensuing meeting of the Board of Directors.

5.12.2. No discussion shall take place upon the minutes except upon their

accuracy or where the Chairman considers discussion appropriate. Any amendment to the minutes shall be agreed at the next ensuing meeting of the Board of Directors and recorded in manuscript on the minutes, which shall be signed by the person presiding at the meeting. Signed minutes shall be retained by the Secretary.

5.12.3. The signed minutes shall be conclusive evidence of the events of the

meeting to which they relate. 5.12.4. Minutes of meetings of the Board of Directors shall be circulated in

accordance with Directors' wishes.

5.12.5. Minutes of the meeting will be sent to the Council of Governors

5.13. Record of Attendance

The names of the Directors present at a meeting shall be recorded in the minutes.

5.14. Meetings: Electronic Communication

5.14.1. In this Standing Order “communication” and “electronic communication” shall have the meanings set out in the Electronic Communications Act 2000 or any statutory modification or re-enactment thereof.

5.14.2. A Director in electronic communication with the Chairman and all other

parties to a meeting of the Board of Directors or of a committee or sub-committee of the Directors shall be regarded for all purposes as personally attending such a meeting provided that, but only for so long as, at such a meeting, he or she has the ability to communicate interactively and simultaneously with all other parties attending the meeting, including all persons attending by way of electronic communication.

5.14.3. A meeting at which one or more of the Directors attends by way of

electronic communication is deemed to be held at such a place as the Directors shall at the said meeting resolve. In the absence of such a resolution, the meeting shall be deemed to be held at the place (if any) where a majority of the Directors attending the meeting are physically

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present, or in default of such a majority, the place at which the Chairman of the meeting is physically present.

5.14.4. Meetings held in accordance with this paragraph 5.14 are subject to the

provisions of paragraph 5.7 in respect of the quorum. For such a meeting to be valid, a quorum must be present and maintained throughout the meeting.

5.14.5. The minutes of a meeting held in this way must state that it was held by

electronic communication and that the Directors were all able to hear each other and were present throughout the meeting.

6. Arrangements for the Exercise of Functions by Delegation

Subject to guidance as may be given by Monitor, the Board of Directors may make arrangements for the exercise of any of its functions by a committee or sub-committee appointed by virtue of paragraph 7 below or by a Director or officer of the Trust, in each case subject to such restrictions and conditions as the Board of Directors considers appropriate.

6.1. Emergency Powers

The powers which the Board of Directors has retained to itself within these Standing Orders and the Schedule of Matters Reserved to the Board may in an emergency be exercised by the Chairman and the Chief Executive after having consulted at least two Non-Executive Directors. The exercise of such powers by the Chairman and the Chief Executive shall be reported to the next formal meeting of the Board of Directors for ratification.

6.2. Delegation to Committees

The Board of Directors may from time to time constitute committees, sub-committees and joint committees and may delegate to them executive powers. The Constitution and terms of reference of these committees, sub-committees or joint committees, including their specific executive powers, shall be approved by the Board of Directors.

6.3. Delegation to Officers

6.3.1. Those functions of the Trust which have not been reserved to the Board of Directors or delegated to a committee, sub-committee or joint committee shall be exercised on behalf of the Board of Directors by the Chief Executive. The Chief Executive shall determine which functions he or she will perform personally and shall nominate officers to undertake the remaining functions, for which he or she will retain accountability to the Board of Directors.

6.3.2. The Chief Executive shall prepare a Scheme of Delegation identifying his

or her proposals, which shall be considered and approved by the Board of Directors, subject to any amendment agreed during the discussion. The Chief Executive may periodically propose amendment to the Scheme of Delegation, which shall be considered and approved by the Board of Directors.

6.3.3. Nothing in the Scheme of Delegation shall impair the discharge of the

direct accountability to the Board of Directors of the Finance Director or other Executive Director to provide information and advise the Board of Directors in accordance with any statutory requirements. Outside these statutory requirements, the Finance Director shall be accountable to the Chief Executive for operational matters.

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6.3.4. The arrangements made by the Board of Directors as set out in the Scheme of Delegation shall have effect as if incorporated in these Standing Orders.

7. Committees

7.1. Appointment of Committees

7.1.1. Subject to paragraph 6 above and to such guidance as may be issued

from time to time by Monitor, the Board of Directors may appoint committees consisting of Directors.

7.1.2. The Board of Directors shall approve the appointments to each of the

committees which it has formally constituted.

7.1.3. A committee appointed under paragraph 6.2 above may, subject to such guidance as may be given by Monitor or the Board of Directors or other health service bodies, appoint sub-committees consisting of Directors of the Trust. A committee may not delegate executive powers to a sub-committee unless expressly authorised by the Board of Directors.

7.2. Terms of Reference

Each such committee or sub-committee shall have such terms of reference and powers and be subject to such conditions (including the requirement to report to the Board of Directors), as the Board of Directors shall decide in accordance with any legislation. Such terms of reference shall have effect as if incorporated into these Standing Orders.

7.3. Confidentiality

7.3.1. A member of a committee shall not disclose a matter dealt with, by, or brought before, the committee without its permission until the committee shall have reported to the Board of Directors or shall otherwise have concluded on that matter.

7.3.2. A Director or a member of a committee shall not disclose any matter

reported to the Board of Directors or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board of Directors or committee shall resolve that it is confidential.

7.4. Applicability of Standing Orders

These Standing Orders of the Board of Directors, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees established by the Board of Directors, in which case the term “Chairman” is to be read as a reference to the chairman of the committee as the context permits, and the term “member" is to be read as a reference to a member of the committee also as the context permits.

8. Interface between the Board of Directors and the Council of Governors

8.1. The Board of Directors will co-operate with the Council of Governors in order to comply with the Regulatory Framework in all respects and in particular in relation to the following matters which are set out specifically within the Constitution:

8.1.1. The Directors, having regard to the views of the Council of Governors,

are to prepare the information as to the Trust’s forward planning in respect of each financial year to be given to Monitor.

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8.1.2. The Directors are to present to the Council of Governors at a general

meeting the annual accounts, any report of the Auditor on them, and the annual report.

8.2. Before holding a meeting, the Board of Directors must send a copy of the agenda

of the meeting to the Council of Governors. As soon as practicable after holding a meeting, the Board of Directors must send a copy of the minutes of the meeting to the Council of Governors.

8.3. The Council of Governors may require a Director to attend one of their meetings to

obtain information about the Trust’s performance.

8.4. The Trust will take steps to ensure that the Governors are equipped with the skills and knowledge they require in their capacity as such.

8.5. The Council of Governors may request that any matter which relates to the Trust's

compliance with the Regulatory Framework is included on the agenda for a meeting of the Board of Directors.

8.6. If the Council of Governors desires that a matter as described in paragraph 8.2 be

included on an agenda for discussion by the Board of Directors, it shall make its request in writing to the Chairman at least 14 Clear Days before the meeting of the Board of Directors. The Chairman shall decide whether the matter is appropriate to be included on the agenda. Requests made less than 14 Clear Days before a meeting may be included on the agenda at the discretion of the Chairman.

9. Declaration of Interests and Register of Directors' Interests

9.1. Declaration of Interests

9.1.1. The Regulatory Framework requires each Director to declare to the Secretary:

9.1.1.1. any actual or potential interest, direct or indirect, which is

relevant and material to the business of the Trust, as described in paragraph 9.2.2 below;

9.1.1.2. any actual or potential pecuniary interest, direct or indirect, in

any contract, proposed contract or other matter which is under consideration concerning the Trust or is to be considered by the Board of Directors, as described in paragraph 9.2.3 below; and

9.1.1.3. any actual or potential family interest, direct or indirect, as

described in paragraph 9.2.6 below. 9.1.2. Such a declaration shall be made either at the time of the Director's

appointment or as soon thereafter as the interest arises, but within five Clear Days of the Director becoming aware of the existence of that interest, and shall be made in such manner as the Secretary shall prescribe from time to time.

9.1.3. In addition, if a Director is present at a meeting of the Board of Directors

and has an interest of any sort in any matter which is the subject of consideration, he or she shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter. At the time that the interests are declared, they should be recorded in the minutes of the meeting.

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9.1.4. If a Director has declared a pecuniary interest in accordance with paragraph 9.2.3 below he shall not take part in the consideration or discussion of the matter in respect of which an interest has been disclosed and shall be excluded from the meeting while the matter is under consideration.

9.1.5. A Director who is aware of an alteration in his or her circumstance which

gives rise to any changes in the interests he or she has previously declared should declare the changes at the next meeting of the Board of Directors following the change occurring.

9.1.6. This paragraph 9 applies to any committee, sub-committee or joint

committee of the Board of Directors and to any member of any such committee, sub-committee or joint committee (whether or not he or she is also a Director).

9.1.7. The interests of Directors in companies likely or possibly seeking to do

business with the NHS should be published in the Trust’s Annual Report. The information should be kept up to date for inclusion in succeeding Annual Reports.

9.2. Nature of Interests

9.2.1. Definitions of the terms "relevant and material", "pecuniary interest" and "family interest" are set out below. If having considered these definitions a Director is in doubt as to the relevance or materiality of an interest, he or she should discuss the matter with the Chairman or the Secretary.

"Relevant and Material" 9.2.2. Interests which should be regarded as "relevant and material" are as

follows and are to be interpreted in accordance with guidance issued by Monitor:

9.2.2.1. Directorships, including non-Executive Directorships held in

private companies or public limited companies (with the exception of those of dormant companies); or

9.2.2.2. ownership, part-ownership or Directorship of private

companies, businesses or consultancies likely or possibly seeking to do business with the NHS; or

9.2.2.3. majority or controlling share holdings in organisations likely or

possibly seeking to do business with the NHS; or

9.2.2.4. a position of authority in a charity or voluntary organisation in the field of health and social care; or

9.2.2.5. an affliction to a health or social care related campaigning

special interest group

9.2.2.6. any connection with a voluntary or other organisation contracting for NHS services or commissioning NHS services; or

9.2.2.7. any connection with an organisation, entity or company

considering entering into or having entered into a financial agreement with the Trust, including but not limited to, lenders or banks.

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"Pecuniary Interest" 9.2.3. A Director shall be treated as having indirectly a pecuniary interest in a

contract, proposed contract or other matter, if:

9.2.3.1. he or she, or a nominee of his or hers, is a Director of a company or other body, not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or

9.2.3.2. he or she is a partner of, or is in the employment of a person

with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration.

9.2.4. A Director shall not be treated as having a pecuniary interest in any

contract, proposed contract or other matter by reason only:

9.2.4.1. of his or her membership of a company or other body, if he or she has no beneficial interest in any securities of that company or other body; or

9.2.4.2. of an interest in any company, body or person with which he or

she is connected which is so remote or insignificant that it cannot reasonably be regarded as likely to influence the Director in the consideration or discussion of or in voting on, any question with respect to that contract or matter; or

9.2.4.3. of any remuneration, compensation or allowances payable to a

Director by virtue of paragraph 18 of Schedule 7 of the 2006 Act; or

9.2.4.4. of any travelling or other expenses or allowances payable to a

Director in accordance with the Constitution. 9.2.5. Where a Director has an indirect pecuniary interest in a contract,

proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body and

9.2.5.1. the total nominal value of those securities does not exceed

£5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less, and

9.2.5.2. if the share capital is of more than one class, the total nominal

value of shares of any one class in which he or she has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class; the Director shall not be prohibited from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it, without prejudice however to the Director's duty to disclose his or her interest.

"Family Interest"

9.2.6. A "family interest" is an interest of the spouse or partner or of any parent, child, brother or sister of a Director which, if it were the interest of that Director, would be a personal interest or a pecuniary interest of his or hers.

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9.3. Register of Directors' Interests

9.3.1. The register of Directors' interests shall contain the names of each Director, whether he or she has declared any interests and, if so, the interests declared in accordance with the Constitution or these Standing Orders.

9.3.2. It is the obligation of the Director to inform the Secretary in writing within

7 Clear Days of becoming aware of the existence of a relevant or material interest. The Secretary must amend the appropriate register of interests upon receipt within 3 Clear Days.

9.3.3. The register of Directors' interests will be available to the public and the

Chairman will take reasonable steps to bring the existence of the register of interests to the attention of the local population and to publicise arrangements for viewing it. Copies or extracts of the register of interests must be provided to Members of the Trust free of charge and within a reasonable time period of the request. A reasonable charge may be imposed on non-members for copies or extracts of the register of interests.

9.3.4. In establishing, maintaining, updating and publicising the register of

interests, the Trust shall comply with all guidance issued from time to time by Monitor. The details of Directors’ interests recorded in the register of interests will be kept up to date by means of a regular review as necessary by the Chief Executive or the Secretary during which any changes of interests recently declared will be incorporated.

10. Standards of Business Conduct

10.1. Directors' Code of Conduct

A Director shall sign and deliver to the Secretary a statement set out in confirming his or her agreement to comply with the Directors' Code of Conduct and shall at all times comply with its provisions, with the provisions of the Trust's policies, procedures and Standing Financial Instructions and with Department of Health Guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff”, "Code of Conduct for NHS Managers"and Fit and Proper persons declaration..

10.2. Interest of Directors and Employees in Contracts

10.2.1. If it comes to the knowledge of a Director or officer of the Trust that a

contract in which he has any pecuniary interest not being a contract to which the Director is a party, has been, or is proposed to be, entered into by the Trust he or she shall at once give notice in writing to the Chairman or Secretary of the fact that he or she is interested therein. In the case of persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

10.2.2. A Director or officer must also declare to the Chairman or Secretary any

other employment or business or other relationship of his or hers, or of a cohabiting spouse or partner, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust in accordance with paragraph 9. The Trust shall require such interests to be recorded in the register of Directors' interests.

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10.3. Canvassing of, and Recommendations by, Directors in Relation to

Appointments

10.3.1. Canvassing of Directors or Members of any committee of the Board of Directors directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph 10.3.1 shall be included in application forms or otherwise brought to the attention of candidates.

10.3.2. A Director shall not solicit for any person any appointment under the

Trust or recommend any person for such appointment, but this shall not preclude a Director from giving written testimonial of a candidate's ability, experience or character for submission to the Trust in relation to any appointment.

10.3.3. Informal discussions outside appointment panels or committees, whether

solicited or unsolicited, should be declared to the panel or committee.

10.4. Relatives of Directors or Officers

10.4.1. Candidates for any staff appointment shall when making an application disclose in writing whether they are related to any Director or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

10.4.2. A Director or officer of the Trust shall disclose to the Chairman any

relationship between himself and a candidate of whose candidature that Director or officer is aware. It shall be the duty of the Chairman to report to the Board of Directors any such disclosure made.

10.4.3. On appointment, Directors (and prior to acceptance of an appointment in

the case of Executive Directors) should disclose to the Board of Directors whether they are related to any other member of the Board of Directors or holder of any office in the Trust.

10.4.4. Where the relationship to an officer or another Director to a Director of

the Trust is disclosed, the provisions of paragraph 9 above shall apply.

10.5. External Consultants

This paragraph 10 will apply equally to all external consultants or other agents acting on behalf of the Trust. The Trust's Scheme of Delegation should be adhered to at all times.

11. Instruments

11.1. Common Seal of the Trust

11.1.1. The Secretary shall keep the Common Seal of the Trust in a secure place.

11.1.2. The Common Seal of the Trust shall not be fixed to any documents

unless the sealing has been authorised by a resolution of the Board of Directors or of a committee thereof, or where the Board of Directors has delegated its powers.

11.1.3. Before any building, engineering, property or capital document is sealed

it must be approved and signed by the Finance Director (or an officer

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nominated by him or her) and authorised and countersigned by the Chief Executive (or an Officer nominated by him or her who shall not be within the originating Directorate).

11.1.4. The Secretary shall make and number consecutively an entry of every

sealing in a book provided for that purpose. Each entry shall be signed by the persons who shall have approved and authorised the document and those who attested the seal. A report of all sealing shall be made to the Board of Directors at least quarterly, giving details of the seal number, the description of the document and date of sealing.

11.2. Signature of Documents

11.2.1. Where the signature of any document will be a necessary step in legal proceedings involving the Trust, it shall be signed by the Chief Executive, unless any enactment otherwise requires or authorises or the Board shall have given the necessary authority to some other person for the purpose of such proceedings.

11.2.2. The Chief Executive or Nominated Officer shall be authorised, by

resolution of the Board of Directors, to sign on behalf of the Trust any agreement or other document (not required to be executed as a deed) the subject matter of which has been approved by the Board of Directors or committee or sub-committee to which the Board of Directors has delegated appropriate authority.

12. Status of Standing Orders

12.1. Standing Orders to be Given to Directors and Officers

The Secretary shall provide a copy of these Standing Orders to each Director and officer of the Trust and shall endeavor to ensure that each Director and officer understands his or her responsibilities within these Standing Orders. 12.2. Documents Having the Standing of Standing Orders The Scheme of Delegation (incorporating the Schedule of Matters reserved to the Board of Directors) and the Standing Financial Instructions (incorporating the Tendering and Contract Procedure) shall have effect as if incorporated into these Standing Orders. 12.3. Duty to Report Non-Compliance with Standing Orders All Directors and officers of the Trust have a duty to disclose any non-compliance with these Standing Orders to the Secretary as soon as possible. Full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Board of Directors for action or ratification. 12.4. Review, Variation and Amendment of Standing Orders

12.4.1. These Standing Orders, including all documents having effect as if incorporated in them, shall be subject to regular review by the Board of Directors at intervals not exceeding every three years.

12.4.2. As prescribed by paragraph 48 of the Core Constitution, amendment by

the Trust of its Constitution, including these Standing Orders, are to be made with the approval of the Board of Directors and the Council of Governors.

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12.4.3. No amendment of these Standing Orders shall be made unless:

12.4.3.1 relevant notice of a meeting has been served in accordance with paragraph 5.2 above;

12.4.3.2 a notice of motion under paragraph 5.3 has been given;

12.4.3.3 at least two-thirds of the Directors are present;

12.4.3.4 no fewer than half the total of the Trust’s Board of Directors vote in favour of amendment; and the amendment proposed does not contravene the Regulatory Framework, any statutory provisions or any guidance made by Monitor.

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ANNEX 8:

FURTHER PROVISIONS

(Paragraph 9) 1. Commitments

The Trust shall at all times exercise its functions effectively, efficiently and economically and operate in accordance with the NHS Core Principles and the Trust Core Principles as set out below.

1.1. NHS Core Principles

1.1.1. The NHS will provide a universal service for all based on clinical need,

not ability to pay. 1.1.2. The NHS will provide a comprehensive range of services. 1.1.3. The NHS will shape its services around the needs and preferences of

individual patients, their families and their carers. 1.1.4. The NHS will respond to different needs of different populations. 1.1.5. The NHS will work continuously to improve quality services and to

minimise errors. 1.1.6. The NHS will support and value its staff. 1.1.7. Public funds for healthcare will be devoted solely to NHS patients. 1.1.8. The NHS will work together with others to ensure a seamless service for

patients. 1.1.9. The NHS will help keep people healthy and work to reduce health

inequalities. 1.1.10. The NHS will respect the confidentiality of individual patients and provide

open access to information about services, treatment and performance.

1.2. Trust Core Principles

General

1.2.1. The Trust aims to provide the best possible patient care, based on evidence and in a culture that encourages continuous improvement.

1.2.2. The Trust will listen to patients and understand what they have to say

and encourage their involvement in decisions about their care. 1.2.3. The Trust will aim to provide a clean, healthy and welcoming hospital

environment for patients, visitors and staff. 1.2.4. The Trust will aim to improve the patient’s experience of care provided at

its Hospitals and by its services respecting their privacy and preserving their dignity.

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1.2.5. The Trust will have open and honest communications between staff and patients.

1.2.6. The Trust will recognise the contribution of staff by developing and

supporting them to do their jobs better, and involving them in decision-making.

1.2.7. The Trust will aim to provide high quality services through working in

partnership.

Representative Membership

1.2.8. The Trust must take steps to strive to ensure that, taken as a whole; its actual membership is representative of those eligible for membership.

1.2.9. To this end, the Trust shall at all times have in place and pursue a

membership strategy which shall be approved by the Council of Governors and shall be reviewed by them from time to time and at least annually.

1.2.10. The Council of Governors shall present to each annual meeting of the

Trust's Members:

1.2.10.1. a report on steps taken to secure that, taken as a whole, the actual membership of its constituencies and the classes of constituencies is representative of those eligible for such membership; and

1.2.10.2. the progress of the membership strategy; and 1.2.10.3. any changes to the membership strategy.

Co-operation with Health Service and Other Bodies

1.2.11. In exercising its functions the Trust shall co-operate with NHS bodies

and any local authority with which the Trust has a Local Authority Partnership Agreement under section 75 of the 2006 Act, or otherwise.

Respects for Rights of People

1.2.12. In conducting its affairs, the Trust shall respect the rights of the Members

of the community it serves, its employees and people dealing with the Trust as set out in the Charter of Fundamental Rights of the European Union.

2. Membership of the Trust

2.1. As provided by paragraphs 5 and 6 of the Core Constitution:

2.1.1. a person who lives in an area specified in Annex 1 as an area for a Public Constituency may become or continue as a Public member of the Trust;

2.1.2. a person who is employed by the Trust under a contract of employment

with the Trust may become or continue as a Staff member of the Trust provided that:

2.1.2.1. he or she is employed by the Trust under a contract of

employment which has no fixed term or has a fixed term of at least 12 months; or

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2.1.2.2. he or she has been continuously employed by the Trust under

a contract of employment for at least 12 months. 2.1.3. a person who exercises functions for the purposes of the Trust,

otherwise than under a contract of employment with the Trust, may become or continue as a member of the Staff Constituency provided that he or she has exercised these functions continuously for a period of at least 12 months.

2.2. Members may attend and participate at Members’ meetings, vote in elections to,

and stand for election to, the Council of Governors, and take such other part in the affairs of the Trust as is provided in this Constitution.

3. Disqualification from Membership of the Trust

3.1. Notwithstanding the provisions of paragraphs 5 and 6 of the Core Constitution, a person may not be a member of the Trust if:

3.1.1. he or she is under 14 years of age at the time of his application to

become a member;

3.1.2. during the five years prior to his or her application, he or she has demonstrated aggressive or violent behavior at any hospital or towards any person working for an NHS body and following such behavior he or she has been asked to leave, has been removed or excluded from any hospital or other NHS establishment under either the Trust’s or other NHS body's policy for withholding treatment from violent/aggressive patients (zero tolerance), or equivalent;

3.1.3. he or she is otherwise ineligible under paragraph 12 of the Core

Constitution to be a member;

3.1.4. he or she has been confirmed as a vexatious complainant.

3.1.5. he or she has been removed as a member from another NHS Foundation Trust;

3.1.6. he or she is the subject of a Sex Offenders Order and/or his name is

included in the Sex Offenders Register;

3.1.7. the Council of Governors resolves (in accordance with the procedure for expulsion set out at paragraph 4 below that for reasonable cause his or her so doing would, or would be likely to:

3.1.7.1. prejudice the ability of the Trust to fulfill its principal purpose or

other of its purposes under this Constitution or otherwise to discharge its duties and functions; or

3.1.7.2. harm the Trust’s work with other persons or bodies with whom

it is engaged or may be engaged in the provision of goods and services; or

3.1.7.3. adversely affect public confidence in the goods or services

provided by the Trust; or

3.1.7.4. otherwise bring the Trust into disrepute.

3.2. It is the responsibility of each member to ensure his or her eligibility at all times and not the responsibility of the Trust to do so on his or her behalf. A member who becomes aware of his or her ineligibility shall inform the Trust as soon as

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practicable and that person shall thereupon be removed forthwith from the register of Members and shall cease to be a member.

3.3. Where the Trust has reason to believe that a member or applicant for membership

may be ineligible for membership or may be disqualified for membership under this Constitution, the Secretary shall carry out reasonable enquiries to establish if this is the case.

3.4. Where the Secretary considers that there may be reasons for concluding that a

member or applicant for membership may be ineligible or be disqualified for membership, he or she shall advise that individual of those reasons in summary form and invite representations from the member or applicant for membership within 21 days or such other reasonable period as the Secretary may in his or her absolute discretion determine. Any representations received shall be considered by the Secretary and he or she shall make a decision on the member’s or applicant’s eligibility or disqualification as soon as reasonably practicable and shall give notice in writing of that decision to the member or applicant within 14 days of the decision being made.

3.5. If no representations are received within the period of 21 days or longer period (if

any) permitted under paragraph 3.4 above, the Secretary shall be entitled to proceed and make a decision on the member’s or applicant’s eligibility or disqualification notwithstanding the absence of any such representations from him or her.

3.6. Upon a decision being made under paragraphs 3.4 or 3.5 above that the member

or applicant is ineligible or disqualified for membership the member’s name shall be removed from the register of Members forthwith and he or she shall cease to be a member.

3.7. Any decision made under paragraphs 3.4, 3.5 or 3.6 to disqualify a member or

applicant for membership may be referred by the member or applicant concerned to the dispute resolution procedure under paragraph 7 below.

4. Expulsion from Membership of the Trust

4.1. A member may be expelled by a resolution approved by not less than two-thirds of the Members of the Council of Governors present and voting at a meeting of the Council of Governors. The procedure set out below is to be adopted.

4.2. Any member or Director may complain to the Secretary that another member has

acted in a way detrimental to the interests of the Trust, or is otherwise disqualified as set out in paragraph 3 above.

4.3. If a complaint is made, the Council of Governors may itself consider the complaint,

having taken such steps as it considers appropriate, to ensure that each member's point of view is heard and may either:

4.3.1. dismiss the complaint and take no further action; or 4.3.2. arrange for the next meeting of the Council of Governors to consider a

motion for the expulsion of the member complained of. 5. Termination of Membership A member shall cease to be a member of the Trust on:

5.1. death; 5.2. resignation by notice in writing to the Secretary;

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5.3. ceasing to fulfill the requirements of paragraphs 5 or 6 of the Core Constitution, as

the case may be; 5.4. being disqualified pursuant to paragraph 12 of the Core Constitution or paragraph

3 above; or 5.5. being expelled pursuant to paragraph 4 above.

6. Indemnity

6.1. Members of the Council of Governors and the Board of Directors (including the Secretary) who act honestly and in good faith will not have to meet out of their personal resources any personal civil liability which is incurred in the execution or purported execution of their functions, including (but not limited to) any liability arising by reason of the Trust acting as a Corporate Trustee, save where they have acted recklessly. Any costs arising in this way will be met by the Trust.

6.2. The Trust may purchase and maintain insurance against this liability for its own

benefit and for the benefit of Members of the Council of Governors and the Board of Directors (including the Secretary) and may participate in risk pooling schemes, including (but not limited to) insurance and schemes operated by the NHS Litigation Authority.

7. Dispute Resolution Procedure

7.1. In the event of any dispute about the entitlement of a person to membership of the Trust, the dispute shall be referred to the Secretary who shall make a determination on the point in issue. If the person (whether or not a member) is aggrieved at the decision of the Secretary he or she may appeal in writing within 14 days of the Secretary’s decision to the Council of Governors, whose decision shall be final.

7.2. In the event of dispute between the Council of Governors and the Board of

Directors:

7.2.1. in the first instance the Senior Independent Director (or another independent Non-Executive Director, if the Senior Independent Director has a conflict of interest), on the advice of the Secretary, and such other advice as the Senior Independent Director may see fit to obtain, shall seek to resolve the dispute;

7.2.2. if the Senior Independent Director is unable to resolve the dispute he or

she shall appoint an ad hoc Dispute Resolution Committee comprising equal numbers of Non-Executive Directors and Governors to consider the circumstances and to make recommendations to the Council of Governors and the Board of Directors with a view to resolving the dispute;

7.2.3. if the recommendations, if any, of the Dispute Resolution Committee are

unsuccessful in resolving the dispute, the Senior Independent Director (or another independent Non-Executive Director, if the Senior Independent Director has a conflict of interest) may refer the dispute to an independent assessor agreeable to both parties, for adjudication. The assessor’s decision will be binding and conclusive on all parties.

8. Notices

8.1. Any notice required by this Constitution to be given shall be given in writing or shall be given using electronic communications to an address for the time being

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notified for that purpose. “Address” in relation to electronic communications includes any number or address used for the purpose of such communications.

8.2. Proof that an envelope containing a notice was properly addressed, prepaid and

posted shall be conclusive evidence that the notice was given. A notice shall be treated as delivered 48 hours after the envelope containing it was posted or, in the case of a notice contained in an electronic communication, 48 hours after it was sent.

9. Prohibition on Distribution

The profits or surpluses of the Trust are not to be distributed either directly or indirectly in any way at all among Members of the Trust.

10. Dissolution of the Trust

The Trust may not be dissolved except by order of the Secretary of State for Health, in accordance with the 2006 Act, as amended by the 2012 Act

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1 | P a g e U:\Trust Board & Committees\Public Trust Board\2015-2016\November 2015\2015_11_26_Board_of_Directors_Paper_11_Deloitte_2_Final_Report.docx


NOVEMBER 2015

Executive Responsible John Grinnell, Acting Chief Executive


Ann Ashworth, Trust Secretary







Executive Summary

The Trust commissioned Deloitte LLP to undertake a review following Whistleblowing allegations. The conclusions and findings from the report are attached and include an action plan to address in full the findings and recommendations from the review.

Subject/Title Deloitte 2 Final Report


For Discussion

For Approval


Recommendation The Board of Directors are asked to approve the attached report and action plan.

Acronyms and

Abbreviations

RTT HR DoO DN DDSD NEDs BMs CoG CCG PTL DNSD BAF

Referral to Treatment Human Resources Director of Operations Director of Nursing Deputy Director of Service Delivery Non-Executive Directors Board Members Council of Governors Clinical Commissioning Group Patient Tracking List Director of Nursing & Service Delivery Board Assurance Framework

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NOVEMBER 2015

DELOITTE 2 FINAL REPORT

Executive summary

This Report details the findings of an independent review into Whistleblowing allegations at the Robert Jones and Agnes Hunt NHS Foundation Trust (RJAH) or ‘The Trust’. This Report should be read in conjunction with our earlier report (June 2015) into RTT reporting processes at the Trust, known hereafter as the Deloitte Phase One Report. The Deloitte Phase One Report concluded that there was long-standing misreporting in relation to RTT (between December 2013 and January 2015). Indeed, this was the second time that the Trust had been investigated by Monitor for issues in relation to RTT reporting, the first having been in 2013; although concerns were raised initially by Monitor in 2011/12. The Terms of Reference for this review, which were drafted in response to whistleblowing concerns raised to Monitor in March 2015, focused predominantly upon RTT reporting and operational processes but also highlighted concerns around leadership, clinical engagement and organisational culture. This Report documents a range of issues which became significant to us during our review. We have grouped these issues thematically in the following order:

• RTT misreporting and the operational context;

• Executive Team leadership;

• Board leadership, insight and scrutiny; and

• Culture, engagement and the role of HR.

Our independent review found a number of material issues which can be said to support a number of the concerns raised by the whistleblower. These issues, or contributory factors, are summarised on page 6. The key question raised within the whistleblower’s allegations was whether there was deliberate and systematic fraud of waiting list performance at the Trust. It has not been possible to answer this question definitively on the basis of the evidence we have gathered as part of this review. However, it is reasonable to conclude the following:

• Delivering RTT at the RJAH is a complex undertaking which requires significant daily

operational input and sustaining this focus has been an issue;

• There was conviction that the original validations were correct, although these began to be

applied in significantly ‘stretched’ numbers;

• There was a pressurised culture where staff, at all levels, felt that there was ‘no option of

failure’;

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• An ‘inhibited’ culture had developed particularly amongst the Executives but there is evidence

of the proliferation of this throughout the Trust’s senior management;

• Executives were placed in charge of the RTT who did not have sufficient knowledge of the

subject and for several months they had no ‘expert’ in post;

• When concerns were eventually raised by junior staff there was no decisive decision making

undertaken by an Executive.

• The Board were not formally informed on the occurrence of these issues for a four month

period; and

• Other assurances, such as Internal Audit and the Intensive Support Team (IST), were unlikely

to identify these challenges because timings were out of step.

Our report examines the above issues in more detail and documents some material sensitivities in relation to culture and leadership at the Trust. The key findings of this review include: RTT misreporting and the operational context:

• The Trust is undoubtedly operating in a complex environment where it is managing different

national access standards between Welsh and English patients. As a smaller Trust, RJAH

has struggled to attract senior and experienced leadership and senior management turnover

in some posts has been high.

• The whole-scale challenges involved in ensuring RTT compliance are significant and demand

intensive daily operational management. RJAH has had a small team managing the

operations, validation and data quality surrounding RTT and there have been gaps in the line

management chain. Closer working between teams had been implemented; however, there

were fractured relationships in some key areas leaving more junior members of staff

unsupported.

• There are multiple contributory factors in relation to how the Trust submitted incorrect

performance data. The small group of staff responsible for applying validations were working

within a target driven culture where several staff stated that ‘failure was not an option’. A

range of exclusions had been developed which we are led to believe have been externally

validated, although we have not seen any evidence of any external validation. In an

environment of increasing pressure, where there was limited support, these rules were

applied in increasing numbers to validate and exclude patients.

Leadership of the Trust

• The Executive Team is comprised of individuals most of whom are in their first board level

appointment. The size of the team was reduced when the experienced DoO left in 2014 and

the role was transferred into the DN’s portfolio (who had very limited experience of RTT). This

move put the organisation at risk, particularly in relation to RTT reporting.

• A culture of inhibition has been allowed to develop amongst the Executive Team. Executives

are sometimes fearful of ‘bringing bad news to the table’ as they are often met with an

unpredictable response. Some Executives do receive positive feedback from peers and staff;

however, the Executive Team as a whole has failed to tackle issues collectively in a

comprehensive way.

• There are tensions in the Executive Team in relation to the decision making process. A

‘command and control’ approach is said to have been adopted where there is limited

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collective decision making. Unilateral decisions have been made, particularly in relation to the

timely escalation of RTT issues to the Board, the extent to which expert advice has influenced

the course of action and in the area of HR.

• One or more very senior managers are not thought to be sufficiently visible within the

organisation and there is a sense that they have become more disconnected from other

managers over time. There are various views expressed around the visibility of other

Executives.

• There is significant pressure upon the senior management tier within the Trust and in some

key roles there has been significant turnover. There are a number of critical reasons for this

turnover which require a whole organisation response to resolve. Pressure to deliver has

been pushed down into the organisation and whilst staff say they are supported locally by

managers, they are clearly aware of leadership issues with the senior managers.

• More recently, a Leadership Strategy has been developed and approved by the Board as well

as a suite of actions in relation to organisation development. Crucially, this has involved an

increase in Executive Team engagement.

• There are mechanisms for staff to raise concerns at the Trust, although there is an over-

reliance upon this being done through the line management process. Some of the staff

involved in RTT were reluctant to raise concerns through this process in response to some of

the more subtle pressures around data validation which were felt.

• When staff did raise concerns in relation to RTT, the Executives did not exercise sufficient

leadership in their response. A decision was made to wait until the new DDSD arrived in post

leaving a critical and substantial time period where further misreporting could have been

prevented.

Board leadership, insight and scrutiny

• The Board is comprised of a range of experienced NEDs. There is a programme of Board

development in place; however, this has not explicitly covered training around the

complexities of RTT, meaning that BMs had limited overall understanding of where to

challenge in this key area. In addition to this, Executives displayed some reluctance to get

involved in RTT prior to the DN and DoO roles being combined.

• Some staff interviewed during our review said that the CoG have been remote from the

Board and that they would benefit from increased development.

• The CCG are able to connect with the Trust on a regular basis and have found the Trust to

be, on the whole, inclusive. The CCG were concerned about the plans to combine the

DN/DoO roles and indicated this to the Trust.

• The CCG had in the past been given assurances around RTT data and had limited reasons to

further scrutinise the information presented until they became concerned about issues in

relation to the PTL in February 2015.

• There was some useful rationale for combining the DN/DoO roles; however a proper

evaluation of the risks surrounding this decision was not undertaken. Making the role interim

for a period of six months and also plans to recruit a new Deputy Director of Service Delivery

were thought to be sufficient mitigations. When the role evaluation occurred in January 2015,

NEDs accepted the reassurance that the role was working effectively (they had also received

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positive feedback from members of the Executive Team). Whilst there was no documented

challenge from NEDs, we understand that challenge did take place.

• The Board sees a broad range of information, however, the BAF is not used as an effective

tool for the Board to identify, monitor and challenge key organisational strategic risks. The full

profile of risks relating to RTT performance are not sufficiently captured in the BAF. The work

of the Board does not clearly influence what is recorded in the BAF and ultimately, the validity

of the risk profile of the Trust.

• The Board has had access to several reviews which have aimed to test RTT reported data

and data quality. The work of the IST and Internal Audit however, preceded the RTT

exclusion issues which began in December 2013. A further (re) review in September 2014

would have also failed to detect issues and to bring these to the attention of Audit Committee.

Culture, engagement and the role of HR

• The Trust has performed well overall in the national staff survey; however, this still indicated

some levels of concern around the extent to which staff have access to regular appraisals,

poor communication between staff and senior managers and raising concerns knowing that

these will be addressed.

• The Deloitte staff survey highlighted the extent of blame culture at the trust and the

disconnect between senior managers and teams

• It is clear that some consultants have readily engaged in trying to help resolve some of the

issues around RTT. However, clinical engagement has had varying degrees of success.

• HR has a complicated role in the organisation. On the whole HR undertake some of their

duties well and provide information in line with what we would expect to find. However, there

are occasions where the role and advice of HR has been bypassed.

We have made a limited number of recommendations in this report in part, because of the investigative profile of the review. The Trust has already begun to progress some of the more operational recommendations from the Deloitte Phase One Report. Overall, the Board must decide how the findings of this Report will impact the current leadership at the Trust. In addition to this, recommendations which have been made in this report are including within the action plan on Page 7

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Contributory Factors Diagram

RTT Reporting

Errors

Referral complexity

Recruitment and retention

Management structures

Target driven environment

Reluctance to raise concerns

‘Inhibited’ Executives

CEO leadership style

Operational Context Trust Leadership

Low visibility of leaders

Other assurances taken

Remote CoG

Limited decision making

Low visibility on issues

Board leadership Culture and HR

Staff ‘burnout’

Tackling Consultants

Communication

HR side-stepped

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Action Plan

RTT misreporting and the operational context

Recommendation Response Who By When

R1: The Trust should ensure that line management structures are appropriate to allow for sufficient lines of seniority around the cascade (and escalation) of Trust information. Ensure that Director posts are sufficiently supported by well-designed deputy arrangements as this will also aid succession planning and support the deliverability of key posts.

Strengthened Interim arrangements in place with Deputy backfill. Key objectives and line managerial responsibilities in place, Permanent structure to be agreed upon commencement of permanent Chief Executive Officer. Regular face-to-face sessions between Directors and support roles on key RTT issues.

Acting chief Executive/Chair

31st March

2016

R2: The Trust should introduce a formal monthly; Executive led Operations Board which includes all service leads, clinical leads, operational management teams and information support staff to ensure complete visibility on performance, actions and operational risks.

Clinical Management Board broadened to include service managers. Strengthened and more formal operational meetings in place. Substantive Chief Executive Officer to finalise meeting structure to best support organisation delivery. Acting Chief Executive Officer undertaking pro-active engagement with clinical leads

Acting Chief Executive Officer

31st March

2016

Leadership of the Trust

R3: The Board must resolve some of the entrenched issues with leadership behaviours and the culture within the Executive Team.

Demonstrable evidence of appropriate values used in Chief Executive Officer and Director appointments. Ongoing programme of development to be established to include openness, involvement, engagement, etc. New Communication Strategy being constructed.

Executive Team 31st March

2016

R4: It is necessary for a programme of Executive development to take place to ensure the cohesiveness of the Executive Team; this should be done when all substantive recruitment is complete. There is also a requirement for some individual executive coaching to take place as part of this development.

A programme of Executive development will be planned for 2016-17

Acting Chief Executive/Chief Executive

30th June

2016

R5: The Trust is working on plans to increase Executive visibility through the OD action plan, however, more must be done to provide clear and visible senior leadership at the Trust (through for example, the introduction of an Operations Board) and to ensure that leaders are acting in line with the Trust values at all times.

Acting Director of Nursing to develop a series of plans to ensure greater Executive and Non Executive visibility

Acting Director of Nursing

31st

January 2016

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R6: Ensure that the implementation of the new Leadership Strategy is evaluated at regular intervals by the Board. In addition to this a range of additional KPIs should be developed to present ‘early warning signs’ to the Board where issues are starting to arise, for example management turnover.

To be reviewed quarterly with KPIs for targets to be developed

Associate Director of Human Resources supported by Non Executive Director Hilary Pepler via Quality & Safety Committee

31st

January 2016

R7: Additional mechanisms should be developed to enable staff to raise concerns such as email addresses or hotlines. These should be well publicised throughout the Trust.

E-guide to raising concerns and e-mail for raising concerns to be introduced

Associate Director of Human Resources supported by Non Executive Director Hilary Pepler via Quality & Safety Committee

31st

December 2015

Board insight, scrutiny and impact

R8: The Council of Governors should increase their overall connectivity to the work of the Board and additional training and development around how to seek assurance on various aspects of risk and performance will be beneficial.

Effective Questioning and Challenge training provided June 2015. Involvement in Executive Director recruitment undertaken. Encourage involvement in Sit and See on Wards. Future training requirements to be identified. Joint Board of Directors/Council of Governor meetings to be a feature of the 2016 meetings agenda.

Trust Secretary/Chairman

28th

February 2016

R9: Ensure that there is sufficient expert input from clinical and managerial leads at Audit Committee to better support and challenge the production of review terms of reference for internal audit.

Terms of reference are being scrutinised by the relevant Director and Executive Team. Risk coverage will be scrutinised by the audit committee. Attendance when appropriate is made at Audit Committee to discuss relevant terms of reference.

Exec Team Immediate

R10: The quality of Board minutes must improve to accurately reflect the levels of challenge which are taking place.

All Board of Directors and Committee minutes now reflect the fuller debates to include challenges that have taken place

Trust Secretary Immediate

Culture, engagement and the role of HR

R11: Ensure a range of ‘staff stories’ are brought to the Board and BMs should increase their visibility within teams to ensure that they are using ‘soft intelligence’ sufficiently to support the hard data received at the Board.

Staff stories to be incorporated into Board of Director meetings. Board members will also be encouraged to bring back the intelligence observed from their ward/department visits back to the Board of Directors

Board of Directors 31st

January 2016

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R12: Ensure that there is sufficient support within the HR department to ensure that HR have the capacity to work in both a strategic and an operational way to support the needs of the organisation and the needs of staff.

To be assessed when the substantive Chief Executive commences in the Trust

Chief Executive Office 31st March

2016