The meeting of the Board of Directors
To be held on Tuesday 27 September 2016 at 9 a.m. in the Boardroom, Montagu Hospital
AGENDA Part I
Enclosures
1. Apologies for absence (Verbal)
2. Register of Directors’ Interests and ‘Fit and Proper Person’ Declarations Enclosure A
3. To approve: Minutes of the meeting held on 23 August 2016 Enclosure B
4. Actions from the previous minutes Enclosure C
5. Matters Arising (Verbal)
6. Chair’s correspondence (Verbal) Chris Scholey – Chair
7. Chief Executive’s Report Enclosure D Mike Pinkerton – Chief Executive
Strategy 8. To approve: Enclosure E Working Together Transformation Programme: Children’s Surgery & Anaesthesia and Hyper Acute Stroke Service Mike Pinkerton – Chief Executive
9. To note: Enclosure F Strategy & Improvement Report Dawn Jarvis – Director of Strategy & Improvement
10. To approve Enclosure G Procurement Strategy Jeremy Cook - Interim Director of Finance
Performance 11. To note: Enclosure H Finance Report as at 31 August 2016 Jeremy Cook – Interim Director of Finance
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12. To note: Enclosure I Business Intelligence Report as at 31 August 2016 David Purdue – Chief Operating Officer Sewa Singh – Medical Director Richard Parker – Director of Nursing, Midwifery & Quality
13. To note: Enclosure J Nursing Workforce Richard Parker – Director of Nursing, Midwifery & Quality
Governance 14. To note: Enclosure K NHS Improvement Undertakings Tracker Matthew Kane – Trust Board Secretary
15. To note: Enclosure L Single Oversight Framework Matthew Kane – Trust Board Secretary
16. To approve: Enclosure M Whistleblowing/Raising Concerns Policy Richard Parker – Director of Nursing, Midwifery & Quality
17. To approve: Enclosure N Annual Statement of Compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR) David Purdue – Chief Operating Officer
Sub-committees of the Board 18. To note: Enclosure O Minutes of the Management Board meeting held on 30 August 2016 (to follow) Mike Pinkerton – Chief Executive
19. To note: Enclosure P Minutes of the Audit & Non-clinical Risk Committee held on 24 June 2016 (to follow) Philippe Serna – Chair of the Audit & Non-clinical Risk Committee
20. To note: Enclosure Q Minutes of the Financial Oversight Committee held on 22 August 2016 John Parker – Chair of the Financial Oversight Committee
21. Items escalated from sub-committees
22. Any other business
23. Governor questions regarding the business of the meeting
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24. Date and time of next meeting Date: 25 October 2016 Time: 09:00 Venue: Boardroom, Doncaster Royal Infirmary
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Doncaster & Bassetlaw Hospitals NHS Foundation Trust Register of Directors’ Interests and ‘Fit and ‘Proper Person’ Declarations
Register of Interests
Alan Armstrong Director, Armstrong Logic Limited (consultancy)
Jeremy Cook, Interim Director of Finance Managing Director and 50% shareholder, J&CA Limited
David Crowe, Non-Executive Director Lay Member, Employment Tribunal Panel, Leeds Member, Central Arbitration Committee Trustee, Bransby Horses Ltd
Dawn Jarvis, Director of Strategy & Improvement Assessor, Civil Service Fast Stream Honorary Lecturer, Academic Unit of Medical Education, University of Sheffield
Martin McAreavey, Non-executive Director Associate Professor, University of Leeds Honorary Consultant, Public Health England
John Parker, Non-Executive Director Senior Lecturer, Sheffield Hallam University
Mike Pinkerton, Chief Executive Trustee, Well Community Projects, Retford Board representative for CEO South, Yorkshire & Humber Academic Health Science Network
Philippe Serna, Non-Executive Director Spouse of director, Premier Care Direct Ltd (renal patient transport provider in Doncaster & Bassetlaw)
Chris Scholey, Chairman Director, Sheffield City Region Local Enterprise Partnership Member, Rotherham Economy Board
Sewa Singh, Medical Director Director, Veincure Ltd (the company currently has no conflict of interest with the Trust)
The following have no relevant interests to declare: Karen Barnard Director of People & Organisational Development Richard Parker Director of Nursing, Midwifery & Quality David Purdue Chief Operating Officer
(as at 19 September 2016)
Fit and Proper Person Declarations
The Trust can confirm that every director currently in post has declared that they:
(i) are not an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged; (ii) are not the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; (iii) are not a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986; (iv) have not made a composition or arrangement with, or granted a trust deed for, their creditors and not been discharged in respect of it; (v) have not within the preceding five years been convicted in the British Islands of any offence and 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 them; (vi) are not subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986; (vii) have the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed; (viii) are able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed; (ix) have not been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity; (x) are not included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; (xi) are not prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment; (xii) have not been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence; (xiii) have not been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals; and (xiv) have not been dismissed from paid employment otherwise than by reason of redundancy, by the coming to an end of fixed term contract or through ill health.
Directors are requested to note the above and to declare any changes to their position as appropriate in order to keep their declaration up to date.
(as at 19 September 2016)
Minutes of the meeting of the Board of Directors held on Tuesday 23 August 2016 in the Boardroom, Bassetlaw Hospital
Present: Chris Scholey Chairman Alan Armstrong Non-executive Director Karen Barnard Director of People & Organisational Development Jeremy Cook Interim Director of Finance David Crowe Non-executive Director Dawn Jarvis Director of Strategy & Improvement Martin McAreavey Non-executive Director Richard Parker Director of Nursing, Midwifery & Quality Mike Pinkerton Chief Executive David Purdue Chief Operating Officer Philippe Serna Non-executive Director Sewa Singh Medical Director
In attendance: Ken Agwuh Director of Infection Prevention & Control Matthew Kane Trust Board Secretary Hailey Pottinger Observing Adam Tingle Communications Manager
ACTION Welcome and apologies for absence 16/8/1 Apologies were received from Chris Mellor and John Parker.
16/8/2 The Chair extended a warm welcome to Anthony Jones, recently appointed Deputy Director of People and Organisational Development, Adam Tingle, Communications Manager (standing in for Emma Bodley, Head of Communications and Engagement) and Hailey Pottinger, an NHS Graduate Trainee who was based at Rotherham, Doncaster and South Humber Hospitals NHS Foundation Trust.
Register of directors’ interests and ‘Fit and Proper Person’ declarations 16/8/3 No changes were noted.
Minutes of the meeting held on 26 July 2016 16/8/4 The minutes of the meeting of the Board of Directors held on 26 July 2016 were APPROVED as a correct record, subject to the following amendments:
16/8/5 16/7/26 – Replace “stakeholders” with “national leaders”.
16/8/6 16/7/27 – Replace “Providers” in the second sentence with “Commissioners”.
16/8/7 16/7/42 – Insert the word “medical” before “productivity”.
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16/8/8 16/7/43 – Replace the last sentence with “Proposal for turnaround projects would be taken through relevant committees”.
16/8/9 16/7/35 – Replace “following the successful trial” with “if the trial proved successful”.
16/8/10 16/ 7/72 – Replace “agency spend” with “agency doctors’ supplier”.
16/8/11 16/ 7/73 – Add “%” at the end of 4.62.
16/8/12 16/ 7/93 – Replace “good” with “adequate”.
Actions from the previous minutes 16/8/13 The action notes from the meeting held on 26 July 2016 were reviewed and updated.
16/8/14 16/7/51 – It was reported that a reformatted finance report would be presented in September (not August) 2016 following meetings with the newly appointed Director of Finance and Board Advisor.
16/8/15 16/7/62 (a) – Responsibility for this action was reallocated to David Purdue. Follow-up ratios would be monitored by Board as well as Financial Oversight Committee.
16/8/16 16/7/62 (c) – Responsibility for this action was reallocated to Richard Parker. Further clarity would be sought regarding the process for Board to receive two anonymised complaints each month along with their responses.
Matters arising 16/8/17 16/7/86 – Board clarified that they wished to see the list of policies and their approval routes with any new policies coming before Board of Directors who would then decide whether or not to delegate.
16/8/18 The Board reiterated their wish to see in the minutes individual non- executives directors’ contributions at meetings attributed to them personally. This was so that appropriate challenge and holding to account could be demonstrated.
Chair’s correspondence The Board considered a report of the Chair which outlined the following:
16/8/19 Timeout - The next Board of Governors’ Timeout would take place on Monday 5 September 2016 at 9am at Bassetlaw Hospital. Topics included internal audit, the STP, patient pathway admin redesign and medical imaging.
16/8/20 Dennis Benfold – It was with regret that the Chair advised of the
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resignation of Doncaster Governor, Dennis Benfold, on grounds of ill health. The Chair placed on record his gratitude to Mr Benfold for his pragmatic and common sense approach on the Board of Governors.
16/8/21 Annual Members’ Meeting (AMM) and Board of Governors - The AMM would take place on 21 September from 4pm at The Ivanhoe Centre.
16/8/22 Non -executive Director recruitment – The Appointments and Remuneration Sub-Committee of the Board of Governors had resolved to advertise for a replacement non-executive director following Geraldine Broderick’s departure. This would go live from early September.
16/8/23 Care groups – The Chair reported on a recent visit to the medical imaging section where he praised the work of staff but warned of pressures on CT scanning despite the Birch work undertaken.
16/8/24 Stroke services - In view of likely capacity issues within stroke services at other local trusts, the Chair felt it was important that a financial case was assembled to show the likely to impact on the Trust. Pinch points within the appointments department, which was currently dealing with 10,000 appointments per month, was emphasised.
16/8/25 Care Quality Commission Inspections – It was reported that the Trust was likely to be subject to a revisit in early 2017 and the format was briefly outlined. The importance of preparedness for the visit was emphasised.
16/8/26 The Chair’s correspondence was NOTED.
Chief Executive’s report
16/8/27 The Board considered a report of the Chief Executive which outlined the following:
16/8/28 Sustainability and Transformation Plans – PwC had been employed by CCGs to provide financial analysis to support the financial bridge and workstream contributions to close the financial gaps identified.
16/8/29 It was reported that the STP were exploring collaboration within ‘back of house’ services which would include services that had previously not been considered appropriate for closer collaborative working.
16/8/30 Working Together Partnership (WTP) – A number of reports had been received from the WTP for presentation to September’s Board which included the children’s surgery and anaesthesia and hyper acute stroke services options appraisals and chemotherapy outreach review and case for change.
16/8/31 NHS Improvement Support –NHS Improvement (North) had advised of the support they would provide to providers moving forwards. The Trust would be hosting a regional launch event on 5 September. Significant
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learning would be shared with the Board through the business intelligence reports.
16/8/32 Hospital Acquired Pressure Ulcers (HAPU) – It was reported that the MSK&F Care Group had reached 100 days without a serious HAPU. This was a noteworthy achievement for the Care Group and a result of their hard work over the past two years.
16/8/33 Trauma Peer Review – The annual peer review of trauma had recently taken place. Feedback was positive with the 11 concerns being relatively minor. Actions would be addressed in an action plan in anticipation of the final report.
16/8/34 Wellbeing at Work – The Trust had successfully achieved the Nottinghamshire Wellbeing at Work Silver Award, building on the Bronze Award achieved in October 2015.
16/8/35 Appointments – It was reported that Jon Sargeant had been appointed Director of Finance and would commence in post at the end of October 2016. Simon Marsh had been appointed Chief Information Officer and had commenced in post on 5 August.
16/8/36 Breast Oncology – An update was provided in relation to the service at Bassetlaw which was provided by Sheffield Teaching Hospitals. The Trust was briefed on 7 July about imminent maternity leave affecting the consultants providing the oncology service. As a result a decision was taken to relocate breast oncology clinics to Doncaster for a temporary period.
16/8/37 Understanding that this change would affect stakeholders, arrangements were made to advise Governors and non-executive directors as soon as the news had been cleared by Sheffield Teaching Hospitals. It was understood that whilst this may have represented a small change for STH its impact upon Bassetlaw patients had not been underestimated and actions were taken as speedily as possible to inform all relevant parties.
16/8/38 The Chief Executive’s report was NOTED.
Infection Control Annual Report
16/8/39 The Board considered the annual report of the Director of Infection Prevention that provided the 2015/16 infection prevention and control annual report.
16/8/40 There had been two cases of MRSA in 2015/16, one of which was avoidable. In response to a question from David Crowe, Board was assured that appropriate sepsis screening was now in place and there was greater awareness about the effects of intravenous paracetamol that often masked sepsis.
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16/8/41 Cases of C. Diff had been reduced by 20% in the year with only five lapses in care against a benchmarked standard of no more than 12 cases. The only area that had seen an increase in cases of C. Diff was specialty services.
16/8/42 The Trust compared well in respect of other hospital acquired infections and had seen a 1% reduction from 4.3% since 2014/15. It had also implemented the findings of the independent review into surgical site infection, undertaken rigorous water quality testing and hand hygiene work and achieved CQUIN targets relating to AMR, sepsis and flu targets.
16/8/43 It was reported that the Trust had experienced challenges in the deep cleaning of wards due to staffing levels but recruitment was taking place which should see the level of deep cleans return to normal levels. In response to a question from Alan Armstrong, the Director of Infection Prevention confirmed that the Trust ran hand hygiene campaigns but that this needed to be focussed on clinicians as much as the public.
16/8/44 Concerns were raised regarding the inclusion of executive directors in Infection Prevention Control Committee attendance figures which were shown as zero. It was agreed that this would be removed from further reports as executive director attendance at the Infection Prevention Control Committee was not required.
16/8/45 In response to a question from Martin McAreavey, Board was advised that the team were managing sepsis management alongside the CCG. The Chair reiterated the Trust’s zero-tolerance approach towards MRSA.
16/8/46 The Board NOTED the annual report of the Director of Infection Prevention.
Strategy & Improvement Report
16/8/47 The Board considered a report of the Director of Strategy and Improvement that included updates on CIP progress, recovery and financial sustainability plans, the strategic planning process and approval of the two year recovery plan.
16/8/48 The report highlighted that savings to month 4 were £2.799m, £0.542m ahead of the original plan and £0.036m ahead of the stretch plan. Total CIPs for 2016/17 amounted to some £11m with internal stretch targets of £13m.
16/8/49 The Board was advised that month 4 had been challenging in respect of delivery of cost improvement plans (CIPS) especially in relation to two workstreams. These issues had been escalated to Financial Oversight Committee and actions had been agreed to get them back on track by month 5.
16/8/50 A detailed review of spending for all areas of the Trust would take place as
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month 4 budget reports became available and would be reconciled against the outcomes of the second round of Grip and Control meetings which had taken place.
16/8/51 Four issues had been escalated at the last Financial Oversight Committee, these being around finance support to prepare business cases for turnaround workstreams as well as the medical productivity, income and infrastructure workstreams. Presentations from each of these workstreams would be given at the next Financial Oversight Committee. The main workstream of concern was infrastructure which had seen several changes in personnel and required additional financial support.
16/8/52 Referring to a presentation given at Financial Oversight Committee by the Infrastructure Team in July 2016, David Crowe expressed concern with regard to the current status of projects within the Infrastructure workstream.
16/8/53 Executive Directors sought to reassure Board that a number of projects including catering, parking and facilities had changed but that they were not aware that inaccurate information had been provided to the Committee. It was felt that in order to provide continuity, senior officers should ensure they were present for workstreams where plans or personnel were subject to change.
16/8/54 Details of the planned strategic framework and financial sustainability strategy were also outlined together with the draft Tunaround Plan which would be considered in part two of the meeting.
16/8/55 The Strategy and Improvement Report was NOTED.
Clinical Audit Strategy and Policy
16/8/56 The Board considered a report of the Medical Director and Deputy Director of Quality and Governance which set out the Clinical Audit Strategy and Policy for approval.
16/8/57 The strategy and policy set out a strategic approach to clinical audits, highlighted how resources would be prioritised, made specific links to the Trust’s objectives and Board Assurance Framework and reflected the change to the typical local audits that doctors in training were required to undertake. It has been considered and recommended by the Clinical Governance and Oversight Committee in July 2016.
16/8/58 Martin McAreavey, as Chair of Clinical Governance Oversight Committee, emphasised the importance of clinical audits as being equivalent to the internal audit function within a Trust. The strategy and policy would be subject to review after three years.
16/8/59 The Clinical Audit Strategy and Policy was APPROVED.
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Finance Report as at 31 July 2016 16/8/60 The Board considered a report of the Interim Director of Finance that set out the Trust’s financial position as at month 4 2016/17.
16/8/61 The Board was advised that the Trust was forecasting to reduce its deficit by £8.7m from the £27.1m forecast in its annual plan to £16.0m. This had been reported to NHS Improvement based on a bottom assessment of its financial position in month 4.
16/8/62 The month 4 position was a £6.0m deficit against a revised planned deficit of £8.1m, a favourable variance of £2.1m. This included a £2.2m provision in expenditure to match planned cost pressures that had yet to materialise.
16/8/63 The Trust had drawn down £8.6m cash against its plan of £8.3m. A new table within the report showed variance of cash funds following a recommendation at the last Board meeting from the Board Advisor. Capital spend to date was £2.7m against a plan of £3.9m with £1.2m slippage due to underspends in estates, medical equipment, charitable funds and a benefit from a review of historic accurals.
16/8/64 Reference was made to outstanding debt which had been escalated at the Financial Oversight Committee held the previous day. The Interim Director of Finance had briefed the Chair of the Audit and Non-clinical risk Committee and would now be speaking with his opposite number at the Trust regarding payment of the debt. Failing that, the next stage would be for chief executives of both trusts to discuss.
16/8/65 There was discussion regarding the reconfiguration of several services and MK need for capital works. It was agreed that this would be discussed at an upcoming Board Brief.
16/8/66 Concern had been raised at Financial Oversight Committee regarding the low number of budgets that had been signed off by service leads. The Interim Director of Finance advised that there was no underlying fundamental problem but that issues remained within the care groups, in particular around nursing, outpatients and MARS. Philippe Serna expressed the view that without sign-off, staff were less likely to be accountable for spend against their budget. It was reported that meetings with budget holders were planned for the forthcoming week and an JC update would be reported to the next Financial Oversight Committee.
16/8/67 The Finance report was NOTED.
Business Intelligence Report as at 31 July 2016 The Board considered a report of the Chief Operating Officer, Medical Director and Director of Nursing, Midwifery and Quality that set out clinical performance in month 4.
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16/8/68 The Trust had achieved a rate of 92.78% of patients being seen within the standard four-hour access time, for a year-to-date perfromance of 93.24%. Doncaster had achieved 90.03% and Bassetlaw 94.88%. This was down on the target of 95% but had seen an exceptionally busy month with 15,147 visits, 1,074 more than July 2015 and 786 more than June 2016. The bed plan had been maintained and outliers had been reduced.
16/8/69 It was reported that the national A&E performance plan began in the following month with the Trust hosting the second national presentation on 5 September. The onus would be on peer review and sharing of best practice, detail of which would be shared with the Board.
16/8/70 Referral to Treatment ended the month having achieved 92.5% performance against a standard of 92% with urology, general surgery, general medicine and trauma and orthopaedics failing to meet the target. It was reported that one patient had waited nine months for treatment, although none of those not seen within the target time came to harm.
16/8/71 Diagnostic waits performance stood at 99.23% with 56 patients not having their tests within six weeks. All cancer targets were achieved in June and quarter one with local 62 day classic performance ending at 87.7% in June and at 85.3% for quarter one.
16/8/72 Stroke performance continued to be below target but was improving following adjustments to teaching to identify key signs of strokes. There was a brief discussion regarding the challenges faced by a number of trusts in dealing with stroke patients. The Board was advised that one of those trusts had 544 confirmed strokes in the previous year and under current plans Doncaster would be required to accept a third of those patients with the rest split between other trusts. Further discussions were required on how stroke patients were redirected to neighbouring trusts.
16/8/73 Concern was raised that some Sustainability and Transformation Plan service configurations appeared to be based on tenuous manpower statistics. The Chair reiterated the need for the Trust to consider the financial impact of taking on extra patients. Whilst the Trust saw the need to step into the breach clinically, that was dependent on an equal willingness from the clinical commissioning group to finance the arrangement.
16/8/74 It was reported that there had been a need to close Paediatrics at Bassetlaw one evening in the previous week due to lack of cover.
16/8/75 The Trust’s rolling 12 month Hospital Standardised Mortality Rate to the end of May 2016 was better than expected and stood at 92.6. The best practice tariff for fractured neck of femur had been received. Although there had been a small increase in serious falls, the overall trend showed a decrease in serious incidents.
16/8/76 In relation to safety and quality, performance in respect of pressure ulcers,
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C. Diff and falls continued to be ahead of trajectory and either in line with or better than last year. Response rates to complaints were below expected standards but improvement work was continuing.
16/8/77 The Business Intelligence report was NOTED.
Nursing Workforce Report 16/8/78 The Board considered a report of the Director of Nursing, Midwifery and Quality which provided detailed information relating to the nursing workforce, highlighting issues which may impact on the Trust’s ability to provide appropriate staffing levels and skill mixes.
16/8/79 The overall planned versus actual hours worked in July 2016 was 98% as against 101% in June. CHPPD stood at 7.2 across the Trust, similar to June, however it was still unclear as to how these figures compared nationally. Results of the recent Safer Nursing Care/AUKUH and Pediatric Acuity and Nurse Dependency Assessments were also provided.
16/8/80 In response to a question from David Crowe about the number of red ratings in relation to the caring element of the Hard Truths feedback for August 2016, the Board was advised that the results were made up from friends and family feedback. David Crowe emphasised the importance of high response rates in order to obtain the most accurate feedback possible. The Director of Nursing, Quality and Midwifery advised that a number of tools were utilised to pull together the story about a ward. This was supplemented by the National Patient Experience Survey involving hundreds of patients selected by Picker.
16/8/81 The report in respect of Nursing Workforce was NOTED.
NHS Improvements Undertaking Tracker
16/8/82 The Board considered a report of the Trust Board Secretary which set out a summary of progress against the undertakings given by the Trust to NHS Improvement.
16/8/83 The Board were advised that the procurement process for the Well Led Governance Review to be undertaken in Quarter 3 was underway with a preferred independent reviewer due to be selected in month 6.
16/8/84 The updated NHS Improvement Undertakings Tracker was NOTED.
Board Assurance Framework and Corporate Risk Register
16/8/85 The Board considered a report of the Trust Board Secretary which presented a revised Board Assurance Framework and Corporate Risk Register following meetings held with executive directors.
16/8/86 The work had resulted in five risks being downgraded as a result of additional assurance and additional commentary in respect of controls
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and assurance.
16/8/87 The updated Board Assurance Framework and Corporate Risk Register was NOTED.
Annual Members’ Meeting Arrangements
16/8/88 The Board considered a report of the Trust Board Secretary which set out arrangements for the Annual Members’ Meeting to be held on 21 September 2016.
16/8/89 The Annual Members’ Meeting arrangements were NOTED.
Minutes of Management Board on 1 August 2016
16/8/90 In response to a question regarding minute MB/16/08/20, the Board was advised that discussions with Nottingham and Sheffield on potentially sharing improvement tools and processes were in an advanced stage.
16/8/91 The minutes of Management Board on 1 August 2016 were NOTED.
Minutes of Audit and Non-clinical Risk Committee held on 24 June 2016
16/8/92 This item was DEFERRED until the next meeting of the Board.
Items escalated from Sub-Committees
16/8/93 None , other than the issues already raised by the Financial Oversight Committee on 22 August 2016.
Board of Directors and Board Briefing Agenda Calendars
16/8/94 The agenda calendars were NOTED.
Annual Revalidation Update
16/8/95 The Board considered a report of the Medical Director which provided an update in respect of the medical revalidation and appraisal for 2015/16.
16/8/96 The Medical Director reported that the Trust was on course to complete revalidation of all Trust medical staff in the first five year cycle of medical revalidation due to be completed by 31 March 2018. As of 1 August 2016, 410 doctors had been recommended for revalidation and all were accepted by the General Medical Council. One doctor had been omitted but has since been connected to the Trust and actions had been taken to progress the doctor through appraisal and revalidation.
16/8/97 Revalidation had been recommended for all full time medical staff and this had been achieved within the first three years after the start of revalidation as originally planned. The revalidation office continued to
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spend time ensuring that medical staff underwent timely, high quality appraisals. This meant the Trust’s annual appraisal rate for medical staff was close to 100%.
16/8/98 It was reported that the format of the data required for bench-marking and the Trust’s appraisal system had been altered. Work was progressing with IT to respond to the appraisal systems required. In response to a question from David Crowe, the Board was advised that all revalidation documentation was checked and, if not robust enough, the applicant would be requested to redo and resubmit it.
16/8/99 The Annual Revalidation Update was NOTED.
Any Other Business
16/8/100 None.
16/8/101 Governors questions regarding business of the meeting
None.
Date and time of next meeting 16/8/102 9am on Tuesday 27 September in the Boardroom, Montagu Hospital.
Chris Scholey Date Chairman
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Action Notes
Meeting: Board of Directors Date of meeting: 23 August 2016 Location: Boardroom, Bassetlaw Hospital Attendees: CS, AA, KB, JC, DC, DJ, MM, MP, DP, SS, RP, PS Apologies: JP
No. Minute No Action Responsibility Target Date 1. 16/7/51 (i) The format of the finance report be JC/LT September 2016 refined and duplication relating to the CIPs be removed.
2. 16/7/62 (i) In relation to follow-up ratios, the DP Ongoing Financial Oversight Committee to explore the CIPs in place for urology, cardiology and diabetes.
(ii) The Chief Executive and Medical MP/RP/SS September 2016 Director to pursue the outstanding report into the serious incident at Bassetlaw Hospital.
(iii) The Board to reinstate the process RP September 2016 whereby they receive two random, anonymised complaints each month and their responses. 3. 16/7/75 A discussion on staff engagement be KB October 2016 brought to a future Board Brief. 4. 16/8/64 A discussion on capital be brought to KB ASAP a future Board Brief. 5. 16/8/64 An update on budget sign-off position JC September 2016 to brought to next Financial Oversight Committee.
Date of next meeting: 27 September 2016 Action notes prepared by: M Kane Dated: 9 September 2016 Circulation: CS, AA, KB, JC, DC, DJ, MM, JP, MP, DP, SS, RP, PS, MH
Title Chief Executive's Report
Report to: Board of Directors Date: 27 September 2016
Author: Mike Pinkerton, Chief Executive
For: Information / Triangulation Purpose of Paper: Executive Summary containing key messages and issues Standing item setting out information the Chief Executive wishes the Board to be aware of, including key risks and exceptions. The report briefs on the following areas: Strategy Update Intermediate Care Fire Compliance Workforce & Job Planning A&E North Focus Week Cancer 28 Day Standard Staff & Appointments Early Skin Care Regime Junior Doctors Industrial Action
Recommendation(s)
The Board is asked to RECEIVE and NOTE the report
Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first By keeping a focus on quality whilst we tackle financial problems Everyone counts - we treat each other with courtesy, honesty, respect and dignity By openly and honestly discussing with staff our quality, outcomes and financial position Committed to quality and continuously improving patient experience By improving key measure of patient safety Always caring and compassionate By focusing on improving the experience of our patients Responsible and accountable for our actions – taking pride in our work By working openly with regulators and partners to improve financial governance Encouraging and valuing our diverse staff and rewarding ability and innovation By recognising staff efforts through local and national awards
Related Strategic Objectives
1 Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks a. Resource b. Governance c. PR & Communications d. Patient, Public & Member Involvement e. NHS Constitution Board Assurance Framework This report relates to the Strategic Direction as a whole, therefore all risks in the Board Assurance Framework are relevant in addition to the specific ones listed below. 1 Failure to achieve compliance with financial performance aspects of 5 4 20 the Monitor Risk Assessment Framework and provider licence, triggering regulatory action 2 Failure to deliver accurate financial reporting underpinned by 4 5 20 effective financial governance 3 Failure to deliver financial plan 4 5 20 4 Failure to deliver Cost Improvement Plans 4 5 20 5 Failure to deliver turnaround / cost reduction programme. 4 5 20 8 Failure to engage and communicate with staff and representatives in 4 4 16 relation to immediate challenges and strategic development 9 Failure to achieve compliance with performance and delivery aspects 4 4 16 of Monitor Risk Assessment Framework, CQC and other regulatory standards, triggering regulatory action 10 Failure to sustain a viable specialist and non-specialist range of 3 4 12 services. 12 Breakdown of relationship with key partners and stakeholders. 3 4 12
2 Service Performance Overview
The business intelligence report was not available at the time of writing.
Finance Performance Overview
At the time of writing the M5 finance report was not available, although early indications have suggested continued progress in line with previous forecast.
Strategy Update:
STP level
Governors have been updated with background and progress to date at the recent time out. Next steps as described in the figure have been shared with all partners for communication onwards. Work on validating finances in terms of baselines and outline expectations per work stream is underway with external assistance. Work will commence shortly on validating previous trust assessments of service viability. A revised submission is required by Mid-October.
Working Together Partnership Level
Work continues in the key areas of procurement services, Medical Agency coordination, Specialty Collaborative Working, Radiology, Informatics, GI Bleeds and Children’s Services. The Working Together Vanguard is positive about the prospect of receiving a further tranche of financial support. New Care Model vanguards are now expected to be extended to March 2018 and there may therefore be further prospects of funding, although national reports indicate that the overall funding envelope for vanguards is being reduced.
The board papers contain the consultation proposals for stroke and children’s services as per the previously described timetable.
Trust level
The board has been briefed about Trusts next steps which involve acquiring, assessing and coordinating the service visions for Care Groups through a forthcoming process in October whilst in parallel developing a financial model to understand the impacts of various options and to support analysis over future years. This is in itself nested to a degree within the STP process and local place plans, but the intention is to make as much progress within our own remit as possible whilst also taking on board various emerging STP steers and also projecting an accurate and compelling view into STP.
1 Place level
Bassetlaw place arrangements are attached as an appendix for approval to proceed as outlined, by taking our place as part of the Accountable Care Partnership Board.
In Doncaster work remains heavily focused on intermediate care as the year 1 priority for the DCCG place plan, an agenda that significantly intersects with most partners.
The next steps will be to test interventions and develop the final model. Other emerging dimensions of the plan will be to plan services in Doncaster along four localities where relevant with joint care and health teams. Accountable care will be delivered through a model of joint commissioning of a provider network or alliance.
2 Fire Compliance
In November 2015 South Yorkshire Fire Service (SYFS) issued Enforcement Notices for DRI and MMH. On 19th July the notice for MMH was lifted as work was assessed as complete by SYFS. However, due to the complexity and volume of work required at DRI, three extensions to the three month notices have been necessary. Following a meeting on 18th August, agreement was reached on a way forward for DRI that allows the Trust to put forward a multi-year improvement programme containing key milestones that will be used to assess the Trust’s progress against the improvement notices. Therefore, the current notice will be rescinded and replaced with a notice requesting a programme with milestones. Once agreed, that notice will be rescinded and a further notice will be issued that will holds us to account for our progress against the agreed milestones.
Work is progressing to develop accurate costings for the entire programme, in addition to developing a programme that, whilst challenging, can be achieved with a level of disruption that does not adversely affect service delivery too greatly. It is envisaged this may be 5 or 6 years in duration. Once a programme is agreed with SYFS, it will be necessary to allocate and ring-fence an annual capital allocation for the duration of the programme.
Progress against the DRI enforcement notice as part of Phase 1 includes:
Level 7 – Ward 22/23 (compartmentalisation, fire stopped, external risers) EWB Basement Corridor Fire Doors EWB Main Entrance Fire Doors EWB Stairwell Fire Doors (basement/ground floor)
Work planned of the reminder of this year includes: Level 7 – Complete Ward 23 Planning for Phase 2
In addition to physical improvement works, staff training was also recognised as requiring improvement with all staff having had appropriate fire training each year. At 31st August at total of 4,368 staff had received some form of fire training within the year. Since April 965 staff have received one of the following enhanced fire training courses, assessed relevant to their job role and responsibilities in the event of a fire:
Level 3 Competency – Fire Incident Manager/Fire Safety Warden Training commenced 11 March 2016 Attendance to date: 420 Level 2 Competency – SET Fire Safety Lecture (1 hour drop in session) Training commenced 27 May 2016 Attendance to date: 545
3 Plans are currently in train to appoint an external Authorising Fire Engineer in line with Health Technical Memorandum (HTM) 05 01, and to deliver Fire Safety training to the Board.
A&E North Conference - DRI
The day went really well, with very positive feedback from the morning session on the work we have undertaken. David Purdue has been asked to present a Masterclass on patient flow and discharge process. Feedback was equally positive from the delegates, NHSI and the CE lead.
Cancer - Achieving the 28-day standard: A baseline position for Yorkshire and Humber
The Achieving World Class Cancer Outcomes: A Strategy for Cancer 2015-2020 made the commitment that “By the end of 2015, NHS England should develop the rules for a new metric for earlier diagnosis measurable at CCG level. Patients referred for testing by a GP, because of
symptoms or clinical judgement, should either be definitively diagnosed with cancer or cancer excluded and this result should be communicated to the patient within four weeks. The ambition should be that CCGs achieve this target for 95% of patients by 2020, with 50% definitively diagnosed or cancer excluded within 2 weeks. Once this new metric is embedded, CCGs and providers should be permitted to phase out the urgent referral (2-week) pathway. The table below shows the Trusts relative performance against a proxy for the new measure and therefore the significant distance to travel for all trusts to achieve this ambition.
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Skin Care Research Honour
DBH has won first place at the Tissue Viability Society’s 2016 conference for a unique skin care routine that counteracts the effects of skin damage. The Trust’s Skin Integrity Nurses beat other worthy contenders for this accolade for carrying out research to improve the treatment of patients with low grade pressure ulcers and incontinence associated dermatitis (IAD). The team were praised for the genuine education and learning value that their research provided to other health professionals and the enhanced quality of care for patients with this type of skin damage.
The skin integrity nurses explored the development of a new single skin care regime for both superficial pressure ulcers and incontinence associated dermatitis (IAD). They reviewed and assessed the effectiveness of several skin care products in use on the wards and designed a quick and easy way for staff to cleanse, protect and restore the skin for both conditions.
The team road tested the new routine for three months with results showing a 26 per cent reduction in low grade pressure ulcers and IAD in 31 patients and by a further 10 per cent in 28
5 patients. The team’s award success frames the Trust’s commitment to reducing pressure sores for its patients.
Preparations for future junior doctor’s industrial action
The next 5 day episode of action which will result in a full withdrawal of labour runs from 0800hrs to 1700hrs split into two periods over a weekend:
Wednesday 5 to Friday 7 October 2016 and; Monday 10 to Tuesday 11 October 2016
Full internal and external assurance and preparations are underway given this unprecedented form of industrial action. The Trust will be using the major incident rooms to coordinate our response, which will be to the same overall “formula” as previous one day strikes.
Ophthalmology Department DRI
The Department has reached practical completion and phase 1 and 2 are now in use. There is some further work to complete the vitreal injection rooms and equipping and decorating the paediatric areas. The reaction of patients and staff alike has been very positive and the design and accommodation, coupled with changes to workflow and workforce to make best use of skill mix is already having a positive impact on efficiency. A formal opening ceremony is being planned.
Workforce & Job Planning
When we discuss job planning, it is often in reference to medical staff. Therapies have been undertaking job planning for some time and on Thursday 8th September Suzanne Bolam presented at a progress event for 45 Trusts at the invitation of the Department of Health AHP Lead – Workforce Efficiency in the Productivity and Efficiency Division. Suzanne shared the Trust approach to capacity and demand, job plans, productive hours and lesson learned and hot tips. It would appear that the Trust is close to the leading edge of this work in the therapies area.
Staff & Appointments
Sheffield Children’s Hospital has announced the appointment of the new Chief Executive, John Somers who will replace Simon Morritt who is due to leave at the end of September. John was the former finance director at the Trust.
Mike Pinkerton Chief Executive
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Title Working Together Commissioner Collaboration - Consultation for children’s surgery and anaesthesia and hyper acute stroke services
Report to: Board of Directors Date: 27 September 2016
Author: Mike Pinkerton, Chief Executive
For: Noting Purpose of Paper: Executive Summary containing key messages and issues
Attached to this report are the WTP option appraisal papers on children's surgery and anaesthesia service and hyper acute stroke service, together with associated papers, prior to the public consultation process.
The documentation includes:
1. Children's surgery and anaesthesia options appraisal and the Executive summary 2. Hyper acute stroke services options appraisal and the Executive summary 3. Communications and engagement strategy for public consultation and Communications and engagement report on pre- consultation activities 4. Chemotherapy outreach review and case for change
Recommendation is to NOTE that these matters will shortly be out to public consultation.
Recommendation(s)
To review and note the attached.
Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Board Assurance Framework 8 Failure to engage and communicate with staff and representatives in relation to 4 x 4 = 16 immediate challenges and strategic development 10 Failure to sustain a viable specialist and non-specialist range of services. 3 x 4 = 12 12 Breakdown of relationship with key partners and stakeholders 3 x 4 = 12
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Working Together Transformation Programme Review of Children’s Surgery and Anaesthesia
Governing Body meeting July 2016
1. Purpose and Context
This paper provides an update on the progress following the report in November to CCGs across the Working Together Programme.
The purpose of this paper is to:
• Summarise the work undertaken to date, by the Working Together programme on behalf of our CCGs, in reviewing Children’s Surgery and Anaesthesia across South Yorkshire, Bassetlaw and North Derbyshire.
• Seek support from Governing Bodies on the options appraisal work and the emerging model of care. Moving towards public consultation in the autumn on the preferred option outlined in the options appraisal document.
• To agree to consider a full business case with recommendation for change for Governing Body approval.
The paper is presented for approval.
2. Background
We know from the review and work undertaken to date that there is variation in provision, this can lead to a variation in the quality of provision available and potentially impact on clinical outcomes, as the care can vary dependant on where services are located.
Referral thresholds to services also vary; therefore the patient journey and provision available will vary dependant on where services are accessed, and at what time, and on what day.
There are problems with developing and sustaining workforce skills, as well as issues with the further development of the paediatric workforce for both anaesthesia and surgery.
Clinicians are identifying that the current configuration is not consistent or sustainable in the short, medium or long term.
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The economic case for change is demonstrated in resource and cost pressure within the NHS overall and we know that.
A needs assessment has been undertaken, which outlines the trajectory of need for future provision as well as some of the challenges to the current administrative data, workforce planning and measures of clinical outcomes.
The solutions and size of change have been tested in an options appraisal around proposed future configuration of services across a tiered model of care.
There would need to be a change in the provision; this could include changes in local access and where care is provided.
A clinical task and finish group has been considering the specified standards of care and the options around organising services across a tiered model.
The project has been supported by the Yorkshire and Humber Strategic Clinical Network, which supported the service specification development through wider clinical engagement and supported the steering group overseeing the project.
The work to date has also been referred to the Yorkshire and the Humber Clinical Senate for consideration and their recommendations have been taken on board and informed the next steps of development of both the overall case for change and the service specification specifically.
The options for modelling the services have been appraised, and an emerging model is developing which requires change in provision from its current configuration.
3. Key Messages for Governing Body Members:
The current configuration needs to change and the case for change was agreed by governing bodies in Autumn 2015. The specification for provision has been agreed clinically and a designation toolkit has been developed to designate providers as part of a network across CCGs A proposed model on future configuration has been drafted and considered by the clinical task and finish group, the basis of the model was clinically supported and now forms part of the options appraisal. An options appraisal around a model has been drafted and appraised and is being discussed more widely. A service model is emerging and needs considering as this will change pathways of care. A managed clinical network has been funded for 16/17, as part of the provider working together vanguard to enable the mobilisation and implementation of change in line with the proposed service model. Pre consultation is now complete and all CCGs and providers are engaged in the consultation and engagement plan for the next phases. A full business case for mobilising change is being drafted, which will include proposals for contracting and commissioning intentions for 17/18 for CCGs.
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The outline of the approach to improve children’s surgery services for all our local populations is taking place in 3 phases. Governing Bodies will be consulted at each stage and at key milestones for their support and approval. The programme is still working within phase 2 of the plan.
Phase 1 January 2015 – September 2015 - included
The development of the case for change including: Engaging with key stakeholders Undertaking a baseline assessment of current services Forming consensus of the issues Identifying best practice models Specifying the pathways that should be in place to meet standards Exploring strengths and benefits of potential models Considering our populations needs for the future Seeking external clinical scrutiny of the work to date (Senate)
Phase 2 October 2015 – September 2016 - current work plan
The development of specification, options on a model and full business case including: Implementation of communication and engagement strategy - Pre –engagement with patient and the public, key stakeholders (Health Overview and Scrutiny Committees) and staff Enacting procurement advice, including a provider engagement event Development of a service specification and gap analysis against existing provision Development of options on a service model and assessment of options Development of full business case including activity and financial impact Formal consultation starts (ends December 2016) Consideration of options to implement change
Phase 3 October 2016 – March 2017
Implementation planning and mobilisation of preferred Option
4. Work to date
4.1 What did we do (phase 1)
We talked with doctors, nurses and healthcare staff in hospitals, NHS staff who commission hospital and GP services, and data and clinical experts about what the future of Children’s Surgical care should look like:
We asked hospitals to look at the national core standards for providing children’s surgery and assess how they were doing against these standards We gathered data on the numbers of people needing the service and assessed what the numbers might look like in the future We asked hospitals to gather information on their current workforce We met with hospitals to assess and agree all the information and their current challenges
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We held a series of workshops with staff and stakeholders to look at and agree the issues We worked with clinical experts to agree possible high level options to consider for the future.
4.2 What have we done so far and progressed in phase 2
We provided an update to CCG governing bodies and asked permission to progress the programme of work, including, the pre consultation phase and the development of options and a service specification for future provision. We continued our conversations with providers and clinicians in a task group.
We have developed and agreed a service specification that provides the clinical care pathways needed, this has been approved by the Clinical Senate following work up regionally and within the local task and finish group. We have undertaken a Prior Information Notice of service changes and held a provider engagement event outlining our intentions to review and propose changes to sustain services. Providers have undertaken a self-assessment of their ability to meet the new proposed service specification. We held an expert assessment panel to review the work to date and advise on development of a new model and redesign, this included national experts as well as regional and local experts. We have developed a designation toolkit for commissioners to use to embed the proposed specified pathways of care. We have developed a proposed tiered model for providing surgery, which outlines the options for future configuration. We have appraised these options and are discussing them more widely and considering how change might be developed into a full business case. We have completed the pre consultation phase of work and gathered information on what is important to patients and the public when considering change to surgical provision. Funding has been secured through the Working Together Programme provider Vanguard to mobilise a Managed Clinical Network to support implementation of a new model.
5. Other factors to consider as part of this phase of work
From the work completed to date we know that there are a number of issues that need consideration when thinking about changes, some of these issues have been raised from the clinical senate others from the task and finish group or local CCG commissioners.
5.1 The interface with the management of acute medical paediatrics is a vital consideration and forms part of both the planned care pathway and is a significant consideration for patients with unplanned surgery needs, and those needing overnight planned recover from a surgical episodes of care.
5.2 The impact on transport services needs further assessment and quantification in the proposed new model as entry points would change from the current configuration.
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5.3 Cross border clinical pathway issues need further consideration and assessment, we would need to manage any impact of changes in the proposed model on clinical pathways already agreed throughout Yorkshire and Humber and across to East Midlands.
5.4 Contractual and financial changes in the proposed model need further consideration and assessment as part of the full business case.
5.5 The development of the work plan for the Managed Clinical Network as part of the implementation plan, as this will be a vital part of mobilisation and the enabler of sustainability of pathways of care in the future.
5.6 The development of common commissioning and contracting intentions as part of the full business case development.
5. Next Steps/Timeframe
The project is now more widely discussing the options for a model, which is emerging following appraisal, and developing a business case for CCGs to consider as part of commissioning intentions for 17/18.
Such a programme of work will require commitment from all Working Together members to ensure that a collective approach is taken to continue delivery of this next phase of work.
6. Recommendation
Governing Body is asked to:
Note the work to date Consider and approve the options appraisal and emerging model. Support the next phase of development of the full business case, and receive a full business case for approval
Paper prepared by: Kate Laurance, Head of Commissioning for Children Young and Maternity on behalf of the Working Together Programme and
Will Cleary-Gray - Working Together Programme Director
June 2016
This paper is to be read in conjunction with the full Options Appraisal document.
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Joint commissioners and provider Working Together Programmes
Non- specialised Children’s Surgery and Anaesthesia – Options Appraisal
June 2016
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June 2016
Title Non- specialised Children’s Surgery and Anaesthesia – Options Appraisal
Author Kate Laurance/ Children’s Services Core Leaders Group
Version V11 Created Date 27/4/2016 Document Final Status
To be read in 3 C Children’s Surgery Options Appraisal conjunction with Document history 27/4/2016 1 KL Worked up following discussion at task and finish group 28/4/16 2 KL Options updated 29/4/16 3 KL Data with analysis and split
supported by activity data being modelled. 13/5/2016 4 KL With feedback from Children’s Core Leaders steering Group 18/5/2016 5 KL Minor changes following Core Leaders Group 27/5/2016 6 KW Re-formatted 30/5/2016 7 LD Expansion of introduction, removal of cross reference from 1.1, reference to assumptions in 2.7 31/5/2016 8 JCS Confirm Draft Status, Intro statement on paper purpose / content, minor amendments to new intro material, amendment to numbering in section 2 from 2.7 onwards, addition of reference to scoring tool and draft matrix, 2.8 extended caveat around 2
assumptions, 2.8 note on status of following RAG rating for options. Changes to sections 3.2,3.3 re OA next steps
1/6/16 9 JCS Update section 3 re process, next steps – consultation, OA, ‘do- ability’, Governing Body sign support. Consistent formatting. Data by options added 2/6/16 10 KL With Updates to Section 2 on matrix for scoring 5/7/16 11 HS Amended numbers to ensure non identifiable Governance Route: Group Date Version Purpose Working 7th June 2016 1 For Sign off and support Together Programme Board
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Contents Introduction and Overview ...... 5 Proposed Model for Planned Surgery ...... 8 Options and Scenario Appraisal ...... 9 Conclusions and Recommendations ...... 17
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Introduction and Overview
This paper has been worked up to give an overview of the potential options and impact for redesigning children’s surgical services across South and Mid Yorkshire, Bassetlaw and North Derbyshire (the Working Together footprint). The paper proposes three main options, gives an early indicative assessment of those options using a ‘traffic light’ scoring, and suggests a systematic option scoring approach to run alongside this.
The enclosed gives an overview of the potential change in flows and impact of redesigning services to meet quality, safety and sustainability requirements.
The impact assessment also covers change in flows from a CCG population perspective which has been developed following the assessment panel and a subsequent meeting of the original task and finish group on the 14th of April 2016.
It is important that the case for change for Children’s Surgery and Anaesthesia services within the Working Together footprint is considered to enable provision commissioned to be equitable, safe and sustainable for the future.
The case for change and subsequent Health Needs Assessment takes into consideration quality aspects of the service, draws on national and regional guidance and clinical best practice within services, and sets out the national standards for Children’s surgical services.
In summary the challenges facing the future provision of children’s surgery raised by stakeholders (surgeons, anaesthetists, Trust managers and commissioners) and identified as the key drivers for the Working Together Programmes (provider and commissioner) at meetings are as below.
Providing a comprehensive range of effective and sustainable children’s surgery and anaesthetic services.
Changes in clinical practice have been influenced in recent years by guidance from the Royal College of Surgeons (RCS) and Royal College of Anaesthetists (RCoA) and an increased focus on clinical governance. One of the more significant changes has been to the training of general surgeons, with a reduction in the paediatric component of general surgical training. Individual general surgical trainees have been given free remit to choose any sub-specialty area, and unfortunately, the numbers training in any given sub-specialty do not always match the needs of the service. As a result, as surgeons retire, they are not being replaced by surgeons with the
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same level of experience in paediatric surgery.
There is evidence, from the workforce profiling undertaken by providers, that concern about the ability to provide safe and effective surgery for children has caused some surgeons to limit the range of surgery that they offer, or limit the age range of children that they treat.
Avoiding unplanned unmanageable changes to referral patterns for children’s surgery.
Within the region there is evidence that the issues identified above have resulted in unplanned changes to service provision and ‘activity flows’ away from smaller DGH’s towards larger centres, leading to problems in capacity planning. There is recognition among clinicians that transformation of services may be required to make best use of clinical manpower, and that this needs to be addressed strategically.
The need to consider clinical interdependencies
The provision of children’s surgical and anaesthetic services is dependent on the provision of other children’s services and vice versa; in particular the provision of a number of children’s services relies on the provision of paediatric anaesthetic services. There is also interdependency between medical paediatrics and maternity and neonatal services. Therefore, changes to individual services can have an impact on the overall ‘portfolio’ of services offered by individual Trusts. We are also taking into account the urgent and emergency care review and the work of the developing South Yorkshire and Bassetlaw Sustainability and Transformation Plan, and those of our neighbouring regions.
Implementation of the Standards for Children’s Surgery and Anaesthesia leads to challenges that are beyond the ability of individual organisations to solve.
There is widespread recognition that meeting the standards in full may be a challenge for some Trusts. The view among clinicians is that there are options for addressing these (e.g. through the provision of in-reach and outreach services, joint training, education and audit), but that this would also require joint working. Alongside this, is the view that for the standards to be effective, they should be monitored by people who understand the services and who are able to make informed assessment against compliance; ideally peers. Also, that the standards will need to be reassessed in light of changes to national clinical guidance, in order to remain relevant.
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In light of all the above, the overwhelming view from attendees at stakeholder meetings and engagement events was that:
There is a need for change because ‘continuing as we are is not sustainable’. Ensuring good quality and sustainable provision of services in future and implementation of standards would require cross-organisational working. There is lack of co-ordination across pathways and patient flows are not managed. The interdependencies of children’s services are complex. There is a need for managerial leadership and clinical leadership across organisations.
Recently, regional CQC visits have highlighted the need to improve staffing levels which have led to the increased usage of locum/bank staff in various providers of children’s surgery.
Between January and April 2016, Commissioners Working Together gathered the views of patients and the public during a pre-consultation phase. The following were the key themes identified as being important to people when accessing children’s surgery and anaesthetic services:
Safe, caring, quality care and treatment Access to specialist care – with a willingness to travel for specialist care Care close to home Communication – between children, parents, carers and their clinicians – and also between hospitals Being seen as soon as possible
Following the expert assessment panel held on 7 March 2016, which considered all aspects of the review and advised on a way forward, and the subsequent task and finish group discussion on the sustainable options for modelling services held on 14 April 2016, the options detailed in the main body of this paper emerged as requiring further consideration. This paper moves towards a formal assessment of those options, prior to them being circulated for public consultation.
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1. Proposed Model for Planned Surgery
1.1 The general principles around provision of safe and sustainable planned surgical care which providers are required to meet are outlined within the Service Specification. The intention of commissioners is to use a ‘designation’ approach, i.e. units meeting the specification will become designated surgical centres. This will mean designation within the tiers described within the service designation toolkit. There will also be a managed clinical network function in organising and sustaining provision across tiers within the designated centres.
Levels of care for surgery will be tiered as follows:
Tier 1 = Day Case Surgery T ier 2 = Tier 1 + elective + out of hours non elective inpatient surgery
Tier 3 = Tier 2 + specialist (tertiary)
Surgery Tiers
1 Day Case
2 Elective in patient / non elective in patient
3 Tertiary
1.2 This will be organised and planned at a sub specialty level, i.e. the service map for one specialty may differ from that for another specialty. The reason for this is acknowledgment of the accessibility of workforce skills in some sub specialties, which enables some aspects of surgery 8
to be undertaken more easily than others.
The use of outreach se rvices to support tiers 1 and 2, as well as outpatient services will be a key function that will need to be further developed and supported from the centre hosting the expertise. Within the Managed Clinical Network (MCN) there should be a clear remit to distribute the workforce across the geography in response to need and to undertake improvement and planning activities to ensure compliant services in the designated units.
There are some common widely acknowledged procedures that have lower or higher thresholds or considerations when thinking of the models of care and specified requirements. There are some procedures, for example in general surgery where age thresholds vary, and in ENT airway management and wider support services are critical.
We also know that there are a number of time critical procedures and we must ensure we can respond and treat these effectively. The example of torsion of testes is a well-sighted example. Also the skills and expertise to respond to surgical and anaesthetic care needed within under 3 year olds is another area of great debate and one that consensus to transfer to an appropriately skilled unit has been reached across clinicians.
This means that the consideration of out of hours surgery needs a clearly defined pathway and protocols in place between centres and hospitals within the area.
2. Options and Scenario Appraisal
2.1 The proposed service model should be tested and considered alongside the current need for surgical care across the patch.
2.2 To enable a sustainable service to be established for the future, there will need to be less entry points, more critical mass of planned provision and clarity across pathways to enable out of hours, non- elective care to be directed to the most appropriate centre.
2.3 Providing the appropriately trained workforce through a managed and organised network will be critical to providing a sustainable model of care, therefore the workforce challenges, new models and skills in existence will need careful planning. 9
2.4 Following discussion at the assessment panel and subsequent service model discussions at the task and finish group, there was a conclusion to propose a model highlighting a range of options for the development of tier 2 hubs for surgical care, as the tier 1 and tier 3 provision are less debatable and easier to plan across the footprint.
2.5 The option needs to provide sustainability, with particular focus on sustaining care across the geography and safe management of the acutely ill child presenting non-electively out of hours.
2.6 There is also a significant interface with the acute care work stream on ensuring that paediatric 24/7 medical care is in place that may further impact on inpatient care levels in the future. As well as this, there is an acknowledged interface with acute maternity and neonatal care due to workforce interdependencies.
2.7 The criteria to assess options and impact of changes within proposals must consider as a minimum:
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Criterion Indicator Questions Access Patients would access the same Will populations from across the WTP footprint access standard of care; provision for urgent surgery care within critical times frames Red – High Impact ensuring care is equitable for treatment? negative Impact across geography and sites. Patients would access the right Would populations particularly from areas of high deprivation Amber- Some care within similar timeframes. have to travel longer distances for treatment and care? Impact and some Therefore population location changes minimal would not mean negative impact What will patients value more access to right care in a Impact on access. location further away, or access to substandard care but in a location need by with quicker access? Green- Changes in access but equitable timeframes
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Activity and flow Any changes in activity or flow can Are there are sufficient activity levels to maintain workforce be sustained and skills? Red- Deliverability managed between providers of changes in Is there sufficient activity to be able to justify planning care for activity are a group of patients? challenging or workforce skill Will there be a mechanism in place to plan for changes maintenance between providers to meet the care needs for surgery would be an issue provision across the WTP? Amber- Sustainability of Have the providers got the ability to deliver an increase in workforce skills activity or will capacity be an issue? although challenging Green – Activity changes should be able to be maintained
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Workforce That workforce skills and Does the proposed option enable workforce development sustainability, competencies are sustainable across a whole system? quality and best longer term and can be practice developed where needed within Can skills be further developed to enable future needs to be the proposed option. met? Red- Workforce sustainability still a Will provision be able to meet specified standards? major challenge Can proposed models to develop workforce be Amber –possible implemented? to maintain but challenging.
Green – Should be sustainable
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Cross boundary That any changes across impact boundaries are managed with the Does this change have a significant impact on transport? least possible negative impact Red – Significant and the potential impact on Will there be patients from one area travelling more to change, high transport is scoped, another area/site for care? If so out of the proposed options impact on understood and assessed. which have the most cross boundary changes? transport and care Cross boundary provision is across boundaries considered, Do the proposals have an impact on provision or care across boundaries to neighboring CCG’s? If so what might the Amber – Some negative impact of change be? change, some impact
Green – Change will have minimum impact or could be managed effectively within proposal
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An indicative “Traffic Lighted” assessment of the models against the relevant criterion (using a “Red, Amber, Green” or “RAG” rating) is included below in sections 2.9 - 2.12. For the implementation of any recommendation it is acknowledged that further collegiate scoring methods should be undertaken in depth by a clinical sub group and by at specialty level in order to support operational delivery and change management requirements.
2.8 There has been some natural migration already within the services into a Tiered approach. This primary gap in service delivery is around paediatrics requiring overnight stay and out of hours services.
2.9 Tier 1 proposals indicate the continued delivery of day case surgery for hospitals that can do two things:-
Firstly, meet the service specificatio n and associated designation to provide day case surgery. Demonstrate enough critical mass to warrant planning and providing this level of activity given that some lists will be provided by an outreach model and at sub specialty may require specific surgical skills.
Tier 2 proposals have focused on appraising and assessing options over 2-4 centre model and will be the area that the largest level of change is needed.
For tier 3 provision this would be provided over only a few centres within the geographical boundaries of the programme.
The options appraisal is based upon current hospital sites, although we know from the needs assessment and the map of population growth rate that the need for provision falls across all areas over time.
Activity numbers associated with each of the options are based upon assumptions, i.e. taking historical patient activity levels in particular sites, and assessing, based upon the shape of each option, a) whether activity would stay at that site or leave and b) if it leaves that site, where it is likely to go to, based upon local geography, transport links, etc.
As this work proceeds, potentially to public consultation against a viable option following appraisal, it may be necessary and good practice to invite further scrutiny of those assumptions. 16
The following RAG rated / traffic lighted options assessments in sections 2.9-2.11 is based upon initial views of the core members of the programme team, with a focus on an option in light of its ability to meet the relevant standards and meet the intentions of the project. Section 3 will talk about the conclusions and recommendations following the RAG rating.
RAG Rating of Options:
Completed by the Working Together Programme and Project Management team and discussed and approved by members of the Children’s Core Leaders Group.
Baseline Activity
The variances associated with each option should be applied to the base 2014- 15 activity data which is shown here:
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2.10 Option One - Development of 4 tier 2 hubs: Based upon the current providers and need across the patch, hubs would be located at Sheffield, Doncaster, Pinderfields and Chesterfield. This would site tier 2 provision over the geography evenly to meet need. There are existing arrangements between Nottingham and Chesterfield Royal these could be explored further and developed further.
Criterion RAG Initial Assessed Impact Access This would mean some cases would be transferred to the proposed Tier 2 units and not have a procedure at units providing Tier 1 care. They might be stabilised and transferred to the nearest tier 2 unit. This would mean continuation of the current configuration with most units and sites sustaining and developing full care pathways for all surgery needed. We know this is unlikely to be sustainable model of care, and from the review to date we know this will mean variation when patients access care, or pose a significant challenge in providing equitable access to care. Activity levels This would mean trying to maintain the and levels of activity levels and flows with some activity in change most sites, so almost status quo on activity assumptions. It is likely that there would be a level of transfer to ensure patients got the right care. This is not easy to quantify or predict. Cross boundary This would mean little cross boundary impact and impact. There would be a level of transfer transport needed which is not easy to quantify given the uncertainty around stabilising clinical appointments on some sites. Adequate T here would not be the ability to provide the Workforce, safety workforce to provide this cover consistently and quality across all sites. Impact on For some care that was not planned this visitors/carers would mean travelling to another site. Finance We know the current position overall is not sustainable financially across all NHS provision and there are less resources available in the future.
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Challenge in N/A This would mean almost status quo delivery Total weighted The status quo is not an option score Option 1 : Indicative Activity Changes:
Four Hubs - Variance Impact by Selected Specialty
1. Emergency ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 518 1354 19 152 1456 214 3713 Variance by Provider BHNFT -42 -262 0 0 -197 0 -501 CRH -6 -26 -1 0 -35 0 -68 DBH -12 75 -2 27 -27 -4 57 MYH 21 106 0 0 89 -2 214 Other 0 0 0 0 0 0 0 SCH 110 401 8 67 408 16 1009 STH 0 0 0 0 0 0 0 TRFT -71 -294 -5 -94 -238 -10 -712
2. Elective with LOS >0 ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 478 16 6 21 215 2 738
Variance by Provider BHNFT -38 -1 0 0 -19 0 -58 CRH -36 0 0 0 -5 0 -40 DBH -23 0 1 -1 -1 0 -24 MYH 36 0 2 0 7 0 45 Other 0 0 0 0 0 0 0 SCH 157 6 3 6 43 0 215 STH 0 0 0 0 0 0 0 TRFT -96 -5 -6 -5 -26 0 -138
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2.11 Option Two - Development of 3 tier 2 hubs: To meet need equitably across the geography these would be at Sheffield, Pinderfields and Doncaster. This would provide even distribution over the geography and stabilise the currently established outreach approach with North Lincolnshire and Goole (NLAG) provision. Chesterfield would need further consideration.
Criterion RAG Initial Assessed Impact Access This would mean some cases would be transferred to the proposed Tier 2 units and not present at units providing Tier 1 care, or be stabilised and transferred to the nearest tier 2 unit. This would mean all CCG populations would have equality of access to the same standards of surgical care, but mean further travel for procedures for some populations.
Activity levels This would change the activity and flow with change some activity moving from existing sites to the designated Tier 2 units. Therefore a change in activity and flow from 2 existing sites. Cross boundary This would mean populations from impact and Rotherham, Bassetlaw and Barnsley transport travelling to Doncaster, Wakefield or Sheffield, if these sites were to be developed as the tier 2 sites. This would impact on transport services, this would need planning in, the number of new transfers overall would increase. Adequate There would need to be concentrated Workforce, safety workforce planning throughout and across and quality the 3 hub sites. Impact on For some care that was not planned this visitors/carers would mean travelling to the Tier 2 centre instead of a local hospital site. Finance Not known at this stage
Challenge in This option although challenging requires a delivery substantial change could be delivered. It would need a level of additional planning for increased capacity in the proposed tier 2 centres.
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Total weighted This option would mean a radical change scores across inpatient provision and moving to a planned network across outpatient and day case surgery.
Option 2 : Indicative Activity Changes: Three Hubs - Variance Impact by Selected Specialty
1. Emergency ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 518 1354 19 152 1456 214 3713 Variance by Provider BHNFT -42 -262 0 0 -197 0 -501 CRH -34 -131 -3 0 -145 0 -313 DBH -12 76 -2 27 -27 -4 58 MYH 20 106 0 0 89 -2 214 Other 0 0 0 0 0 0 0 SCH 139 505 8 67 518 16 1252 STH 0 0 0 0 0 0 0 TRFT -71 -294 -5 -94 -238 -10 -712
2. Elective with LOS >0 ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 478 16 6 21 215 2 738
Variance by Provider BHNFT -38 -1 0 0 -19 0 -58 CRH -130 -1 0 0 -23 0 -154 DBH -23 0 1 -1 -1 0 -24 MYH 36 0 2 0 7 0 45 Other 0 0 0 0 0 0 0 SCH 251 6 3 6 62 0 329 STH 0 0 0 0 0 0 0 TRFT -96 -5 -6 -5 -26 0 -138
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2.12 Option Three - Development of 2 tier 2 hubs across the geography: These would be located at Sheffield and Pinderfields. This would provide a site for inpatient care within the geography based at a larger distance apart to the current configuration.
Criterion RAG Initial Assessed Impact Access This would mean some cases would be transferred to the proposed Tier 2 units and not present at units providing Tier 1 care, or be stabilised and transferred to the nearest tier 2 unit. This would mean all CCG populations would have equality of access to the same standards of surgical care, but mean further travel for procedures and may build in a time delay to treatment. Activity levels – This would change the activity and flow with levels of change some activity moving from Rotherham, Barnsley, Doncaster and Bassetlaw to the tier 2 units. The level of activity needed at the 2 sites would be challenging to provide. Cross boundary This would mean populations from impact and Rotherham, Barnsley, Bassetlaw and transport Chesterfield travelling and would impact on transport services as there would be a significant number of transfers. Adequate There would be the ability to plan the workforce workforce to provide this cover apart from the acute paediatric workforce in the future for this care Impact on For some care that was not planned this visitors/carers would mean travelling to the Tier 2 centre Finance Not known at this stage Challenge in There would be bed capacity issues with this delivery proposal as the shift of inpatient activity would be significant Total weighted This could have a significant impact on score patients access to care without a radical upgrade in transport and capacity at the 2 site proposed.
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Option 3 : Indicative Activity Changes:
Two Hubs - Variance Impact by Selected Specialty
1. Emergency ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 518 1354 19 152 1456 214 3713 Variance by Provider BHNFT -42 -262 0 0 -197 0 -501 CRH -34 -131 -3 0 -145 0 -313 DBH -175 -195 -8 -12 -407 -20 -817 MYH 48 163 1 1 108 3 324 Other 0 0 0 0 0 0 0 SCH 274 719 15 105 879 27 2019 STH 0 0 0 0 0 0 0 TRFT -71 -294 -5 -94 -238 -10 -712
2. Elective with LOS >0 ENT Gen Surg Ophth Oral Surg T&O Urology TOTAL Current Activity 478 16 6 21 215 2 738
Variance by Provider BHNFT -38 -1 0 0 -19 0 -58 CRH -130 -1 0 0 -23 0 -154 DBH -140 -4 0 -11 -48 0 -203 MYH 47 1 2 2 16 0 67 Other 0 0 0 0 0 0 0 SCH 357 10 4 14 100 0 486 STH 0 0 0 0 0 0 0 TRFT -96 -5 -6 -5 -26 0 -138
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3. Conclusions and Recommendations
3.1 Governing Bodies are ask ed to support the designation of Tier 1 and Tier 3 surgical care, enabling the implementation of this through the Managed Clinical Network and through commissioning and contracting teams within CCGs.
3.2 Governing Bodies are also asked to support further consideration of the options. Building upon the initial, indicative RAG scores above, and noting that (at this stage) the three-hub model appears to offer the greatest benefit and scope for feasibility, and should be appraised further.
3.3 This is likely to lead to the formal classification a “Preferred Option”, with subsequent development of a business case to examine detailed implementation aspects.
3.4 It is acknowledged from the outset and from the RAG scoring and supporting data that there will be potential capacity issues, to a greater or lesser degree, with all options, as well as potential sustainability impacts upon other services at sites not designated as Tier 2. The ‘do-ability’ of options should be a substantial factor in their appraisal.
3.5 Following the first phase of work on the Acute Care pathway in May and the STP initial modelling to be completed in June 2016, further consideration of the potential impacts of these upon surgical models will need to be undertaken. There is an acknowledged interdependency between the assessment and management of acute care within paediatric assessment and the pathway to surgical care for procedure and intervention.
3.6 At this stage, whilst the three-hub model presents the most promising initial findings, the Working Together Programmes recognise that, in addition to option scoring, all proposals will and should be subject to adequate public consultation, and that this should take place in a transparent way. It is anticipated that this consultation will start in September 2016.
Kate Laurance on behalf of Commissioners Working Together and the Working Together Programme 1 June 2016
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Hyper Acute Stroke Services Options Appraisal
Executive Summary
1. Purpose The purpose of this paper is to:
Summarise the work undertaken to date, by our CCGs, in reviewing hyper acute stroke services (HAS) across South Yorkshire and Bassetlaw and North Derbyshire.
Seek support from Governing Body to continue to progress the work (HAS). Moving towards public consultation in the autumn on the preferred option outlined in the options appraisal document.
Following public consultation bring back a full business case with recommendation for change for Governing Body approval.
This change is confined to the hyper acute part of the stroke pathway which is the first 72 hours of care.
2. Background and Context Over the past eighteen months CCGs have undertaken a review of hyper acute stroke services across South Yorkshire, Bassetlaw and North Derbyshire as Commissioners Working Together. The current model of delivery for hyper acute stroke services (HAS) is delivered from 5 units in Barnsley, Chesterfield, Doncaster, Rotherham and Sheffield.
The main drivers for considering change are outlined below and these remain. In particular a sustainable workforce to deliver hype acute stroke services remains a significant challenge.
Key messages from the review:
3 out of 5 HASU centers admit less than the best practice minimum of 600 per unit There is a shortage of medical, nursing and therapy staffing Door to needle time of over 1 hour in most places Low thrombolysis rates across all providers Not achieving 1 hour scanning time Unsustainable medical rotas Gaps in early supported discharge Education and training required for delegated staff Delays in endarterectomy
Our review was shared with the Yorkshire and the Humber Senate who supported our 1
findings. The senate also recommended that our review was considered in context of the full regional picture and any potential impact.
In June 2015, CCGs supported the case for change with a clear mandate to develop options for future service delivery and the Yorkshire and the Humber Strategic Clinical Network (SCN) took forward the development of a ‘Blueprint’ for HAS across Yorkshire and the Humber.
The principle of the Blueprint was to provide a high level overview of what would provide clinically safe and sustainable HAS services and ensure the best equity of access for all our local populations.
Summary of key themes from ‘HAS Blueprint’:
Reconfiguration in South Yorkshire and Bassetlaw should include:
A plan to reduce the number of HAS within the South Yorkshire and Bassetlaw and move to a minimum of 2 units Consider the cross-boundary impact and East Midland review for Chesterfield unit Transformation should include a review of patients flows No center should exceed the maximum stroke numbers of 1500 Best practice travel time of 45 minutes and clinical viability Steps to improve clinical outcomes and provide sustainable stroke services. Reconfigure total number of HAS (services should deliver more than 900 interventions per year) to support clinical outcomes and improve performance seen in the SSNAP reports
The SCN presented the ‘Blueprint’ in April 2016 and subsequently the Senate reviewed the findings.
The final June recommendations in the SCN Blueprint for Hyper Acute Stroke now recommends that for South Yorkshire and Bassetlaw for HAS services should include consideration of the viability of reducing the number of HAS services to a minimum of 2.
3. Stakeholder engagement and pre-consultation Commissioners Working Together have facilitated significant stakeholder engagement throughout the review process engaging in particular with providers and commissioners and other key partners via a series of workshops, engagement events and the stroke steering group between January 2015 and May 2016.
Between January and April 2016, Commissioners Working Together, of which we are a partner, held an open pre-consultation for the review of hyper acute stroke services across South and Mid Yorkshire, Bassetlaw and North Derbyshire. Asking ‘what matters to you when accessing urgent stroke services’ the conversations were held face to face and across social media. Thousands of people accessed the website to read about the case for change, hundreds were involved in face to face discussions and several hundred responses were received.
The key themes emerging were: being seen quickly when get to hospital, being seen and treated by knowledgeable staff, safety and quality of service, fast ambulance response/travel times and good access to rehabilitation services locally.
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A communication and engagement strategy for consultation has been developed for the next phase of this work and to enable us to progress to consultation with the public about proposed changes to HAS in the autumn.
4. Developing options The development of the options appraisal framework to support improvements to the delivery of HASU has been undertaken working with the Stroke Steering Group, comprising of commissioners and providers from across our Working Together partners. The Steering group has also been established to support and oversee this work. The focus has been on ensuring that the appropriate outcome measures and weighting were allocated to the options appraisal matrix this was then used to review the various options and those that are most likely to impact on overall improvements to outcomes and sustainability of services.
The matrix reviewed:
Access meets 45 mins (provided by YAS) HASU activity levels (and the impact from reducing a HASU) Cross boundary impact (recognising Mid Yorkshire and East Midlands) 7 day working Workforce Impact on visitors (information obtained from pre –consultation) Finance
This approach provided a comprehensive review and evaluation to support recommendations to improve clinical outcomes and sustainability. A full business case with detailed financial analysis is currently being developed based on the outcome of the options appraisal and will be completed in the next 2 months. The working hypothesis is that positive impact on outcomes can be achieved at null cost. This is based on change that has taken place in other parts of the country with a similar approach. We are also working with our partners in West Yorkshire and Derbyshire on the potential cross-boundary impact.
Summary of the outcome of the optional appraisal matrix
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The outcome of the options appraisal identifies a preferred option and it is proposed that we consult the public on this preferred option.
The preferred option is that we will move from a 5 hyper acute stroke unit’s model to a 3 unit model in the first stage.
The preferred option is that hyper acute stroke will be provided at Sheffield, Doncaster and Chesterfield.
Chesterfield is currently being considered as part of the East Midlands review and therefore any potential changes to the hyper acute stroke unit in Chesterfield will need to be considered in light of this review and therefore in stage 2.
The benefits of this change are that we will move to a more sustainable model of Stroke care provision for all parts of the clinical pathway and impact on the original divers for change outline in the case for change and specifically:
Hyper acute – first 72 hours Acute stroke service – delivered in all 5 local sites Rehabilitation - delivered in all 5 local sites
Further work is required on the “do-ability “ aspect which will support the operationalizing of the recommendations in the future and following any eventual. This is being taken forward with the Stroke Steering Group. This work is currently taking place and will support the final business case and implementation plan which will come back to Governing Bodies for a final decision.
5. Summary next steps Change and outcome of options appraisal presented to Joint OSC in August Stage 2 Assurance for NHS England 17th August Financial analysis and full business case development September Formal consolation on preferred option 1st October for 14 weeks
6. Recommendation
Governing Body is asked to:
Note progress of the work. Support the preferred option to consult the public on. Agree to receiving the full business case with recommendation for change for final Governing Body approval following formal consultation in January 2017.
Paper prepared by Mandy Philbin on behalf of Will-Cleary-Gray June 2016
To be read in conjunction with the full Options Appraisal
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Commissioners Working Together HASU – Stage 3 - Detailed Option Appraisal
June 2016
Title HASU Option Appraisal
Author Rebecca Brown, Mandy Philbin & Stroke Steering Group Target Audience Commissioner Working Together Board
Version V6 WTP Reference WTPC Created Date 02/04/16 Date of Issue 28/6/16 Document Status FINAL To be read in Case for change conjunction with Scenario appraisal document SCN HASU Blueprint for Yorkshire and the Humber Yorkshire and the Humber Senate report on the case for change Yorkshire and the Humber Senate report on the SCN HASU Blueprint File name and path HASU Appraisal V6 for Boards Document History: Date Version Author Details 02/04/16 1 RB 18/04/16 2 Amends/additions from WCG/MP 10/05/16 3 MP Matrix completed post Steering Group sign off. 02/06/16 4 W C-G 14/06/16 5 MP Visual added for activity and options (post board) 29th June 6 MP/WC Consideration for 1500 based on SCN Blueprint Approval by: Programme Executive Group (PEG) Governance route: Group Date Version Purpose Commissioners 7/6/16 5 For discussion Working Together Board Stroke Steering 8/6/16 5 For discussion Group Working Together 24/6/16 5 For discussion Senior Management Team
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Contents 1.0 Executive Summary ...... 4 2.0 Introduction ...... 6 2.1 Purpose of the document ...... 7 3.0 High level options appraisal – To date ...... 7 3.1 Case for Change - Stage 1 Option appraisal ...... 9 3.2 Y&H Blueprint - Stage 2 Option appraisal ...... 8 3.3 Options going forward to stage 3 option appraisal ...... 10 4.0 Evaluating the options in stage 3 ...... 10 4.1 Learning from elsewhere ...... 10 4.2 Principles of Redesigning Services ...... 11 4.3 Option Appraisal Criteria ...... 11 5.0 Option Appraisal ...... 12 5.1 Configuration for consolidation of HASU (further working detail Appendix 1) ...... 12 6.0 Conclusion ...... 13 6.1 Preferred Option/s ...... 13
Appendix 1 – Assessment Criteria and Options Appraisal
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1.0 Executive Summary
In 2007 the Department of Health published the National Stroke Strategy providing a national quality framework to secure improvements across the stroke pathway. Then in 2014, the NHS Five Year Forward View set out a positive view for future new models of care, indicating the need for rationalisation and sustainability in services in order to meet growing demands, provide high quality and remain financially viable.
A detailed baseline review across South Yorkshire, Bassetlaw and North Derbyshire demonstrated a gap analysis for the delivery of Hyper Acute Stroke Units (HASUs) within the region and formulated a “Case for Change (May 2015)” which was supported by the Commissioners Working Together partner CCGs, received positive support from the Yorkshire and the Humber Clinical Senate and was shared with acute provider Boards.
Further support and recommendations have been identified in the Hyper Acute Stroke Services Yorkshire and Humber “Blueprint” report which was undertaken by the Yorkshire and the Humber Strategic Clinical Networks.
Gaps were identified within service delivery and highlighted in both documents, difficulties in the ability to provide high quality, Sentinel Stroke National Audit Programme SSNAP performance data and sustainable services due to recurrent issues with :-
Workforce, skills and expertise Capacity and demand
And being able to meet fundamental minimum numbers of stokes per HASU recognised as being key criteria required to meet national standards and enable sustainable services for the future.
All documents have been fundamental in supporting the development for this Options Appraisal.
This Options Appraisal provides a comprehensive review, evaluation and proposal for a new model of care based on quantitative data for HASU activity, ambulance transfer times, SSNAP submission data (as seen in the Blueprint) and qualitative data gained through the Commissioners Working Together (CWT) engagement with service staff, clinicians and managers and pre-consultation with service users regarding potential changes to current models of service delivery.
The outcome of the Option Appraisal supports the radical transformation and reduction of HASUs from 5 to 4, 3 or, supporting the Networks regional requirements of 2. Based on the options appraisal matrix it would be viable to reduce the number of HASUs based on true data outcomes.
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Consideration to the potential reviews/impact of any transformational changes within North Derbyshire and Mid York’s given the impact on cross boundary patient flow
To be able to develop a more sustainable network for stroke care a consideration needs to be given to the following options:-
Option Number of Units Continue to Remove deliver HASU services Option 3b 4 unit delivery Sheffield, Rotherham (Working Barnsley, Together Chesterfield Footprint) and Doncaster Option 3c 3 unit delivery Sheffield Barnsley and (Working Doncaster Rotherham Together and Footprint) Chesterfield Option 3d 2 unit delivery Sheffield and Barnsley (Supporting Doncaster Rotherham and Network Chesterfield changes)
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It is important to note that this Options Appraisal considers changes to the Hyper-Acute Stroke Service, not the wider service. Hyper acute stroke care is for a clearly defined period (up to 72 hours). The proposed changes refer to the first 72 hours of emergency stroke treatment, and not acute stroke care or rehabilitation.
Further consideration is required leading to implementation of the options. This specifically related to the do ability of each option. The identified organisations need to be able to demonstrate their “do-abiity” to be able to support the increase in activity. This will mean detailed capability assessments for:-
o Capacity and demand assessment, o Understand displaced activity, o Financial modelling o Pathway review, supporting repatriation/rehabilitation.
Considerations of future impact and developments need to be kept within the sight of the developing South Yorkshire and Bassetlaw and neighbouring Sustainability Transformation Plans and regional Clinical Network recommendations (i.e. the impact on Chesterfield/ Nottingham and Sherwood Forest review).
2.0 Introduction
The way that stroke services are organised will have a major impact on a person’s recovery after a stroke. We know that the most important interventions are maintaining homeostasis and preventing stroke-associated complications. We know that thrombolysis delivered quickly will reduce the chances of a disability. There is also a strong evidence base that effective prevention strategies after stroke and transient ischaemic attack (TIA) will reduce the risk of reoccurrence when supported by specialist rehabilitation both in hospital and in the community. Data from the Sentinel Stroke National Audit Programme (SSNAP) has shown that larger stroke services operate more efficiently than smaller services and they are more likely to be financially viable as well. It has been shown that levels of nurse staffing also have a direct impact on the chance of patients surviving.
To deliver the best outcomes, it is therefore vital that patients are managed in a well organised service that can deliver the best quality of care and unfortunately the SSNAP data clearly shows that there are still unacceptable variations in the quality of care across England. Given the major shortages in medical workforce that are going to increase in the coming years, the most rational solution, particularly in parts of the country with high population density, will be for providers and commissioners to work together to centralise inpatient care in a smaller number of stroke centres, as suggested in the NHS Five Year Forward View published in 2014. Where this is not possible, for 6 whatever reason, then telemedicine will provide at least partial solutions to existing variations in the care that a patient might expect to receive. Professor Tony Rudd CBE. National Clinical Director for Stroke, NHS England.
2.1 Purpose of the document
This Options Appraisal document sets out the options being considered by commissioners for the long term provision of Hyper-Acute Stroke Services within South Yorkshire, Bassetlaw and North Derbyshire and the risks and benefits with each. The purpose of this paper is to provide the information required by the Governing Bodies from each of the Clinical Commissioning Groups, along with the Commissioners Working Together programme executive group to make a decision on a preferred option/s that will be taken to public consultation in September 2016.
3.0 High level options appraisal – to date
The three sub regions of Yorkshire and Humber have identified the need to undertake an assurance review to ascertain resilience of the current HASU provision. The review has been mandated by the Yorkshire and Humber Chief Officers and is being delivered through existing sub-regional governing and accounting arrangements. For South Yorkshire, Bassetlaw and North Derbyshire, the review is being undertaken as part of Commissioners Working Together.
Figure 1 - Summary of Option Appraisal Process
Stage 1 Stage 2 Stage 3
Senate Senate review Senate review review Senate review
Senate review Preferred Case for change 3 high level HASU ‘Blueprint’ 3 detailed WT detailed Preferred option(s) High level options options 5 options options option appraisal option(s)
Y&H stakeholder Governing Event Governing Bodies/board WT stroke steering Bodies/board group
In the early part of 2015 a HASU case for change and scenario appraisal document were developed with key stakeholders and taken through CWT 7 governance. This resulted in a clinical senate review of the aforementioned documents in July 2015.
As is clear from the phase 1 HASU case for change, the variation in quality and performance against standards across South Yorkshire, Bassetlaw and North Derbyshire, is of concern to commissioners. The key messages from the phase 1 review are as follows:
3/5 of HASU centres admit less than 600 strokes per annum. There is a shortage of medical, nursing & therapy staffing in all provider organisations. Door to needle times of over 1 hour in most cases Very low thrombolysis rates across all providers. Not achieving1 hour scanning. Unsustainable medical rotas. Education & training required for delegated staff. Gaps in Early Supported Discharge. Delays in endarterectomy. 2 units within 15 miles of each other. There is further work required to ensure effective use of telemedicine.
3.1 Case for Change - Stage 1 Option Appraisal
All Commissioners Working Together partner CCGs supported ‘transformation’ of HASUs across the CWT footprint. This decision was also supported by the Yorkshire and the Humber Clinical Senate. Stage 1 of the option appraisal outlined in the table below.
Case for Change - Stage 1 Option Outcome Appraisal Option 1 – Do nothing Discounted on the basis of current quality, performance and sustainability challenges Option 2 – Improve quality and Discounted on the basis of the sustainability of current configuration likelihood of efforts leading to of 5 HASU’s improved quality, performance and sustainability Option 3 – Transformation of Supported on the basis of likelihood HASU’s across CWT footprint to improve quality performance and sustainability of HAS for all local population
3.2 Y&H Blueprint - Stage 2 Option Appraisal
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Stage 2 involved a ‘purest’ approach by the SCN which ruled out/discounted keeping 5 centres on the basis of not meeting minimum recommended number of strokes for each centre. Stage 2 is outlined in the table below.
Y&H Blueprint - Stage 2 option Outcome appraisal Option 3a – 5 centres Discounted on basis of 5 centres not being able to meet the minimum recommended number of stroke cases for each single centre Option 3b - 4 centres Option includes consideration of the North Derbyshire and Hardwick populations and the Chesterfield HASU centre Option 3c – 3 centres Option uses 1200 as upper limit and does not take potential services changes in East Midlands into consideration Option 3d – 2 centres To be considered on the basis of the Y&H blueprint – using the 1500 scale of ambition required in STP metrics development, dependant on configuration across the region Option 3e – 1 centre Discounted on basis of number of stokes across CWT and maximum number for a single centre
Using the principles of travel times and size of unit, the final recommendation from the SCN Blueprint for South Yorkshire, Bassetlaw region was for a minimum of 2 units for South Yorkshire and Bassetlaw.
There needs to be consideration and recognition of any transformational changes to stroke service delivery within the East Midlands Clinical Network and the potential impact in South Yorkshire and Bassetlaw. A verbal update from East Midlands Clinical Senate in May 2016 identified that the strategic review for this catchment remained outstanding.
The blueprint analysis in its early draft form did not use 1,500 as the upper limit for the size of a HASU unit; instead the clinical consensus in the SCN was to use 1,200 strokes per annum. Given the scale of ambition required in Sustainability and Transformation Plans to ensure services are sustainable for the future, the Commissioners Working Together partners have made the decision to model options on the upper threshold for size of a unit. If taken in the context of Yorkshire and Humber, and the upper limit applied, potentially there would be scope to move to fewer units across the region. This potentially could result in 2 units for South Yorkshire, Bassetlaw and North Derbyshire. It should be noted that this configuration will have the potential to increase HASU unit/s to exceed the 1200 threshold endorsed by the SCN but be supported by the ambitions of Yorkshire and Humber Senate of 1500 patient threshold.
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The final recommendation from the Blueprint now recommends the use of 1500 strokes as the maximum number of strokes per unit.
3.3 Options going forward to stage 3 option appraisal
Given the outcome of the two stages of option appraisal already undertaken, the options being taken forward to stage 3 are as follows:
Option 3b – reduce to 4 HASU centres Option 3c – reduce to 3 HASU centres Option 3d –reduce to 2 HASU centres – consideration needs to be made when supporting “do ability” given the impact of reviews ongoing in Mid Yorks and North Derbyshire.
4.0 Evaluating the options in stage 3
4.1 Learning from elsewhere
CCGs must make sure that they have a process in place for appraising and testing options. There should be a robust, documented process for sifting any long- list of options into a shortlist. There should also be a framework in place to further test shortlisted options to make sure that they are sufficiently robust and fit for purpose. This framework should also be used on any new options that emerge from the consultation. The options appraisal must include an analysis of the implications of no change. In order to arrive at such decisions, it is essential that sound, robust analysis is undertaken.
The evidence is strong that being admitted to a specialist stroke centre with access to stroke expertise 24 hours a day, seven days a week, results in better outcomes than being managed without these resources. The improved outcomes arise from careful attention and treatment to maintain homeostasis, skilled nursing and medicine to avoid complications and early intervention to treat complications before they become life-threatening.
Reorganisation of stroke services therefore needs to take into account where the benefits lie for the population that the hyper acute stroke services are serving. High quality care, including access to intravenous thrombolysis should be available to all, with sufficient provision in place, in areas with a high population density.
However, it is important to recognise that in rural areas providing a well- staffed unit working 24/7 that is also within a 45-60 minute drive in a blue light ambulance might not be possible.
As supported by the case for change and feedback from the Clinical Senate, doing nothing and maintaining poor services for all is not an option. We need 10 to ensure that the greatest number of people as possible receive high quality, safe and sustainable services, for 95% of the population
4.2 Principles of Redesigning Services
Factors to consider for urban areas
The following factors should be considered when looking into redesigning stroke services in urban areas:
• Clinical and financial critical mass, of >600 and <1,500 stroke admissions per annum. • Balance between volumes and financial viability. • Travel time should be ideally 30 minutes but no more than 60 minutes.
Factors to consider for rural areas
The following factors should be considered when looking into redesigning stroke services in rural areas:
Clinical and financial critical mass standards achievable in urban areas may not always be feasible in low population density areas. Balance between volumes, travel times and financial viability. Standards that must not be compromised are:
Specialist assessment on admission (24 hours a day) and daily thereafter during hyper-acute phase (the first 72 hours after having a stroke). Stroke unit staffed and equipped in line with best practice specification (guidance is in the development phase). 24-hour access to scanning. Access to thrombolysis, but less important than other aspects of care. Access to therapy. Door to needle time.
4.3 Option Appraisal Criteria
Commissioners Working Together have developed an evaluation criteria to use as part of the decision making process to assess potential options against criteria which have been weighted in order of importance by the Stroke Steering Group. The criteria use the principles that are set out in the Stroke Services: Decision support Guide. These have then been weighted by the CWT stroke steering group and options assessed against these.
It is agreed that quality of care should be the highest priority when it comes to decisions about service provision. However it is important to balance the other elements of the criteria to ensure that our services are maintained with the right level of skilled workforce, at locations that are accessible for patients, and in a way that uses our resources as efficiently as possible. 11
Agreement at the April Stoke Steering group facilitated the appropriate priority and weighting criteria to support the options appraisal matrix: Matching the criteria against the impact provides a weighted outcome measure that supports the future decision making process
Commissioners Working Together evaluation criteria
Criteria and data to support Indicator evaluation
Access meets 45 minutes Access meets 45 minutes for 95% of population (ambulance conveyance times)
HASS activity levels (displaced Clinical critical mass, of >600 and <1,500 stroke activity) admissions per annum
Cross boundary impact (outside Transformation should minimise cross-boundary impact WTP footprint)
7 day working Is there a 7 day service being offered?
Adequate workforce Performance against SSNAP scores (case for change)
Impact on visitors/carers Impact of change on visitors and carers travel time (Pre consultation evaluation)
5.0 Option Appraisal
Building on the evaluation criteria the Stroke Steering Group provided clinical guidance and judgement around the importance and value on each element. This supported a weighting scoring system which when matched against a value score (1 being excellent to 5 very badly) there was clear demonstration to the capability and impact of individual organisations to deliver a HASU The evaluation of the matrix is consolidated in 5.1 with the working documentation shown in Appendix 1.
5.1 Configuration for consolidation of HASU (further working detail Appendix 1)
Option 3b Remove Rotherham Reduce to 4 units Option 3c Remove Rotherham and Reduce to 3 units Barnsley Option 3d Remove Rotherham, Barnsley, Reduce to 2 units Chesterfield
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6.0 Conclusion
6.1 Preferred Option/s
Support option 3c as the preferred option to consult the public on and recommend to CCG commissioners. This option would result in decommissioning HASU from a Barnsley & Rotherham. Support the implementation of any future change managed through the Stroke Steering Group & SRG’s.
Give further consideration to the scale of ambition and change required to achieve Option 3d. It may be appropriate to undertake a stepped approach to this option, over a longer period of time with support and direction from the Clinical Senate pending east Midland review of HASU and transformation plans within Mid Yorks.
It is the recommendation that option(s) 3c is for consideration by the Commissioners Working Together board and is taken forward to public consultation in South Yorkshire and Bassetlaw. In addition and as part of the consultation we would wish to raise awareness of the impact of any further potential change as part of East Midlands review of HASU services and the potential of what is described in option 3d This option and approach is now supported by the most recent recommendations from the SCN June Blueprint for HAS which recommended that a minimum of 1500 strokes should be considered in any reconfiguration of stroke services.
13
Appendix 1 7.1 Assessment Criteria
Assessment (Consensious Stroke Criteria Translation Steering Group 4.5.16) Access meets 45 Access meets 45 min for 95% population (meets 5 – excellent minutes current model) Based on YAS transfer time . Optimum benchmark 45mins. 4 – good Access meets 45 min for 75 - 94% population Transfer time is for total stroke population
3 – adequate Access meets 45 min for 51 - 76% population
Weighted as 3 2 – poor Access meets 45 min for 26 - 50% population
1 – very poor Access meets 45 min for 25 - 0% population
Criteria Assessment Translation Ensures 2 other HASUs are viable due to transfer in HASU activity levels 5 – excellent activity (over 900) Based on a viable option of 900- Ensures 2 other HASUs are viable due to transfer in 1,200 as optimum delivery for 4 – good activity (over 600) all units. For 2 units to be modelled on Ensures 1 other HASUs are viable due to transfer in 3 – adequate 1500 patients activity (over 900) Ensures 1 other HASUs are viable due to transfer in 2 - poor activity (over 600) Ensures 0 other HASUs are viable due to transfer in Weighted as 4 1 – very poor activity
Criteria Assessment Translation
Cross boundary impact 5 – excellent No impact
Minimal impact (affects 2 HASU, not tipping them over 3 – adequate 1200) Weighted as 2 1 – very poor Tips one centre over 1500
Criteria Assessment Translation 7 day working 5 – excellent Reduces number of non-compliant centres by 4
Based on accessibility and 4 – good Reduces number of non-compliant centres by 3 impact on clinical outcomes 3 – adequate Reduces number of non-compliant centres by 2 2 - poor Reduces number of non-compliant centres by 1 Weighted as 5 1 – very poor Does not reduce non-compliant centres
Criteria Assessment Translation Adequate workforce Removes 2 HASU who have less staffing than required 5 – excellent Based on resilience and in 3 of the reported SSNAP areas sustainability of service.
Removes 1 HASU who have less staffing than required 4 – good in 3 of the reported SSNAP areas Removes 1 HASU who have less staffing than required 3 – adequate in 2 of the reported SSNAP areas Removes 1 HASU who have less staffing than required 2 - poor in 1 of the reported SSNAP areas Weighted as 6 1 – very poor Does not affect any underperforming HASUs
Criteria Assessment Translation Patient experience and Impact on 5 – excellent Travel times are increased for 20% of the population visitors/carers
4 – good Travel times are increased for 40% of the population
3 – adequate Travel times are increased for 60% of the population
2 - poor Travel times are increased for 80% of the population
Weighted as 1 1 – very poor Travel times are increased for 100% of the population Option 3b - 4 Units
HASU 2016 OPTION APPRAISAL
Step 1 - Weight the parameters
Weight Criteria Relative score (%)
Access meets 45 mins 30 30 14%
HASU activity levels 40 40 19%
Cross boundary impact 20 20 10%
7 day working 50 50 24%
Workforce 60 60 29%
Patient experience - Impact on visitors 10 10 5%
210 100%
Step 2 - Score each option 5 = excellent 4 = good 3 = adequate 2 = poor 1 = very poor
Unweighted Scores Weight Criteria Option 3b (i) Option 3b (ii) Option 3b (iii) Option 3b (iiii) (%) Displace Barnsley Doncaster Rotherham Chesterfield
Access meets 45 mins 5 5 5 5 14%
HASU activity levels 4 4 3 3 19%
Cross boundary impact 3 3 5 3 10%
7 day working 2 1 2 2 24%
Workforce 1 3 4 4 29%
Impact on visitors 5 5 5 5 5%
20 21 24 22 100%
Step 3 - Weighted results
Criteria Weighted Result Option 3b (i) Option 3b (ii) Option 3b (iii) Option 3b (iiii) Displace Barnsley Doncaster Rotherham Chesterfield
Access meets 45 mins 0.71 0.71 0.71 0.71
HASU activity levels 0.76 0.76 0.57 0.57
Cross boundary impact 0.29 0.29 0.48 0.29
7 day working 0.48 0.24 0.48 0.48
Workforce 0.29 0.86 1.14 1.14
Impact on visitors 0.24 0.24 0.24 0.24
The higher the score the more positive option is for removal 2.76 3.10 3.62 3.43 Option 3c - 3 Units
HASU 2016 OPTION APPRAISAL
Step 1 - Weight the parameters
Relative Weight Criteria score (%)
Access meets 45 mins 30 30 14%
HASU activity levels 40 40 19%
Cross boundary impact 20 20 10%
7 day working 50 50 24%
Workforce 60 60 29%
Impact on visitors 10 10 5%
210 100%
Step 2 - Score each option 5 = excellent 4 = good 3 = adequate 2 = poor 1 = very poor
Unweighted Scores Option 3c Weight Criteria Option 3c (i) Option 3c (ii) Option 3c (iii) Option 3c (iiii) Option 3c (iiiii) (iiiiii) (%)
Barnsley & Barnsley & Barnsley & Doncaster & Doncaster & Rotherham & Displace Doncaster Chesterfield Rotherham Chesterfield Rotherham Chesterfield
Access meets 45 mins 5 5 5 5 5 5 14%
HASU activity levels 3 5 5 4 4 5 19%
Cross boundary impact 3 3 3 3 3 3 10%
7 day working 2 3 3 2 3 3 24%
Workforce 1 2 4 4 4 1 29%
Impact on visitors 5 5 5 5 5 5 5%
19 23 25 23 24 22 100%
Step 3 - Weighted results
Criteria Weighted Result Option 3c (i) Option 3c (ii) Option 3c (iii) Option 3c (iiii)
Barnsley & Barnsley & Barnsley & Doncaster & Doncaster & Rotherham & Displace Doncaster Chesterfield Rotherham Chesterfield Rotherham Chesterfield
Access meets 45 mins 0.71 0.71 0.71 0.71 0.71 0.71
HASU activity levels 0.57 0.95 0.95 0.76 0.76 0.95
Cross boundary impact 0.29 0.29 0.29 0.29 0.29 0.29
7 day working 0.48 0.71 0.71 0.48 0.71 0.71
Workforce 0.29 0.57 1.14 1.14 1.14 0.29
Impact on visitors 0.24 0.24 0.24 0.24 0.24 0.24
The higher the score the more positive option is for removal 2.57 3.48 4.05 3.62 3.86 3.19 Option 3d - 2 Units
HASU 2016 OPTION APPRAISAL
Step 1 - Weight the parameters
Relative Weight Criteria score (%)
Access meets 45 mins 30 30 14%
HASU activity levels 40 40 19%
Cross boundary impact 20 20 10%
7 day working 50 50 24%
Workforce 60 60 29%
Impact on visitors 10 10 5%
210 100%
Step 2 - Score each option 5 = excellent 4 = good 3 = adequate 2 = poor 1 = very poor
Unweighted Scores Weight Criteria Option 3d (i) Option 3d (ii) Option 3d(iii) Option 3d (iiii) (%) Sheffield & Sheffield & Sheffield & Sheffield & Retain Barnsley Chesterfield Doncaster Rotherham
Access meets 45 mins 5 2 5 2 14%
HASU activity levels 2 1 5 1 19%
Cross boundary impact 1 3 5 1 10%
7 day working 2 2 1 2 24%
Workforce 2 3 3 4 29%
Impact on visitors 5 5 5 5 5%
17 16 24 15 100%
Step 3 - Weighted results
Criteria Weighted Result Option 3d (i) Option 3d (ii) Option 3d(iii) Option 3d (iiii) Sheffield & Sheffield & Sheffield & Sheffield & Retain Barnsley Chesterfield Doncaster Rotherham
Access meets 45 mins 0.71 0.29 0.71 0.29
HASU activity levels 0.38 0.19 0.95 0.19
Cross boundary impact 0.10 0.29 0.48 0.10
7 day working 0.48 0.48 0.24 0.48
Workforce 0.57 0.86 0.86 1.14
Impact on visitors 0.24 0.24 0.24 0.24
The higher the score the more positive option is for retention of those services 2.48 2.33 3.48 2.43
Communications and engagement strategy and plans for public consultation
April 2016
Contents:
Commissioners Working Together overarching communications and engagement strategy for public consultation
Communications and engagement plan for public consultation on children’s surgery and anaesthesia services
Communications and engagement plan for public consultation on hyper acute stroke services
Communications and engagement strategy for public consultation
Introduction
As Commissioners Working Together, we are a collaborative of eight NHS clinical commissioning groups across South and Mid Yorkshire, Bassetlaw and North Derbyshire and NHS England. Some people have better experiences, better outcomes and better access to services than others – and to ensure that everyone experiences the highest quality and safest services possible, we are working with all local hospitals and care providers, staff and patient groups to understand how best to do this for the benefit of our combined population of 2.8 million. Our key partners are:
NHS Barnsley Clinical Commissioning Group
NHS Bassetlaw Clinical Commissioning Group
NHS Doncaster Clinical Commissioning Group
NHS England
NHS Hardwick Clinical Commissioning Group
NHS North Derbyshire Clinical Commissioning Group
NHS Rotherham Clinical Commissioning Group
NHS Sheffield Clinical Commissioning Group
NHS Wakefield Clinical Commissioning Group
We also work with voluntary and community sector partners as well as gaining assurance and input from national and regional clinical advisors and experts.
Between January and April 2016 we held an open pre-consultation for the review of children’s surgery and anaesthesia and hyper acute stroke services. During this phase we gathered the views of our key stakeholders to inform plans for future service configuration and consultation. We are now preparing to enter XX week public consultations on the options for reconfiguring children’s
surgery and anaesthesia and hyper acute stroke services across our commissioning and provider partners in the region.
Effective communication and engagement is a two-way process. Our activity will focus on informing, sharing, listening and responding. Being proactive is central to our communications and engagement strategy of:
Proactively and effectively communicating our purpose, priorities, messages and values.
Developing effective, two-way mechanisms where we share news, we listen and respond whilst being open and transparent.
Identifying relevant and effective methods for audience and stakeholder engagement.
In all communications and engagement activity, we will work with all our local partners and tailor our messages and methods accordingly to each individual group to ensure we maximise all opportunities for connecting with, informing and engaging with our target audiences.
Aims and Objectives
Raise awareness and understanding of the current provision and need for changes to children’s surgery and anaesthesia and hyper acute stroke services in South and Mid Yorkshire, Bassetlaw and North Derbyshire
Ensure patients, families, carers and the public are involved, are able to share their views on the proposed options and are listened to
Inform key staff and clinicians in each locality about proposed change options and keep them updated throughout the consultation process
Ensure existing patients, family and carers have the information they need about any changes to services
Inform all stakeholders of new proposed models of care and opportunities to have their say in the consultations
Provide high quality support, advice and updates on consultation activity to the Commissioners Working Together board, partners and staff within each member organisation.
Key Messages
Alongside service and consultation specific messages, underpinning all our communications will be the following overarching messages of Commissioners Working Together:
We know that there’s variation in people’s experiences of services across our region, with some people getting better access and outcomes than others.
We know that many people are treated in hospital when their needs could be better met elsewhere or closer to home.
If we are to continue providing high quality, safe and sustainable NHS services – we need to change, together.
Our ambition is to develop excellent healthcare together by reconsidering how services are delivered, redefining how we work together as commissioners, and coming together with all our partners and stakeholders to find the best solutions for our populations.
Planning and commissioning across a larger area is becoming increasingly urgent as more and more people use NHS services, are living longer and using more advanced technology to improve care.
For some services, there won’t be enough trained and experienced staff in the future if we continue to provide services the way we do today, with the quality and accessibility of services being reduced.
At the same time, costs are increasing. If we don’t act now, more people will suffer from unnecessary poor health.
Target Audiences
Prior to the pre-consultation phase, a full stakeholder mapping exercise was carried out to identify all stakeholders involved in and affected by any proposed changes to the services reviewed (Appendix 1).
Through various and tailored communications and engagement methods, the following groups have been identified for targeted communications and engagement activity:
Patients and the public - including seldom heard groups and those identified in the following protected characteristics (Equality Act 2010):
- Age
- Disability
- Gender reassignment
- Pregnancy and maternity
- Race (Appendix 2: BME breakdown per population)
- Religion or belief
- Sex
- Sexual orientation
National and local patient groups
Local Authorities, MPs and councillors
Public health
Governing body members of all CCGs
Executive board members of all providers
Clinicians – acute, primary and community care
Foundation trust and CCG members
Clinical Senates
Healthwatch
Voluntary sector organisations
Health and Wellbeing boards
Local, regional and trade media
Communications Approach
Overall communications and engagement activity will be pro-actively co-ordinated by the Commissioners Working Together communications team who will work with the programme management team, workstream leads and communications and engagement leads from our commissioner and provider partners to ensure all activity is joined up, timely and appropriate.
After evaluating the communications and engagement activity carried out during the pre-consultation phase, we agreed that our activity for consultations will follow and build on the approach already taken and in place. Our inclusive approach will include:
Overarching strategic communications and engagement planning and support from the Commissioners Working Together team.
CCG-led local conversation and awareness raising based on comprehensive, place-based communications and engagement plans.
Regionally-led clinical and managerial engagement.
Clinically informed communication materials.
Clinically led conversations.
Patient and public involvement in the development of communication materials.
We have established a working group with all communications and engagement leads from our CCG partners, along with communications leads from the region’s acute provider organisations and NHS England, which has been meeting regularly since June 2015. As well as helping to shape and evaluate our communications and engagement approach, the group will meet to discuss and update on consultation feedback and progress.
Our communications and engagement approach for consultation has been further developed from patient and public response during our pre-consultation phase in terms of which methods were most favoured - which we will now use as a focus for our approach eg, website, social media, e-bulletins (Appendix 3).
To further strengthen our communications and engagement working group and activity we will build on our relationships with our public health and also local authority communications colleagues – allowing us to work together to disseminate messages and target existing networks, eg, for seldom heard groups and those included in the protected characteristics.
Communications Principles
All communications and engagement activity carried out by and on behalf of Commissioners Working Together will be:
Accessible and inclusive – to all our audiences
Clear and concise – allowing messages to be easily understood by all
Consistent and accountable – in line with our vision, messages and purpose
Flexible – ensuring communications and engagement activity follows a variety of formats, tailored to and appropriate for each audience
Open, honest and transparent – we will be clear from the start of the consultations what our plans are, what is and what isn’t negotiable, the reasons why and ultimately, how decisions will be made
Targeted – making sure we get messages to the right people and in the right way
Timely – making sure people have enough time to respond and are kept updated on a regular basis
Two-way – we will listen and respond accordingly, letting people know the outcome of all conversations.
Methods
No single communications channel will be effective in reaching and engaging all our audiences, therefore it is important that a variety of different communications and engagement methods are used, presenting relevant information in a timely and proactive way that best meets the needs of our individual stakeholders (as identified during pre-consultation).
Although full details of communications and engagement methods for individual audiences will be included in the communications and engagement planners for each of the consultations, some of our quantitative, qualitative and participatory methods will include the following:
Stakeholder briefings
Attendance at partner and stakeholder meetings and events
Focus groups
Flyers
Newsletters and e-bulletins
Local, regional and trade print and broadcast media
Internal bulletins
Public website
Online surveys
Deliberative events
Videos and vox pops
Alongside these methods, a key mechanism for consultation communications and engagement activity will be through the use of social media. We know from the Commissioners Working Together pre- consultations and also by identifying key trends and best practice from similar health and care transformation projects in other regions, that social media is an effective way of communicating and engaging with a variety of audiences.
Social media is a useful way of:
Disseminating information and signposting
Raising awareness
Collecting demographic data
Demonstrating willingness to engage in dialogue with a target audience
Speaking to a large number and variety of audiences in real-time.
By developing and creating a number of communications materials and assets, through social media we will listen and respond to and motivate our audience to both share the information we are communicating and also engage with us by taking part in the consultations.
Branding
Brand identity is important – particularly when multiple partners are involved. As a partnership we want to be seen as joined up, open and honest, approachable, clinically sound and responsive.
We have developed a Commissioners Working Together logo and identity that will be used on all communications and engagement materials for the two public consultations. Based on feedback from the pre-consultations, a single logo avoids confusion between the eight partners and will be clear to anyone across the region that the consultations are being delivered on behalf of all partners and organisations in the Commissioners Working Together partnership.
Consultation and engagement legislation
Throughout our communications and engagement activity for consultations into children’s surgery and anaesthesia and hyper acute stroke services, we as a collaborative of clinical commissioning groups will abide by the following legislation:
Health and Social Care Act 2012
The Health and Social Care Act 2012 makes provision for Clinical Commissioning Groups (CCGs) to establish appropriate collaborative arrangements with other CCGs, local authorities and other partners. It also places a specific duty on CCGs to ensure that health services are provided in a way which promotes the NHS Constitution – and to promote awareness of the NHS Constitution.
Health Commissioners must involve and consult patients and the public:
in their planning of commissioning arrangements
in the development and consideration of proposals for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and In decisions affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.
The Act also updates Section 244 of the consolidated NHS Act 2006 which requires NHS organisations to consult relevant Overview and Scrutiny Committees (OSCs) on any proposals for a substantial development of the health service in the area of the local authority, or a substantial variation in the provision of services.
The NHS Constitution
The NHS Constitution came into force in January 2010 following the Health Act 2009. The constitution places a statutory duty on NHS bodies and explains a number of patient rights which are a legal entitlement protected by law. One of these rights is the right to be involved directly or through representatives: In the planning of healthcare services The development and consideration of proposals for changes in the way those services are provided, and In the decisions to be made affecting the operation of those services.
Commissioners will ensure that the duties required in legislation are met and that patient, the public and stakeholders have the opportunity to have meaningful input in shaping future health services within the scope of the programme.
In undertaking public consultation commissioners we ensure that it is clear to public, patients and stakeholders what they are able to shape or influence and what areas are set due to national policy or safety reasons.
The Equality Act 2010
The Equality Act 2010 unifies and extends previous equality legislation. The characteristics that are protected by the Act are: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation.
Section 149 of the Equality At 2010 states all public authorities must have due regard to the need to a) eliminate discrimination, harassment and victimisation, b) advance ‘equality of opportunity,’ and c) foster good relations between persons who share a relevant protected characteristics and persons who do not share it.
The Gunning Principals of Consultation
The four ‘Gunning Principals’ are recommended as a framework for all engagement activity but are particularly relevant for consultation and would be used, in the event of a judicial review, to measure whether the process followed was appropriate. The Gunning Principles state that:
Consultation must take place when the proposal is still at a formative stage: Decision-makers cannot consult on a decision that has already been made. If the outcome has been pre-determined, the consultation is not only unfair, but it is also pointless.
This principle does not mean that the decision-maker has to consult on all possible options of achieving a particular objective. A decision-maker can consult on a ‘preferred option’, and even a ‘decision in principle’, so long as its mind is genuinely open - ‘to have an open mind does not mean an empty mind.’
If a decision-maker has formed a provisional view as to the course to be adopted, or is ‘minded’ to take a particular course subject to the outcome of consultations, those being consulted should be informed of this ‘so as to better focus their responses’.
Sufficient reasons must be put forward for the proposal to allow for intelligent consideration and response: Consultees should be made aware of the basis on which a proposal for consultation has been considered and will thereafter be considered. Those consulted should be aware of the criteria that will be applied when considering proposals and what factors will be considered ‘decisive’ or ‘of substantial importance’ at the end of the process.
Adequate time must be given for consideration and response: Unless statutory time requirements are prescribed, there is no necessary time frame within which the consultation must take place. The decision- maker may adopt a policy as to the necessary time-frame (e.g. Cabinet Office guidance, or compact with the voluntary sector), and if it wishes to depart from that policy it should have a good reason for doing so. Otherwise, it may be guilty of a breach of a legitimate expectation that the policy will be adhered to.
The product of consultation must be conscientiously taken into account: If the decision-maker does not properly consider the material produced by the consultation, then it can be accused of having made up its mind; or of failing to take into account a relevant consideration.
Evaluation and Monitoring
Evaluation will play an important part in our communications and engagement activity, evidencing whether we have achieved our objectives by engaging with our target audiences successfully. We will monitor our activity throughout the consultation period to ensure we are reaching our audiences effectively and providing equal and appropriate opportunities for involvement and feedback.
Through monitoring and evaluation we will be able to learn lessons and gain valuable insight into public and stakeholder sentiment and behaviour, allowing us to tailor our methods appropriately. Examples of how we will monitor our activity include:
Media and social media monitoring
Stakeholder meetings for discussions and feedback (particularly Healthwatch and OSC)
Staff feedback via briefings
Patient and public feedback via our various methods
Where necessary we will update the strategy to adapt to staff, clinical, patient, public and stakeholder feedback. It is vital that we are able to demonstrate that we listen to comments and suggestions from all our stakeholders, including seeking assurance from independent advisors, in order that they are fully involved and engaged in the reconfiguration of services.
DRAFT Communications and engagement plan for public consultation on children’s surgery and anaesthesia services
Introduction
As Commissioners Working Together, we are a collaborative of eight clinical commissioning groups across South and Mid Yorkshire, Bassetlaw and North Derbyshire and NHS England. Some people have better experiences, better outcomes and better access to services than others – and to ensure that everyone experiences the highest quality and safest services possible, we are working with all local hospitals and care providers, staff and patient groups to understand how best to do this for the benefit of our combined population of 2.8 million.
Between January and April 2016 we held an open pre-consultation for the review of children’s surgery and anaesthesia services. During this phase we gathered the views of our key stakeholders to inform plans for future service configuration and consultation. We are now preparing to enter a XX week public consultation on the options for reconfiguring children’s surgery and anaesthesia services across our commissioning and provider partners in the region:
NHS Barnsley Clinical Commissioning Group Barnsley Hospital NHS Foundation Trust
NHS Bassetlaw Clinical Commissioning Group Chesterfield Royal Hospital NHS Foundation Trust
NHS Doncaster Clinical Commissioning Group Doncaster and Bassetlaw Hospitals NHS Foundation Trust
NHS Hardwick Clinical Commissioning Group Sheffield Children’s Hospital NHS Foundation Trust
NHS North Derbyshire Clinical Commissioning Group Sheffield Teaching Hospitals NHS Foundation Trust
NHS Rotherham Clinical Commissioning Group The Mid Yorkshire Hospitals NHS Trust
NHS Sheffield Clinical Commissioning Group The Rotherham NHS Foundation Trust
NHS Wakefield Clinical Commissioning Group
We will be consulting on the following options: XXX
Aims and objectives
Raise awareness and understanding of the current provision and need for changes to children’s surgery and anaesthesia services in South and Mid Yorkshire, Bassetlaw and North Derbyshire Ensure patients, families, carers and the public are involved, able to have their say on the proposed options, and are listened to Inform key staff and clinicians in each locality about proposed change options Ensure patients, family and carers have the information they need about any changes to children’s services Inform all stakeholders of new proposed models of care and opportunities to be involved
Target audiences
The following audiences will be targeted through tailored communications activity. We will use a variety of methods to connect with each of our key stakeholders, ensuring our messages remain consistent and appropriate for each.
Patients and the public (including parent and carer forums, Foundation trust and CCG members seldom heard groups and identified protected characteristics) Clinical Senate
Local Authorities, MPs and councillors Healthwatch
Governing body members of all CCGs Health and Wellbeing boards
Executive board members of all providers Local, regional and trade media
Clinicians – acute, primary and community care Public health Key messages
As with pre-consultation, our key messages will focus on the reasons why changes are needed to children’s surgery and anaesthesia services whilst highlighting the importance of, and opportunities to get involved in, and take part in the consultation. These messages include:
We know that across our region some people have better experiences, better outcomes and better access to services than others. We want everyone to experience the highest quality and safest service possible.
We improving children’s surgery services for everyone across South and Mid Yorkshire, Bassetlaw and North Derbyshire – and we need your help!
Why are we changing services? At the moment:
- Different hospitals refer children in different ways
- Doctors in our smaller hospitals don’t treat as many children as our bigger ones
- Nationally, there aren’t enough health care professionals qualified to treat children, and;
- Some people have better experiences than others – we want this to change.
Note: Key messages will be tailored and confirmed once the business case for change is agreed and there are definite options for consultation.
Communications and engagement methods
To deliver the aims of our communications and engagement plan, we will carry out a range of activity across all geographic areas covered by the Working Together partnership, including both providers and commissioners. The methods and messages used to communicate will be tailored for each audience to maximise every opportunity for public and stakeholder involvement.
A key mechanism for consultation communications and engagement activity will be through the use of social media. We know from the Commissioners Working Together pre-consultations and also by identifying key trends and best practice from similar health and care transformation projects in other regions, that social media is an effective way of communicating and engaging with a variety of audiences.
Social media is a useful way of:
• Disseminating information and signposting
• Raising awareness
• Collecting demographic data
• Demonstrating willingness to engage in dialogue with a target audience
• Speaking to a large number and variety of audiences in real-time.
By developing and creating a number of communications materials and assets, through social media we will listen and respond to and motivate our audience to both share the information we are communicating and also engage with us by taking part in the consultations.
Further details of specific qualitative, quantitative and participatory communications and engagement methods for individual audiences are included in the planners below.
Engagement planner
Type of engagement Audience Method examples Responsibility
Qualitative Patients and the public, Focus groups CCG and provider partners parent and carer forums, supported by the Commissioners MPs, Local Authorities Attendance at relevant groups/events Working Together team
Stakeholder briefings
Vox pops
Seldom heard groups Attendance at existing groups eg, and protected parents with children with learning characteristics disabilities, Mosques, homeless charities, LGBT forums, sixth form colleges
Disseminate information through existing networks for 1:1 and group
conversations (eg, via public health colleagues to reach rural communities, BME groups, gypsy and traveller communities, asylum seekers, refugees, mental health support groups)
Quantitative Patients and the public, Online survey Commissioners Working healthcare staff Together team Flyers in various locations: GP practices, outpatient departments, libraries, supermarkets, children’s
centres, schools and nurseries
Seldom heard groups Flyers translated into most popular and protected languages (identified through census characteristics data in Appendix 2) and disseminated in various locations
Participatory Patients and the public, Deliberative events (x8) Commissioners Working parent and carer forums, Together team supported by seldom heard groups, Listening events CCG and provider partners healthcare staff and Focus groups clinicians
Attendance at existing groups and Seldom heard groups and protected
characteristics events
Focus groups
Social media All Twitter and Facebook – blanket and Commissioners Working targeted posts to various groups, Together team supported by including health and care organisations, CCG and provider partners patient groups, Healthwatch organisations, local authorities, press accounts, LGBT networks, youth groups, high profile local/regional businesses, activity centres, schools, parent and carer groups (eg, Mumsnet)
Communications planner
Communication Type Audience Method examples Responsibility
Promotion/ Participation Patients and the public including Newsletters Commissioners Working Together targeted to parents and carers, team supported by CCG and voluntary sector organisations Social media provider partners and staff Media
Blogs/case studies
Event presence
‘Market stalls’
Attendance at partners AGMs
Submissions to targeted Seldom heard groups and publications and protected characteristics newsletters, eg, parent’s assembly, BME community newspapers
Updates and briefings Staff from all partners, members NHS internal comms Commissioners Working Together of all organisations, GPs, practice team supported by CCG and staff, Local Authorities, MPs, E-bulletins provider partners as appropriate councillors, board and governing Briefing papers body members, OSC Verbal briefings/attendance at partner and stakeholder meetings
Media Patients, the public and staff Press releases Commissioners Working Together including trade publications team supported by CCG and Media interviews provider partners
Media briefings
Submissions to targeted Seldom heard groups and publications and
protected characteristics newsletters, eg, BME community newspapers
Social media All Twitter and Facebook – Commissioners Working Together blanket and targeted posts team supported by CCG and to various groups, provider partners including health and care organisations, patient groups, Healthwatch organisations, local authorities, press accounts, LGBT networks, youth groups, high profile local/regional businesses, activity centres, schools, parent and carer groups (eg, Mumsnet)
DRAFT Communications and engagement plan for public consultation on hyper acute stroke services
Introduction
As Commissioners Working Together, we are a collaborative of eight clinical commissioning groups across South Yorkshire and Bassetlaw and North Derbyshire and NHS England. Some people have better experiences, better outcomes and better access to services than others – and to ensure that everyone experiences the highest quality and safest services possible, we are working with all local hospitals and care providers, staff and patient groups to understand how best to do this for the benefit of our combined population of 2.8 million.
Between January and April 2016 we held an open pre-consultation for the review of critical care for people who have had a stroke (hyper acute stroke services). During this phase we gathered the views of our key stakeholders to inform plans for future service configuration and consultation. We are now preparing to enter a XX week public consultation on the options for reconfiguring hyper acute stroke services across our commissioning and provider partners in the region:
NHS Barnsley Clinical Commissioning Group Barnsley Hospital NHS Foundation Trust
NHS Bassetlaw Clinical Commissioning Group Chesterfield Royal Hospital NHS Foundation Trust
NHS Doncaster Clinical Commissioning Group Doncaster and Bassetlaw Hospitals NHS Foundation Trust
NHS Hardwick Clinical Commissioning Group Sheffield Children’s Hospital NHS Foundation Trust
NHS North Derbyshire Clinical Commissioning Group Sheffield Teaching Hospitals NHS Foundation Trust
NHS Rotherham Clinical Commissioning Group The Rotherham NHS Foundation Trust
NHS Sheffield Clinical Commissioning Group
Our consultation has also been informed by the review into hyper acute stroke services by the Yorkshire and the Humber Strategic Clinical Network which made the recommendation, based on current and projected activity, that the number of hyper acute stroke services (HASUs) should be reduced from five to three or four in South Yorkshire and Bassetlaw.
We will be consulting on the following options: XXX
Aims and objectives
Raise awareness and understanding of the current provision and need for changes to hyper acute stroke services across South Yorkshire, Bassetlaw and North Derbyshire Ensure patients, families, carers and the public are involved, able to have their say on the proposed options, and are listened to Inform key staff and clinicians in each locality about proposed change options Ensure patients, family and carers have the information they need about any changes to hyper acute stroke services Inform all stakeholders of new proposed models of care and opportunities to be involved
Target audiences
The following audiences will be targeted through tailored communications activity. We will use a very of methods to connect with each of our key stakeholders, ensuring our messages remain consistent and appropriate for each.
Patients and the public (including stroke support groups, Foundation trust and CCG members seldom heard groups and identified protected characteristics) Clinical Senate
Local Authorities, MPs and councillors Healthwatch
Governing body members of all CCGs Health and Wellbeing boards
Executive board members of all providers Local, regional and trade media
Clinicians – acute, primary and community care Public health Key messages
As with pre-consultation, our key messages will focus on the reasons why changes are needed to hyper acute stroke services whilst highlighting the importance of and opportunities to get involved in and taking part in the consultation. These messages include:
We know that across our region some people have better experiences, better outcomes and better access to services than others. We want everyone to experience the highest quality and safest service possible.
We are improving critical care stroke services for everyone across South Yorkshire, Bassetlaw and North Derbyshire – and we need your help!
Why do we need to change services? At the moment:
- We need more stroke doctors and nurses to run our services – but there aren’t enough locally or nationally
- Not all stroke patients are seen by a stroke doctor or admitted onto a stroke unit as quickly as they should be
- There is also a shortage of speech and language and occupational therapists who help rehabilitate people who have had a stroke
- How fast tests are done, which helps to diagnose patients, varies from hospital to hospital
For the above reasons, it is getting harder to provide high quality services and doctors, nurses and healthcare staff all agree that this needs to change.
Note: Key messages will be tailored and confirmed once the business case for change is agreed and there are agreed options for consultation.
Communications and engagement methods
To deliver the aims of our communications and engagement plan, we will carry out a range of activity across all geographic areas covered by the Working Together partnership, including both providers and commissioners. The methods and messages used to communicate will be tailored for each audience to maximise every opportunity for public and stakeholder involvement.
A key mechanism for consultation communications and engagement activity will be through the use of social media. We know from the Commissioners Working Together pre-consultations and also by identifying key trends and best practice from similar health and care transformation projects in other regions, that social media is an effective way of communicating and engaging with a variety of audiences.
Social media is a useful way of:
• Disseminating information and signposting
• Raising awareness
• Collecting demographic data
• Demonstrating willingness to engage in dialogue with a target audience
• Speaking to a large number and variety of audiences in real-time.
By developing and creating a number of communications materials and assets, through social media we will listen and respond to and motivate our audience to both share the information we are communicating and also engage with us by taking part in the consultations.
Further details of specific qualitative, quantitative and participatory communications and engagement methods for individual audiences are included in the planners below.
Engagement planner
Type of engagement Audience Method examples Responsibility
Qualitative Patients and the public, Focus groups CCG and provider partners parent and carer forums, supported by the Commissioners MPs, Local Authorities Attendance at relevant groups/events Working Together team
Stakeholder briefings
Vox pops
Seldom heard groups Attendance at existing groups eg, and protected Mosques, homeless charities, LGBT characteristics forums, social network groups
Disseminate information through existing networks for 1:1 and group conversations (eg, via public health colleagues to reach rural communities, BME groups, gypsy and traveller communities, asylum seekers,
refugees, mental health support groups)
Quantitative Patients and the public, Online survey Commissioners Working healthcare staff Together team Flyers in various locations: GP practices, outpatient departments, libraries, supermarkets, stroke support
groups, post offices, social network groups
Seldom heard groups Flyers translated into most popular and protected languages (identified through census characteristics data in Appendix 2) and disseminated in various locations, eg social network groups, Women’s Institute, Mosques, LGBT groups/events, activity centres (eg for people with learning disabilities).
Participatory Patients and the public, Deliberative events (x8) Commissioners Working parent and carer forums, Together team supported by seldom heard groups, Listening events CCG and provider partners healthcare staff and Focus groups clinicians
Seldom heard groups Attendance at existing groups and and protected events characteristics
Focus groups
Social media All Twitter and Facebook – blanket and Commissioners Working targeted posts to various groups, Together team supported by including health and care organisations, CCG and provider partners patient groups, Healthwatch organisations, local authorities, press accounts, LGBT networks, youth groups, high profile local/regional businesses, activity centres, the Stroke Association, Patient Opinion etc
Communications planner
Communication Type Audience Method examples Responsibility
Promotion/ Participation Patients and the public including Newsletters Commissioners Working Together targeted to parents and carers team supported by CCG and and staff Social media provider partners
Media
Blogs/case studies
Event presence
‘Market stalls’
Attendance at partners AGMs
Submissions to targeted Seldom heard groups and publications and protected characteristics newsletters, eg, parent’s assembly, BME community newspapers
Updates and briefings Staff from all partners, members NHS internal comms Commissioners Working Together of all organisations, GPs, practice team supported by CCG and staff, Local Authorities, MPs, E-bulletins provider partners as appropriate councillors, board and governing Briefing papers body members, OSC Verbal briefings/attendance at partner and stakeholder meetings
Media Patients, the public and staff Press releases Commissioners Working Together including trade publications team supported by CCG and Media interviews provider partners
Media briefings
Submissions to targeted Seldom heard groups and publications and protected characteristics newsletters, eg, parent’s assembly, BME
community newspapers
Social media All Twitter and Facebook – Commissioners Working Together blanket and targeted posts team supported by CCG and to various groups, provider partners including health and care organisations, patient groups, Healthwatch organisations, local authorities, press accounts, LGBT networks, youth groups, high profile local/regional businesses, activity centres, the Stroke Association, Patient Opinion etc
List of appendices:
Appendix 1 – Stakeholder map
Appendix 2 – Population demographics per area
Appendix 3 – Favoured methods of communication as outlined in pre-consultation feedback
Appendix 1
Commissioners Working Together Stakeholder map: Power/influence and interest level
Little or no interest Moderate interest High interest
High All media: (currently at low interest, high power but some titles Regulators (Monitor, CQC). Monitor is currently MPs: Sarah Champion, Kevin Barron and John Healey Power/Influence will shift right as the programme progresses and will require working with Rotherham Hospital trust on an action (Rotherham); John Mann (Bassetlaw); Harry Harpham, Paul watching brief): BBC online, BBC Look North, BBC East Midlands, plan and may also be involved in discussions with other Blomfield, Nick Clegg, Louise Haigh, Clive Betts, Angela Smith ITV Calendar, ITV Central East BBC Radio Leeds, BBC Radio hospitals. All of the hospitals will be subject to CQC (Sheffield); Rosie Winterton, Ed Miliband, Jon Trickett, Caroline Sheffield, BBC Radio Derby, Dearne FM, Hallam FM, Trax FM, Sine inspections Flint (Doncaster); Mary Creagh, Yvette Cooper, Paul Sherriff (Mid FM, Rother FM, Capital FM, Derbyshire Times, Worksop Guardian, Yorks); Natascha Engel, Toby Perkins, Dennis Skinner (NE NHS England area teams:(East Midlands, Yorkshire and Gainsborough Standard, The Star, Sheffield Telegraph, Barnsley Derbyshire, Hardwick); Dan Jarvis, Michael Dugher (Barnsley) Chronicle, Doncaster Star, Doncaster Free Press, Wakefield Express, the Humber) Pontefract and Castleford Express, Yorkshire Evening Post, Council cabinet members with relevant portfolio : Sheffield - Clinical Senates: (East Midlands, Yorkshire and the Rotherham Advertiser Jackie Drayton (CYP), Mazher Iqbal (public health), Mary Lea Humber) (health, care independent living). Doncaster – Nuala Fennelly Health and Wellbeing Boards: Barnsley, Derbyshire, (CYP), Pat Knight (public health and wellbeing), Chris McGuinness Doncaster, Nottinghamshire, Rotherham, Sheffield, (vol sector). Chesterfield – Chris Ludlow (health and wellbeing), Wakefield Helen Bagley (health and wellbeing). Barnsley – Margaret Bruff (children and safeguarding), Jenny Platts (communities). Wakefield – O M Rowley (CYP), P A Garbutt (adults and health). N E Derbyshire – Lilian Robinson (community safety and health). Bassetlaw – none listed for health. Rotherham – currently decisions taken by government appointed commissioners.
Joint OSC members:
Clinical staff working in the services where change may happen (Barnsley Hospital, Chesterfield Royal Hospital. Doncaster and Bassetlaw Hospitals, Mid Yorkshire Hospitals, Rotherham Hosptial, Sheffield Children’s Hospital, Sheffield Teaching Hospital)
Chairs and chief officers of all CCGs: Barnsley – Nick Balac, Lesley Smith. Bassetlaw – Steve Kell, Phil Metham. Doncaster – Nick Tupper, Chris Stainforth. Hardwick – Steven Lloyd, andy Gregory. North Derbyshire – Ben Milton, Jackie Pendleton. Rotherham – Julie Kitlowski, Chris Edwards. Sheffield – Tim Moorhead, Maddy Ruff. Wakefield – Phillip Earnshaw, Jo Webster.
Members of all CCGS, via the governing body and comms teams in each CCG.
Moderate Local Authority commissioners Healthwatch: Sheffield – Carrie McKenzie (chief officer). Barnsley Power/Influence – Carrianne Stones (chief officer). Rotherham – Tony Clabby (chief All mental health provider trust boards: (via chairs and officer). Doncaster – Philip Kerr (chief officer). Bassetlaw – chief executives) Rotherham, Doncaster and South Christine Watson (chief officer). Derbyshire – Karen Ritchie (chief Humber – Lawson Pater, Kathryn Singh. South West officer). Wakefield – Nicholas Esmond (chief officer). Yorkshire Partnership – Ian Black, Steven Michael. Nottinghamshire – Joe Pidgeon (chief officer). Sheffield Health and Social Care – Alan Walker, Kevan Taylor. Nottinghamshire Healthcare – Professor Dean Patient groups related to any potential service changes (will Fathers, Ruth Hawkins. move up the grid if become organised)
Voluntary organisations working with people who Working Together Provider Partnership may be affected by changes All foundation trust governors: (via membership offices in trusts). Barnsley, Sheffield Teaching, Sheffield Children’s, Rotherham, Doncaster and Bassetlaw, Chesterfield.
All acute hospital trust boards: (via chairs and chief executives). Barnsley – Stephen Wragg, Diane Wake. Doncaster and Bassetlaw – Chris Scholey, Mike Pinkerton. Chesterfield – Helen Phillips, Gavin Boyle. Mid Yorkshire – Jules Preston, Stephen Eames. Rotherham – Martin Havenhand, Louise Barnett. Sheffield Children’s – Nicholas Jeffrey, Simon Morrit. Sheffield Teaching – Tony Pedder, Sir Andrew Cash.
Ambulance service trust boards: (via chairs and chief executives). East Midlands – Pauline Tagg, Sue Noyes. Yorkshire – Della Cummings, Rod Barnes.
Unions representing staff where changes could be made. Regional reps for Unite, Royal Colleges, MiP, Unison, GMB.
Little or no Staff at NHS Greater East Midlands Commissioning Support unit Staff in CCGs power/influence Staff in NHS provider organisations (acute, mental health, ambulance)
Staff in GP practices
Voluntary groups (could move up and right)
Communities and community groups (could move up and right)
All foundation trust members (via membership offices in trusts). Barnsley, Sheffield Teaching, Sheffield Children’s, Rotherham, Doncaster and Bassetlaw, Chesterfield.
General stakeholder list for reference:
NHS Organisations/ Partnerships NHS England – Area Teams NHS Rotherham CCG NHS Doncaster CCG NHS Sheffield CCG NHS Barnsley CCG NHS Bassetlaw CCG NHS North Derbyshire CCG NHS Hardwick CCG NHS Wakefield CCG Yorkshire and Humber Clinical Senate East Midlands Clinical Senate The Working Together Provider Partnership Barnsley Hospital NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust Doncaster and Bassetlaw Hospitals NHS Foundation Trust The Mid Yorkshire Hospitals NHS Trust The Rotherham NHS Foundation Trust Sheffield Children’s NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Yorkshire Ambulance Service East Midlands Ambulance Service Public Health England NHS Yorkshire & Humber Commissioning Support Unit NHS Greater East Midlands Commissioning Support Unit Acute Clinical Care Operational Delivery Network
Wider Public Sector Organisations/ Partnerships Healthwatch Health and Wellbeing Boards MPs Local Overview and Scrutiny Committees Council members and staff
Public/ Patients and Groups Public Patients National & local patient/ pressure groups Voluntary groups Community groups BME groups
Staff and Members Staff at all of the provider and commissioner organisations GP Members of the CCGs Senior teams and Boards/ Governing Bodies at each of the commissioner organisations Unions
Appendix 2
Demographic data per area
Barnsley
231,221 total population
49.1% male
50.9% female
White: 96.03%
White Irish: 0.24%
White gypsy or Irish traveller: 0.07%
White other: 1.46%
Mixed /multiple ethnic groups – white and black Caribbean – 0.27%
Mixed /multiple ethnic groups – white and black African – 0.07%
Mixed /multiple ethnic groups – white and Asian – 0.18%
Mixed /multiple ethnic groups – other mixed – 0.16%
Asian/Asian British – Indian – 0.19%
Asian/Asian British – Pakistani – 0.09%
Asian/Asian British- Bangladeshi – 0.02%
Asian/Asian British – Chinese – 0.19%
Asian/Asian British – other Asian – 0.21%
Black/African/Caribbean/Black British: African – 0.43%
Black/African/Caribbean/Black British – Caribbean – 0.06%
Black/African/Caribbean/Black British – Other black –0.03%
Other ethnic group – Arab – 0.07%
Other ethnic group – any other ethnic group – 0.11%
Bassetlaw:
112,863 total population
56,024 male
56,839 female
White: 94.5%
White Irish: 0.33%
White gypsy or Irish traveller: 0.08%
White other: 2.44%
Mixed /multiple ethnic groups – white and black Caribbean – 0.4%
Mixed /multiple ethnic groups – white and black African – 0.07%
Mixed /multiple ethnic groups – white and Asian – 0.2%
Mixed /multiple ethnic groups – other mixed – 0.2%
Asian/Asian British – Indian – 0.38%
Asian/Asian British – Pakistani – 0.25%
Asian/Asian British- Bangladeshi – 0.06%
Asian/Asian British – Chinese – 0.16%
Asian/Asian British – other Asian – 0.24%
Black/African/Caribbean/Black British: African – 0.19%
Black/African/Caribbean/Black British – Caribbean – 0.21%
Black/African/Caribbean/Black British – Other black – 0.05%
Other ethnic group – Arab – 0.04%
Other ethnic group – any other ethnic group – 0.13%
Doncaster:
302,402 population
149,230 male
153,172 female
White: 91.8%
White Irish: 0.39%
White gypsy or Irish traveller: 0.19%
White other: 2.82%
Mixed /multiple ethnic groups – white and black Caribbean – 0.46%
Mixed /multiple ethnic groups – white and black African – 0.15%
Mixed /multiple ethnic groups – white and Asian – 0.29%
Mixed /multiple ethnic groups – other mixed – 0.2%
Asian/Asian British – Indian – 0.6%
Asian/Asian British – Pakistani – 0.9%
Asian/Asian British- Bangladeshi – 0.04%
Asian/Asian British – Chinese – 0.37%
Asian/Asian British – other Asian – 0.58%
Black/African/Caribbean/Black British: African – 0.43%
Black/African/Caribbean/Black British – Caribbean – 0.25%
Black/African/Caribbean/Black British – Other black – 0.08%
Other ethnic group – Arab – 0.07%
Other ethnic group – any other ethnic group – 0.27%
NE Derbyshire:
99,023 total population
48,564 male
50,459 female
White: 96.9%
White Irish: 0.26%
White gypsy or Irish traveller: 0.07%
White other: 0.79%
Mixed /multiple ethnic groups – white and black Caribbean – 0.32%
Mixed /multiple ethnic groups – white and black African – 0.1%
Mixed /multiple ethnic groups – white and Asian – 0.25%
Mixed /multiple ethnic groups – other mixed – 0.11%
Asian/Asian British – Indian – 0.35%
Asian/Asian British – Pakistani – 0.08%
Asian/Asian British- Bangladeshi – 0.03%
Asian/Asian British – Chinese – 0.18%
Asian/Asian British – other Asian – 0.15%
Black/African/Caribbean/Black British: African – 0.15%
Black/African/Caribbean/Black British – Caribbean – 0.06%
Black/African/Caribbean/Black British – Other black – 0.02
Other ethnic group – Arab – 0.04%
Other ethnic group – any other ethnic group – 0.08%
Chesterfield
103,788 total population
50,900 male
52,888 female
White: 94.8%
White Irish: 0.37%
White gypsy or Irish traveller: 0.004%
White other: 1.2%
Mixed /multiple ethnic groups – white and black Caribbean – 0.5%
Mixed /multiple ethnic groups – white and black African – 0.09%
Mixed /multiple ethnic groups – white and Asian – 0.27%
Mixed /multiple ethnic groups – other mixed – 0.17%
Asian/Asian British – Indian – 0.47%
Asian/Asian British – Pakistani – 0.32%
Asian/Asian British- Bangladeshi – 0.13%
Asian/Asian British – Chinese – 0.35%
Asian/Asian British – other Asian – 0.25
Black/African/Caribbean/Black British: African – 0.41%
Black/African/Caribbean/Black British – Caribbean – 0.26%
Black/African/Caribbean/Black British – Other black –0.07%
Other ethnic group – Arab – 0.06%
Other ethnic group – any other ethnic group – 0.08%
Rotherham
257,280 total population
126,247 male
131,033
White: 91.9%
White Irish: 0.3%
White gypsy or Irish traveller: 0.05%
White other: 1.3%
Mixed /multiple ethnic groups – white and black Caribbean – 0.3%
Mixed /multiple ethnic groups – white and black African – 0.11%
Mixed /multiple ethnic groups – white and Asian – 0.33%
Mixed /multiple ethnic groups – other mixed – 0.23%
Asian/Asian British – Indian – 0.37%
Asian/Asian British – Pakistani – 2.96%
Asian/Asian British- Bangladeshi – 0.04%
Asian/Asian British – Chinese – 0.23%
Asian/Asian British – other Asian – 0.5%
Black/African/Caribbean/Black British: African – 0.65%
Black/African/Caribbean/Black British – Caribbean – 0.11%
Black/African/Caribbean/Black British – Other black –0.06%
Other ethnic group – Arab – 0.22%
Other ethnic group – any other ethnic group – 0.28%
Sheffield
552,698 population
272,661 male
280,037 female
White: 80.84%
White Irish: 0.5%
White gypsy or Irish traveller: 0.06%
White other: 2.25%
Mixed /multiple ethnic groups – white and black Caribbean – 0.98%
Mixed /multiple ethnic groups – white and black African – 0.23%
Mixed /multiple ethnic groups – white and Asian – 0.63%
Mixed /multiple ethnic groups – other mixed – 0.55%
Asian/Asian British – Indian – 1.06%
Asian/Asian British – Pakistani – 3.97%
Asian/Asian British- Bangladeshi – 0.6%
Asian/Asian British – Chinese – 1.33%
Asian/Asian British – other Asian – 1.04%
Black/African/Caribbean/Black British: African – 2.0%
Black/African/Caribbean/Black British – Caribbean – 0.99%
Black/African/Caribbean/Black British – Other black – 0.54%
Other ethnic group – Arab – 1.52%
Other ethnic group – any other ethnic group – 0.7%
Wakefield
325,832 total population
159,913 male
165,924 female
White: 92.76%
White Irish – 0.27%
White gypsy or Irish traveller: 0.09%
White other: 2.27%
Mixed /multiple ethnic groups – white and black Caribbean – 0.33%
Mixed /multiple ethnic groups – white and black African – 0.11%
Mixed /multiple ethnic groups – white and Asian – 0.27%
Mixed /multiple ethnic groups – other mixed – 0.17%
Asian/Asian British – Indian – 0.47%
Asian/Asian British – Pakistani – 1.5%
Asian/Asian British- Bangladeshi – 0.009%
Asian/Asian British – Chinese – 0.26%
Asian/Asian British – other Asian – 0.36%
Black/African/Caribbean/Black British: African – 0.6%
Black/African/Caribbean/Black British – Caribbean – 0.1%
Black/African/Caribbean/Black British – Other black –0.07%
Other ethnic group – Arab – 0.11%
Other ethnic group – any other ethnic group – 0.17%
Appendix 3
During the pre-consultation phase we asked people, “How would you want to see/read/hear about the formal consultation?”
Summary of responses:
By email: 42.7% (82 out of 192 responses)
Online (social and digital media): 34.9% (67 out of 192 responses)
Local media (print and broadcast): 12.5 % (24 out of 192 responses)
Face to face meetings and events: 9.9% (19 out of 192 responses)
Chemotherapy Delivery Model – Case for Change
Background and Context
Improving cancer survival is one of the key challenges identified in “Achieving World-Class Cancer Outcomes - A Strategy for England 2015–2020”, and cancer survival has been improving for many years. Better treatment, better detection and awareness initiatives are all factors that may have contributed to this improvement. However, South Yorkshire, Bassetlaw and North East Derbyshire still have some of the poorest survival rates for cancer in Yorkshire and the Humber and are below the England average for both one and five year survival . It is also clear from the strategy that there is an expectation that all cancer treatment services will be required to be sustainable and cost effective in the longer term, whilst flexing to meet patient demand and expectation.
In December 2014, discussions took place in the South Yorkshire, Bassetlaw and North East Derbyshire Cancer Strategy Group (CSG) about the ongoing issues with the current provision of Chemotherapy Outreach in the locality, which had not been addressed to a satisfactory conclusion despite enthusiasm to do so from the commissioners and providers of the services. These being:
Inequitable regimes at the outreach locations Oncology recruitment and workforce pressures to support the current model(s) The fit with long term commissioner plans Meeting the long term patient demand whilst remaining value for money
Papers were presented to the CSG throughout 2015, outlining the ongoing issues with the current model and subsequently a project was supported to carry out:
A baseline assessment of the current Chemotherapy Outreach Services to understand the issues and variation across South Yorkshire, Bassetlaw and North East Derbyshire Identify the overarching elements of what a ‘Fit for the Future’ Chemotherapy service would include (and would need to be considered as part of a future model appraisal) Gain clinical and organisational consensus of the issues to be resolved (long and short term) and explore the willingness of providers to collaborate and work differently on potential change Consolidation of a case for change
Key points
The baseline assessment identified a number of areas of significant variation which would benefit from reform. As demand across South Yorkshire, Bassetlaw and North Derbyshire increases, it would be unsustainable for Sheffield Teaching Hospitals to continue providing the current level of treatments. One of strongest drivers for change is pressure on medical staffing resource.
Services across the locality are functioning day to day, in a reactive manner. All providers agree that the current provision is unsustainable and have an ambition to take forward a collaborative and ambitious model for the future, with full commissioner support.
Recommendation
The options following the review were identified as:
1. Do nothing 2. Retain current model, implementing best practice across all outreach localities 3. Assess and review the needs of South Yorkshire, Bassetlaw and North East Derbyshire to inform and implement a new model
The recommendation of the review is to progress with Option 3.
Commissioners Working Together Programme Chemotherapy Outreach Review Case for Change
June 2016
1
Title WTP Chemotherapy Outreach Review – Case for Change Lynsey Blackshaw, Clinical Networks (Cancer) Author South Yorkshire, Bassetlaw & North East Derbyshire Commissioner Target Audience and Provider Organisations Version V4.2
WTP Reference WTPS2015
Created Date April 2016
Date of Issue May 2016 FINAL Document Status To be read in Chemotherapy Outreach Review PID v3.2 June 2015 conjunction with
File name and path
Document History:
Date Version Author Details 15th April 2016 2.0 Lynsey Blackshaw First Draft for comments 27th April 2016 3.0 Lynsey Blackshaw Second Draft for comments
13th May 2016 4.0 Lynsey Blackshaw Final Draft for approval to progress through governance structure 25th May 2016 4.1 Lynsey Blackshaw Final formatting amendments following feedback 6th June 2016 4.2 Lynsey Blackshaw Final formatting
Approval by: Working Together Programme Governance route:
Group Date Version Purpose Working Together 27th May 2016 4.1 Endorsement of Phase Programme Senior 2 (Option 3) in Management Team principle prior to Strategy Group South Yorkshire Cancer 3rd June 2016 4.1 Endorsement of Phase Strategy Group 2 (Option 3)
Working Together 6th June 2016 4.1 Endorsement of Phase Programme 2 (Option 3) (subject to Commissioner Group South Yorkshire Strategy Group endorsement
2
Contents Executive Summary ...... 5 Context ...... 5 Baseline Data Collection ...... 6 Identifying and Addressing Variance ...... 6 Options and Recommendation ...... 7 Next Steps ...... 7 1 Purpose and Methodology ...... 8 1.1 Purpose...... 8 1.2 Background ...... 8 1.3 Project Initiation Document Summary ...... 9 1.4 Methodology and Accountability ...... 9 2 Context ...... 10 2.1 South Yorkshire Bassetlaw and North East Derbyshire Overview ...... 10 2.2 Drivers for change ...... 10 3 Current Service Infrastructure ...... 12 3.1 Baseline Data Collection ...... 12 3.2 Regime Coverage ...... 12 3.3 Contracting and Finance ...... 12 3.4 Chair Capacity and Activity ...... 13 3.5 Workforce ...... 14 3.6 Patient Experience ...... 16 3.7 Performance and Demand Management ...... 17 3.8 Governance and Communication ...... 18 3.9 Service Developments ...... 18 4 Fit for the Future ...... 19 4.1 Defining Resilience and Fit for the Future...... 19 4.2 Patient Priorities ...... 20 4.3 Commissioner Priorities ...... 20 4.4 Provider Priorities ...... 20 5 Summary ...... 21 5.1 Addressing Variation ...... 21 5.1.1 Contracting and Finance ...... 21 5.1.2 Regime Provision ...... 21 5.1.3 Capacity and Activity ...... 22 3
5.1.4 Staffing ...... 22 5.1.5 Patient Experience ...... 22 5.1.6 Governance and Communication ...... 22 6 Conclusion and Options ...... 23 6.1 Activity Reallocation ...... 23 6.2 Options ...... 23 7 Recommendation & Next Steps ...... 25 7.1 Recommendation ...... 25 7.2 Next Steps ...... 25 Appendix A ...... 26 Appendix C ...... 48 Appendix D ...... 49 Appendix E ...... 51
4
Executive Summary
Purpose
The purpose of this report is to act as the consolidated case for change for Chemotherapy Outreach Service Provision in South Yorkshire, Bassetlaw and North East Derbyshire and should be considered as part of any independent appraisal and recommendation for future models of Chemotherapy. This report: Summarises relevant national and local context Reflects on the insights gained through a baseline assessment exercise Identifies and recommends options for consideration
Background
In December 2014, discussions took place in the South Yorkshire, Bassetlaw and North East Derbyshire Cancer Strategy Group (CSG) about the ongoing issues with the current provision of Chemotherapy Outreach in the locality, which had not been addressed to a satisfactory conclusion despite enthusiasm to do so from the commissioners and providers of the services. These being: Inequitable regimes at the outreach locations Oncology recruitment and workforce pressures to support the current model(s) The fit with long term commissioner plans Meeting the long term patient demand whilst remaining value for money
Papers were presented to the CSG throughout 2015, outlining the ongoing issues with the current model and subsequently a project was supported to carry out: A baseline assessment of the current Chemotherapy Outreach Services to understand the issues and variation across South Yorkshire, Bassetlaw and North East Derbyshire Identify the overarching elements of what a ‘Fit for the Future’ Chemotherapy service would include (and would need to be considered as part of a future model appraisal) Gain clinical and organisational consensus of the issues to be resolved (long and short term) and explore the willingness of providers to collaborate and work differently on potential change Consolidation of a Case for Change (this report)
Context
Improving cancer survival is one of the key challenges identified in “Achieving World- Class Cancer Outcomes - A Strategy for England 2015–2020”, and cancer survival has been improving for many years. Better treatment, better detection and awareness initiatives are all factors that may have contributed to this improvement, however South Yorkshire, Bassetlaw and North East Derbyshire still have some of the poorest survival rates for cancer in Yorkshire and the Humber and are below the England average for both one and five year survival . It is also clear from the strategy that there is an expectation that all cancer treatment services will be required to be sustainable and cost effective in the longer term, whilst flexing to meet patient demand and expectation.
Chemotherapy services are under pressure as patient numbers increase and new treatments are approved. Cancer is becoming a long-term condition and, with higher survivorship rates leading to more years of anti-cancer therapy and increased rates of
5 recurrence, treatment capacity will continue to be an issue. Advances in chemotherapy treatments available and patients tolerating chemotherapy and its side effects because of improved supportive medication and management of other side effects, means more people are more likely to accept treatment.
The NHS is already facing a national shortage of staff to support their services, in addition to having to address the tightening of budgets, increase in population as described and 7 day working to name a few. It is these factors which require the whole health economy to think differently about how chemotherapy services are configured and delivered.
Baseline Data Collection
A series of data metrics were identified to be part of the audit, the high level summaries of which were: Regime coverage Contracting and Financial Information Chair Capacity and Activity Workforce Patient Experience Performance and Demand Management Governance and Communication
Identifying and Addressing Variance
The baseline assessment identified a number of areas of significant variation which would benefit reform, and areas of good practice which could be shared across the system in the absence of a whole model review.
Best Practice Identified Reviews New Service Model Development Introducing 2 Stop Clinics Workforce structure Develop detailed review (collective assessment criteria / agreement) ranking Electronic Booking / Diary Review and change of appointment systems Communication Access to STH Beds improvements Capacity identification / Integrated IT Systems review Treatment Chair usage (potentially using more robust data information systems such as SACT) Pharmacy at Home Introduce systematic patient flow analysis
There have also been a number of positives identified with the current system, all of which provide a good grounding for any potential change or review: Good governance structures and processes Positive patient feedback Staffing attitude and commitment Ambition to continue, expand and reduce variation of provision
6
Options and Recommendation
As demand across South Yorkshire, Bassetlaw and North Derbyshire increases, it would be unsustainable for Sheffield Teaching Hospitals to continue providing the current level of treatments, in addition to the anticipated increase in demand.
The options following this review are identified as:
1. Do nothing 2. Retain current model, implementing best practice across all outreach localities 3. Assess and review the needs of South Yorkshire, Bassetlaw and North East Derbyshire to inform and implement a new model
One of strongest drivers for this review is medical staffing and the continued provision of chemotherapy services needs to take into account the available consultant coverage.
Services across the locality are functioning day to day, in a reactive manner. All providers agree that the current provision is unsustainable and have an ambition to take forward a collaborative model for the future, with full commissioner support. Current pressures are unfortunately preventing proactive planning.
There is an acceptance that there needs to be a radical change to future provision and this report outlines why we need to think differently about how chemotherapy services are designed, delivered, configured and integrated.
There is an acknowledgment that service developments to date have been to a larger extent reactive rather than proactive and that this needs to change, and therefore although there may be short term benefits in progressing with option 2, option 3 is the recommended way forward which will provide a long term plan for sustainability.
Next Steps
The recommendation to progress with Option 3, will be formally presented to:
South Yorkshire, Bassetlaw and North East Derbyshire Cancer Strategy Group Commissioners Working Together Programme Senior Management Team Commissioners Working Together Programme Accountable Officers Group NHS England Specialised Commissioning Oversight Group
If fully endorsed, a Project Initiation Document will be developed outlining the aims, objectives, timescales and resources required, and processed through the appropriate governance structures.
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1 Purpose and Methodology
1.1 Purpose
The purpose of this report is to act as the consolidated case for change for Chemotherapy Outreach Service Provision in South Yorkshire, Bassetlaw and North East Derbyshire and should be considered as part of any independent appraisal and recommendation for future models of Chemotherapy. This report: Summarises relevant national and local context Reflects on the insights gained through a baseline assessment exercise Identifies and recommends options for consideration
This case for change is not a business case for what the future will be. It is a baseline exercise to help identify what the future of chemotherapy service could look like, and inform what the next steps would be to move towards this.
1.2 Background
In December 2014, discussions took place in the South Yorkshire, Bassetlaw and North East Derbyshire Cancer Strategy Group (CSG) about the ongoing issues with the current provision of Chemotherapy Outreach in the locality, which had not been addressed to a satisfactory conclusion despite enthusiasm to do so from the commissioners and providers of the services.
Papers were presented to the CSG in February 2015 outlining the issues formally, which in summary were: Inequitable ways of working at the outreach locations Oncology recruitment and workforce pressures to support the current model(s) The fit with long term commissioner plans Meeting the long term patient demand whilst remaining value for money
These issues had been raised and acknowledged on an individual outreach basis, but not consolidated.
A paper was presented to the CSG in April 2015, which outlined the work to date (from 2007) and summarised: Financing and contracting outreach models were varied and confusing, resulting in delays in resolving issues with service provision A lack of service level agreements prevented further expansion and development All provider localities had capacity issues (space and resource) preventing further development Funding differences were resulting in inequitable oncology provision Different provision models were apparent in the outreach localities (e.g. one stop / 2 stop systems) Dual clinics in some outreach localities meant provision was unclear in terms of oncology and haematology patients
The CSG supported a short term project to capture: The activity and efficiency levels The impact of workforce issues on delivery The equity of service across South Yorkshire, Bassetlaw and North East Derbyshire 8
The current model alignment with long term commissioner intention and goals
1.3 Project Initiation Document Summary
A Project Initiation Document (PID) was produced and submitted in June 2015 to both the CSG and the Working Together Partnership Executive Group for approval. Both groups agreed phase 1 of the PID (phase 2 to be discussed and agreed following phase 1 completion): A baseline assessment of the current Chemotherapy Outreach Services to understand the issues and variation across South Yorkshire, Bassetlaw and North East Derbyshire Identify the overarching elements of what a ‘Fit for the Future’ Chemotherapy service would include (and would need to be considered as part of a future model appraisal) Gain clinical and organisational consensus of the issues to be resolved (long and short term) and explore the willingness of providers to collaborate and work differently on potential change Consolidation of a Case for Change (this report)
1.4 Methodology and Accountability
A structured approach was developed to bring together a range of both quantitative and qualitative information, providing clear understanding of current provision and potential opportunities to improve the quality and safety of services. In some cases a slight variation on this agreed methodology was used; influenced by the availability of data, agreed local, national or the appropriateness of undertaking a detailed financial assessment at this stage. Concurrently communications and engagement activities which took place reflected this. The project used a project management approach accountable to the overarching Working Together Governance Structure, reporting updates through the CSG.
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2 Context
2.1 South Yorkshire Bassetlaw and North East Derbyshire Overview
South Yorkshire, Bassetlaw and North East Derbyshire covers a population of 1.9 million people and includes Barnsley CCG (population c. 255,890), Bassetlaw CCG (population c. 133,900), Doncaster CCG (population c. 313,000), Rotherham CCG (population c. 259,700), Sheffield CCG (population c. 590,000), Hardwick CCG (population c.100,000) and North East Derbyshire (population c. 288,000).
Health services are commissioned on behalf of local people by Barnsley, Bassetlaw, Doncaster, Hardwick, North East Derbyshire, Rotherham and Sheffield Clinical Commissioning Groups and NHS England.
There are five hospital trusts providing acute hospital services including A&E, emergency and elective (planned) surgery, inpatient children’s services plus a range of specialist services.
Sheffield Teaching Hospital is the tertiary centre for Cancer Services, the remaining being; Doncaster Royal Infirmary, Chesterfield Royal Hospital, Rotherham District General, Barnsley District Hospital. Some specialist cancer services are only provided at the Cancer Centre meaning that some patients have to travel to receive these.
2.2 Drivers for change
South Yorkshire, Bassetlaw and North East Derbyshire have some of the poorest survival rates for cancer in Yorkshire and the Humber and are below the England average (both one and 5 year survival). Cancer incidence is also above the England average, influenced by a number of factors such as deprivation, age and smoking as shown in Appendix A.
Improving cancer survival is one of the key challenges identified in “Achieving World- Class Cancer Outcomes. A Strategy for England 2015–2020”, and cancer survival has been improving for many years. Better treatment, better detection and awareness initiatives are all factors that may have contributed to this improvement. It is also clear from the strategy that there is an expectation that all cancer treatment services will be required to be sustainable and cost effective in the longer term, whilst flexing to meet patient demand and expectation. Patient experience is becoming more explicit when services are assessed for quality, and it is clear that there is often great variation in the perceived quality of a service by patients.
Chemotherapy services are under pressure as patient numbers increase and new treatments are approved. Cancer is becoming a long-term condition and, with higher survivorship rates leading to more years of anti-cancer therapy and increased rates of recurrence, treatment capacity will continue to be an issue.
South Yorkshire, Bassetlaw and North East Derbyshire does not have a common approach to outreach chemotherapy in terms of regime provision and disease sites due to capacity and infrastructure challenges, which will be compounded by the expected increase in demand. Advances in chemotherapy treatments available (e.g. less cycles) and patients tolerating chemotherapy and its side effects because of improved supportive medication and management of other side effects, means more people are 10
more likely to accept treatment.
The latest ONS estimates are that the UKs population was 64.6 million in 2014, an increase of 11.6% (6.7 million) from 20 years ago (ONS, 2015). The ONS predict that this will increase by 12.6% to 72.7 million by 2034, a larger number of which will be older people living longer and therefore more likely to require health services including access to cancer treatments.
The NHS is already facing a national shortage of staff to support services, in addition to having to working within constrained budgets, increase in population as described and 7 day working. It is these factors which require the whole health economy to think differently about how chemotherapy services are configured and delivered.
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3 Current Service Infrastructure
3.1 Baseline Data Collection
The first element of the project to gain an understanding of the baseline position of Chemotherapy Outreach Services was carried out by way of an audit during December 2015 and January 2016. A series of data metrics were identified to be part of the audit by a small working party of the stakeholder organisations, based on an existing audit tool used by one of the providers. The high level summaries of which were: Regime coverage Contracting and Financial Information Chair Capacity and Activity Workforce Patient Experience Performance and Demand Management Governance and Communication
It was agreed that the above criteria would capture an overview of the outreach services and help to identify where variation were significant, thus driving any future recommendations.
Each outreach locality provided data from a 6 week period, which was followed up by a validation interview with key individuals from the providers, selected because of their in depth knowledge of the service and contracting and development expertise.
3.2 Regime Coverage
An overview of the site specific regimes provided at the time of the audit is shown below, however a full list of the regimes types provided against each can be seen in Appendix B, supplemented by 2011 SACT information in Appendix C.
Outreach Breast Gynae UGI Lung Prostate Col Renal Locality Barnsley X X X Rotherham X X X Doncaster X X X X X X X Chesterfield X X X X X Sheffield X X X X X X X
Patient flow diagrams provided by Public Health England in Appendix D, show the treating hospital in relation to the patient home postcode. These demonstrate the outreach model clearly when compared to other areas within Yorkshire and the Humber (for example West Yorkshire).
3.3 Contracting and Finance
The main contract is held by Sheffield Teaching Hospitals, whom sub-contract elements to the respective outreach hospitals. These sub contracts are agreed on an individual basis and have differing levels of funding, resource, provision and associated expected activity which are outlined in the forthcoming sections. In addition to the standard contract value, all contracts have a number of associated pass through costs which cover elements such as pharmacy, which have not been identified in this review.
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Provider Contract Value Contract Type Additional Information Barnsley £205,692 Block Currently meeting the expected level of activity within the contract Rotherham £288,744 Block Currently meeting the expected level of activity within the contract Doncaster £1m (15/16) Activity 16/17 contract agreed on 15/16 basis with staff uplift adjustment and additional regime provision for colorectal. Currently exceeding the expected level of activity in the contract Chesterfield £383k Block Currently not meeting the expected level of activity in the contract (as at month 9, however achieved expected activity average over the 6 week audit period) Sheffield £3.8m (total Activity Currently meeting the expected level of top line SY activity within the contract (inclusive of service) sub contracts)
3.4 Chair Capacity and Activity
Each outreach locality has different chair time capacity dependent on physical space, regime provision and staffing resource.
The total hours available which has been calculated as part of this review, is based on time/chair numbers only and does not take into account staffing levels required to essentially ‘fill’ these chairs with patients to full capacity throughout the service opening times. Nor does this reflect other aspects influencing chair usage such as new patient assessments and aftercare monitoring. In addition, some of the outreach localities have dual clinics running haematology services which further impacts on chair usage. An overview of the chair utilisation at the time of the audit can be seen below.
Provider Service Chair Total Annual Annual Annual Activity Time/Days No. Chair Activity Hours Haematology Time Oncology Treatment** Only*** Available Only* Barnsley 9am-5pm 6 240 2,591 3,285 4,047 5d/p/w Rotherham 9am-5pm 6 144 2,036 2,087 Not provided 3d/p/w (oncology chairs ring-fenced – no dual use) Doncaster 8.30am- 31-33 1,288 4,481 6,985 5,200 5.30pm 5 d/p/w Chesterfield 9.00am – 8 (plus 268 1,650 1,910 3,189 5.00pm 1 bed 4d/p/w on 1 day) Sheffield 5 d/p/w 38 1,888 11,110 12,900 Not Provided varying chairs (plus circa (haematology times 3k delivered in additional Hallamshire not Hospital) included in the audit) *pro rata actual activity **Treatment provision only based on data collection timings ***pro rata actual activity
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Sheffield Teaching Hospital have the largest chair capacity in the South Yorkshire region and delivers 51% of all chemotherapy provision at the Weston Park Hospital in Sheffield, reaching anecdotally an optimum chair usage of between 80-90% (usually circa 4 empty chairs out of the 38 available), however this has not been fully demonstrable in the data collection due to the restricted regimes provided on the data collection audit tool. Activity data suggested an additional 3,000 contacts are provided per annum for other regimes but are not included in the audit.
Doncaster and Bassetlaw Hospital have the largest chair capacity of all the outreach locations and deliver the fullest range of oncology regimes, recently expanding their colorectal provision. They deliver 20% of the chemotherapy treatment* through a dual clinic system (with haematology) and are currently exceeding the expected activity level by circa 12% per annum. Demand for services has been estimated at an increase of 10% year on year based on current regime provision. In addition, there is an estimated additional 12 new patients per week who require pre-treatment counselling which requires additional nurse time. An extensive analysis was undertaken subsequent to this review which took into consideration the funded nursing capacity (6 nurses) available to cover the oncology treatments, concluding that the optimum capacity for the service would be 10-15 chair capacity (filled continually throughout the day and allowing for circa 10 chairs for haematology usage).
Barnsley Hospital provides a 6 chair capacity service, 5 days per week providing 12% of oncology treatments*, however solid tumour treatment is only conducted on a Tuesday and a Thursday with the remaining time being ring-fenced for haematology. The service runs a mix of one stop and 2 stop clinics (breast only) and oral chemotherapy is provided to colorectal patients.
Rotherham Hospital currently provides a 6 chair service over 3 days, which are specifically ring fenced for oncology and provides 9% of the oncology treatments*. A recent temporary ward move within the hospital has become longer term.
Chesterfield Royal Hospital currently provides an 8 chair treatment, 4 days per week (plus 1x bed 1 day per week) and provide 8% of oncology treatments*. Since the audit, the service has extended to offer additional regimes in haematology and solid tumour (docetaxel combination regimens for breast with trastuzumab, paclitaxel (breast), FOLFOX (colorectal - this is a significant number of patients), docetaxel and nintedanib (lung), pemetrexed (lung), carboplatin/etoposide (non-lung), as well as an single patient exceptions such as carboplatin AUC6 course (breast)). More regimes are planned for February / March 2016 (XELOX).
*As specified in the audit
3.5 Workforce
Staffing structures and resource to deliver the oncology treatments at the outreach localities are determined by the providing trust, so therefore there is variation across providers. The tables below provide an overview of the different staffing groups, bands and whole time equivalents within each outreach locality. An element not demonstrated in this overview is the medical cover provided across the locality.
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Band Sheffield Doncaster Barnsley Rotherham Chesterfield Nursing (Chemo) 8a 0.7 Nursing (Chemo) 7 1.6 1 Nursing (Chemo) 6 4.5 3.5 3.06 1 Nursing (Chemo) 5 17 8.99 0.8 1.31 (0.8 2.81 RDGH funded) Nursing (Chemo) 3 2.4 Nursing (Chemo) 2 5 0.6 (RDGH 1.98 funded) Nursing (Clinic) 6 0.6 (lung & BM) Nursing (Clinic) 5 10.85 1.53 1 0.15 0.3 Nursing (Clinic) 4 Nursing (Clinic) 3 1.27 Nursing (Clinic) 2 0.63 HCP 8a 0.1 HCP 7 0.55 0.24 HCP 6 0.85 0.2 CNS 8a 0.01 CNS 7 1.07 0.96 CNS 6 1.51 0.6 1 Auxiliary (HCA) 2 8.5 1 0.2 0.2
(Clinical / Pharm) Band Sheffield Doncaster Barnsley Rotherham Chesterfield Principal 8b 0.6 Pharmacist Senior Clinical 8a 4 1 (Haem- 0.6 0.45 Pharmacist Oncology) (independent (Oncology) prescriber RDGH funded) Senior Clinical 8a 2 Pharmacist (Haematology) Clinical Pharmacist 7 1 0.76 0.56 (Oncology) (Chemo) Clinical Pharmacist 7 1 (Haematology) Rotational 7 1 Pharmacist Rotational 6 1 Pharmacist Pharmacist 8a 1 Pharmacist 7 1
(Aseptics) Band Sheffield Doncaster Barnsley* Rotherham Chesterfield Lead Pharmacist 8b 0.8 Pharmacist 8a 1 0.9 1.8 (RDGH funded) Lead Technician 7 0.5 1 0.13 Team Leader 6 1 1 1 Technician Senior Technician 5 1 1 (chemo 1.2 (RDGH 0.13 verification) funded) Technician 4 4 1 2.4 0.88 Assistant 3 6 1 1.2 (RDGH funded) Assistant 2 2 2 0.24 15
*No cover arrangements for Aseptics staff. Spend a proportion of time on Weston Park Hospital. There is no dedicated chemotherapy technician/ assistants. The locum pharmacist accuracy checks chemotherapy.
(Dispensary) Band Sheffield Doncaster Barnsley Rotherham Chesterfield Lead technician 6 1.16 Senior technician 5 1 Technician 4 2 0.21 Assistant 3 2.43 Assistant 2 0.21
(Clinical Trials) Band Sheffield Doncaster Barnsley Rotherham Chesterfield Principal 8b 1 Pharmacist Senior Trials 8a 0.63 Pharmacist (Oncology) Senior Technician 5 2 (trials)
Band Sheffield Doncaster Barnsley Rotherham Chesterfield Secretarial Support 4 8.58 Secretarial Support 3 3.58 Day Case Admin 4 2 1.2 0.51 (RDGH funded) Outpatient Admin 2 7 2.57 Support Receptionist 2 3 1.69 1.2 0.53 Receptionist 1 0.53
3.6 Patient Experience
All participating Trusts provided patient feedback, either via national and local questionnaires or direct patient comments, a summary of the national patient experience results can be seen in Appendix E. On the whole, all feedback received was very positive from the patients who had responded.
Very few patients commented on long waits for treatment, and for those who did, the trusts had followed up the concerns with specific actions to remedy the issue. Sheffield Teaching Hospitals had implemented a microsystems review following feedback about long delays to improve patient flow, and other outreach services provide 2 stop clinic systems to reduce patient waiting times. Where one stop clinics were in operation, there were patient comments on long waits however these were often supported by positive patient comments about the environment and staff.
All services reported having access to a wide range of complimentary services which varied from patient information to therapeutic massage. The wellbeing element of the service provision seems to be well established and considered an inherent part of the treatment journey. Sheffield Teaching Hospitals have a long standing relationship through the Cancer Information Centre based at Weston Park Hospital which provides a more holistic service to its patients, similarly the outreach localities had access to wellbeing centres such as the Aurora Centre. Patient information provision was also reported as being a key part of the treatment provision which all providers commit to.
It is reported anecdotally from hospital staff that some patients do avoid accessing emergency treatment over the weekend period as this often results in an admission to
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Sheffield Teaching Hospitals rather than being admitted at their local, treating hospital. The information does not outline whether the reasons for this are patient experience related or due to other influencing factors such as travel.
3.7 Performance and Demand Management
All trusts reported meeting the ‘referral to treatment’ expectations; emergency within 1-2 days; urgent within 1 week; routine within 1-3 weeks. In addition to this the waiting time from appointment to receiving treatment on the whole is achieved within 2-3 hours for same day chemotherapy and within 1 hour for 2 stop chemotherapy treatment.
DNAs and cancellations across all localities were relatively small in number and were generally related to the health of the patient i.e. too ill to attend clinic, or being managed through a different part of the treatment system, and this to a large extent is managed sufficiently, without negatively impacting on delivery.
The outreach localities clinic booking mechanisms varied from being handled at source electronically to paper diary bookings. Some of the outreach localities reported that the paper diary booking method was very problematic as it restricted access to and sharing of clinic information.
Patient flow is managed differently across the localities dependent on the clinic type. The most significant bottlenecks reported were: Clinic space (also affected by booking systems, joint clinics etc.) Access and availability of inpatient beds at Sheffield teaching Hospital New patient assessments / counselling Pharmacy capacity (where 1 stop clinics are in place) Consultant cover in clinics (which also impacts on integrated services)
Sheffield Teaching Hospitals review patient flow and scheduling management regularly to ensure effective throughput of patients is achieved whilst balancing clinical demand and availability. As part of the microsystems review, a pilot was taking place to uncouple the counselling sessions for new patients, on the day prior to treatment commencement outside of the normal treatment hours (5-8pm). It was anticipated that this would release ‘treatment time’ during the day clinic. Sheffield Teaching Hospitals also worked with local pharmacies to deliver a treatment at home service for oral medication which released clinic time.
Doncaster and Bassetlaw Hospital had introduced a new booking system which staggers appointments throughout the day. Further development of this system will book patients to a ‘nurse’ rather than an ‘appointment slot’ which would improve patient flow and streamline patient flow in the department.
Barnsley Hospital carries out new patient assessments the day before treatment which releases the treatment chair time on the treatment days, thus improving patient flow. They do however report carrying out after treatment observations in the ‘treatment’ chairs, which does impact on capacity and patient flow. This is also reported from other providers.
Consultant clinics have a major impact on patient flow at times where there is anticipated no cover (e.g. annual leave). Often additional patients are given appointments prior to planned absences which can impact on the ability to provide chemotherapy, and delay treatment, thus negatively impacting on patient waits and experience. Medical cover was reported throughout as a significant and substantial pressure.
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3.8 Governance and Communication
All of the outreach localities reported structured and robust governance processes via: Regular chemotherapy operational meetings Joint Incident and risk reviews Clear Multi-Disciplinary Team process Network agreed pathways Links to Acute Oncology Service (Local or networked)
Although these formal arrangements were well established, there was variance in the reported informal communication efficiency between the cancer centre at Weston Park Hospital and some of its outreach locations, particularly in circumstances where there has been a patient admission at the tertiary centre.
There was variance on patient held information and treatment summary provision across the providers and the level of detail provided in these. In addition to the patient held information, there was variation with how each provider maintained patient records, some reporting significant amounts of photocopying or duplicate entries into nursing documentation, whilst others reporting an acceptance of writing key information just in the Sheffield Teaching Hospital patient notes. However it should be noted that these processes are all compliant with clinical governance standards.
3.9 Service Developments
Following the audit period, a number of the providers had subsequently extended regime provision and/or activity, which weren’t subject to this analysis.
Doncaster and Bassetlaw Hospital future plans for the service include further colorectal treatment (phase 1 has started with phase 2 planned from April 2016) and extended opening hours (until 6pm) for which recruitment had commenced. The service was also confident that they could offer more intravenous treatments, but report that this would require additional clinical resource.
Barnsley Hospital reported an increase in the number of breast cancer treatments provided and were in the process of developing its HCP role which was anticipated to free up oncology time once established. Further plans to expand the service by having protected beds however, were and continue to be hampered by internal operational pressures. Other service improvements had been identified such as the introduction of a non-medical prescriber and 2 stop treatments for lung patients.
Rotherham Hospital was in the process of reviewing its operational requirements, planning to open 8am – 6pm to allow more flexibility for delays and blood tests prior to clinic etc (not to increase activity). The service had identified several funding issues relating to further development, these being; moving to a nurse led service; additional nurse in clinic to support the consultants; moving to a 2 stop service (current service is not flexible). It is noted that Rotherham had no resource or staffing issues and could expand, both staff and patients are happy with the service, with ambition to deliver more. The team was also developing an electronic diary to improve efficiency with chair time.
Chesterfield Royal Hospital has a new Cancer Centre development which is due for completion in November 2016. This will include an information centre and provide a 21 chair and 2 bed capacity covering all oncology and haematology blood transfusions. The expectation is that over the next 5 years capacity will be increased to fully utilise these chairs and further strengthen the partnership with Sheffield Teaching Hospitals.
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4 Fit for the Future
4.1 Defining Resilience and Fit for the Future
As part of this review, a work stream was identified to look at high level ‘fit for the future’ principles, recognising that further in depth detailed criteria would need to be developed using wider stakeholder engagement should future service redesign and evaluation take place.
A workshop was arranged with a number of stakeholders to identify these principles, accepting that the priorities would differ depending on the stakeholder group. Four main categories were used, the results of which can be seen in the below diagram.
Finance Sustainability Patient experience Performance and Outcomes
Using the high level criteria identified, a very simple analysis was applied to the data sourced as part of the review.
Whilst some aspects of the current infrastructure are meeting expectations, there are areas which need to be considered and explored further. The initial workshop identified the ambition and commitment to do this, and the below headline priorities would need to be developed further and collectively ranked to effectively assess any proposed future service model.
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4.2 Patient Priorities
Patients on the whole focus on the qualitative aspects of care as it is more personal and real. The current system from the patient feedback received, meets and sometimes exceeds patient expectations in terms of the complimentary services they can access and experience when receiving treatment. Any future model or reconfiguration would need to take into account the positives already experienced by the patients. As future ‘performance measures’ move towards quality of life aspects, this will be an important consideration. Contradicting this element however would be the ‘best possible service regardless of cost’. Clearly there are resource limitations associated with service provision and reconfiguration. Good patient engagement and involvement would be essential to ensure expectations are managed effectively.
4.3 Commissioner Priorities
The focus in this instance identifies services which should be safe, sustainable, equitable, accessible and innovative. Clearly current demand is being met as there are no excessive waiting times for treatment, however the provision is not equitable from a locality and regime perspective. Failure to address the increasing demand and inequitable service provision would mean that the main provider would be unable to deliver a safe and effective service in the future. There are some elements of the service which are higher risk in terms of patient safety, for example the access to patient notes and current method of inputting duplicate entries. Services being ‘accessible’ is open to variation as this means different things to different stakeholders. The innovative principle is one which links to sustainability more closely and at this current time, with the collaborative development of Sustainability and Transformation Plans, the collective have an opportunity to develop services which are truly innovative.
4.4 Provider Priorities
Providers focus on wider support required for them to develop their services; financial support to develop innovative solutions whilst engaging and considering wider stakeholder support. There is acknowledgement that these are somewhat reliant on the wider health service and not specifically related to cancer services (e.g. training and recruitment), however the providers evidently require support from their local and national commissioners to change and innovate.
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5 Summary
Patient cancer outcomes in South Yorkshire, Bassetlaw and North East Derbyshire are worse than England, and have some of the worst within the Yorkshire and the Humber area. Elements of this can be accounted for by the demographics (i.e. age, deprivation, smoking prevalence etc.), however this alone does not explain the differences when comparing similar localities.
Chemotherapy services in South Yorkshire, Bassetlaw and North East Derbyshire have evolved over time and have not been formally reviewed as a collective. This review has highlighted the areas of variation across the locality, which is to a large extent the result of space, staffing and resource. In the absence of proposing and implementing a new service model however, there are potential changes that could be put in place to improve the current system which form part of the recommendations within this case for change.
5.1 Addressing Variation
It is currently not possible to make the service fully equitable in all areas identified, as this would immediately put additional pressure on the system in terms of workforce recruitment, even if the physical space and resource issues were to be resolved.
5.1.1 Contracting and Finance
Contracting and financing an equal service across the locality may not currently be possible, as the practicalities of specifying such things as staffing structures may not fit in with the wider trust sustainability plan and integrated service models. This may also stifle innovation at a local level. The benefits however of having a “one model fits all” across the locality would be the ability to review, manage and compare service performance and patient outcomes.
Although there is a mix of block and activity based contracts with the outreach localities, the block contracts do have an expected level of activity so changing this would currently be senseless, as it is not addressing the core issues, and any changes to activity would be remunerated. However a future financing model would benefit a pricing structure which reflects the level, range and activity level of the regimes provided, however this would need to be considered in terms of the mandated standing financial instructions and any tariff payment mechanisms and structures.
5.1.2 Regime Provision
The ideal provision for patients would be for an equitable service in terms of oncology regimes across the wider locality, however because of the restrictions outlined in this report (e.g. space / staffing) this has not always been possible, despite in many cases the enthusiasm to do so. The expansion of regimes at each locality has to be addressed on an individual basis taking all of these, and other recommendations in the report, into account.
The process of any expansion, however is reported by some of the providers as being extensive and complex, which leaves the outreach locality ‘in limbo’ in terms of timing any additional training, changing clinics etc.
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5.1.3 Capacity and Activity
The method of identifying capacity in each of the outreach localities is varied, but should be calculated based on a number of things such as nursing / space / dependent services. As part of the review, Doncaster and Bassetlaw Hospitals reflected on this specifically, as having the highest number of available chairs in the region for treatment was not an accurate reflection on the treatment time available, due to the number of staffing available to support the treatment provision. Expectations about treatment activity numbers cannot also be based solely on chair numbers and therefore should not be commissioned on this basis, as the added complexities of regime provision (type, intricacy) also need to be an element of contract and performance management.
Although there is a variation in the activity levels and regime provision at each localities, on the whole the providers are meeting the expected levels of activity within their contracts (with the exception of Chesterfield Royal Hospital who at month 9 were 259 treatments below the expected activity level, however were meeting the average treatments per week during the 6 week period, suggesting delivery issues earlier in the financial year).
5.1.4 Staffing
There is variation in the workforce structures across the localities which may be related to the interdependencies within the trusts (and to a large extent have influenced the funding), however there seems to be no clinical or managerial consensus about the staffing resource and level e.g. what level of nurse can provide chemotherapy (as in the physical provision / oversight). Acknowledging the potential interdependencies, there may be merit in collectively addressing and agreeing a staffing capability structure which could influence any future service modelling.
The issues outlined in terms of outreach oncology provision (i.e. clinic cover) can only be resolved sufficiently and equitably by introduction of a new model which has recruitment and resource attached. Although the providers report planned nonattendance at clinic is manageable because of the notice period that is provided, the additional patient attendance prior to this is often not. The medical cover for the outreach service has been identified as a significant issue in the continuation of a sustainable and safe service.
5.1.5 Patient Experience
Patient experience is very similar across the outreach localities in terms of the treatment they receive, acknowledging that negative feedback centres around waits for treatment and/or pharmacy. Using the information that is currently available as a benchmark, and re-evaluating patient experience following any changes to the service will be invaluable, in addition to maintaining the elements which patients find most beneficial e.g. access to complimentary services.
5.1.6 Governance and Communication
Formal and robust systems are in place across all of the outreach localities, with no significant issues reported. Some communication (i.e. the informal sharing of patient information and updates) however is not as efficient as it could be.
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6 Conclusion and Options
6.1 Activity Reallocation
As demand across South Yorkshire, Bassetlaw and North Derbyshire increases, it is unlikely that Sheffield Teaching Hospital would be able to continue to provide 51% of the oncology treatments. By using the population split aligned to the local provider as a proxy measure (acknowledging that there may be different incidence rates in each localities and assuming the information provided in the audit against the regimes can be provided in any of the outreach localities from a clinical perspective), an activity percentage increase can be provided as below, which would free up a proportional amount of treatment time at the cancer centre to focus on specialist treatment.
The most significant change to delivery would be for Rotherham Hospital (which is willing and able to increase capacity with additional resource) and Chesterfield Royal Hospital (the opening of the new cancer centre will have a positive impact on releasing capacity from Weston Park Hospital). Although this in practice is more complex than activity numbers as described throughout this report, any expansion would initially have to be around extending the regimes whilst accommodating a natural increase in incidence.
CCG (aligned to Provider) Population Oncology Percentage Provision Percentage Barnsley 13% 12% Rotherham 13% 9% Doncaster & Bassetlaw 23% 20% North East Derbyshire & 20% 8% Hardwick Sheffield 31% 51%
One of strongest drivers for this review is medical staffing, however this has not fully been taken into account in detail in this review. The continued provision of chemotherapy services needs to take into account the available consultant coverage. Services across the locality are functioning day to day, in a reactive manner. All providers agree that the current provision in unsustainable and have an ambition to take forward a collaborative model for the future, with full commissioner support. Current pressures are preventing any future proactive planning.
6.2 Options
There have been a number of positives identified with the current system, all of which provide a good grounding for any recommended change or review: Good governance structures and processes Positive patient feedback Staffing attitude and commitment Ambition to continue, expand and reduce variation of provision
The current Chemotherapy Outreach service does however have elements of variation across the South Yorkshire, Bassetlaw and North East Derbyshire region, some of which could be resolved collectively based on best practice, and some of which could only be resolved via the introduction of a new service model or extensive review.
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The information provided as part of this baseline assessment has highlighted a range of potential changes in the absence of implementing a new model, which could see an improvement in the service in its current form in terms of patient flow management, patient access to treatments (not all of which will be applicable to all outreach localities)
Best Practice Identified Reviews New Service Model Development Introducing 2 Stop Workforce structure Develop detailed Clinics review (collective assessment criteria / agreement) ranking Electronic Booking / Review and change of Diary appointment systems Communication Access to STH Beds improvements Capacity identification / Integrated IT Systems review Treatment Chair usage (potentially using more robust data information systems such as SACT) Pharmacy at Home Introduce systematic patient flow analysis
Taking into account the above, the options going forward are identified as:
1. Do nothing 2. Retain current model, implementing best practice across all outreach localities 3. Assess and review the needs of South Yorkshire, Bassetlaw and North East Derbyshire to inform and implement a new model
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7 Recommendation & Next Steps
7.1 Recommendation
The current model(s) provided in South Yorkshire, Bassetlaw and North East Derbyshire are under pressure. There is an acceptance that there needs to be a radical change to future provision and this report outlines why we need to think differently about how chemotherapy services are designed, delivered, configured and integrated.
The findings of the baseline assessment were discussed with the provider stakeholders who agree that although the areas of variation identified were valid for a number of reasons, it is unlikely in the absence of any shared service specification that the information is completely consistent between providers and given the current constraints it is difficult to mitigate this. There is a requirement for commissioner input (local CCG and NHS England) for any of the options going forward, to enable any demonstrable value of the model ) in a truly comparable way.
There is an acknowledgment that service developments to date have been to a larger extent reactive rather than proactive and that this needs to change, and therefore although there may be short term benefits in progressing with option 2, option 3 is the only way forward which will provide a long term plan for sustainability.
7.2 Next Steps
The recommended to progress with Option 3, will be formally presented to:
South Yorkshire, Bassetlaw and North East Derbyshire Cancer Strategy Group Commissioners Working Together Programme Senior Management Team Commissioners Working Together Programme Accountable Officers Group NHS England Specialised Commissioning Oversight Group
If fully endorsed, a Project Initiation Document will be developed outlining the aims, objectives, timescales and resources required, and processed through the appropriate governance structures.
25
Appendix A
Proportion of over 65 year olds Light Blue Higher than England Orange Similar to England Purple Lower than England
26
Crude Incidence Light Blue Higher than England Orange Similar to England Purple Lower than England
Emergency Presentations (all cancers) Light Blue Higher than England Orange Similar to England Purple Lower than England
27
28
2001-2003 2011-2013
mean mean relative males females deaths ASR deaths ASR change (change (change per year per year (%) %) %)
Barnsley 343 197 315 153.9 -21.9 -22.7 -20.9
Bassetlaw 168 188.5 154 144.6 -23.3 -26.9 -17.9
Doncaster 453 196 453 179.4 -8.5 -8.9 -7.9
Hardwick 164 187 153 149 -20.3 -14.9 -26.8
North Derbyshire 391 173.3 368 139.5 -19.5 -16.4 -23.2
Rotherham 385 195.9 372 163.3 -16.6 -18.0 -15.1
Sheffield 687 180.1 763 190.3 +5.7 +4.1 +7.9
Yorkshire and The Humber 7439 180.9 7213 155 -14.3 -16.0 -12.0
England 64102 170.4 62099 144.7 -15.1 -16.9 -12.6
29
Appendix B Sheffield Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
Breast Adjuvant FEC 75 01:05 01:30 2 3 7 4 3 3
FEC 75 Including Cool Cap 01:05 04:00 2 3 2 6 4 2
FEC 100 01:05 01:30 1 0 0 0 0 0
FEC 100 Including Cool Cap 01:05 04:00 0 0 0 0 0 0
TAC 00:50 02:10 4 3 5 5 3 6
TCH 01:05 04:40 5 0 5 5 1 5
TCH C1 01:45 05:40 0 0 0 0 0 0
T-Cyclo 00:45 02:00 0 0 0 0 0 0
Docetaxel 01:00 01:50 5 3 3 3 3 3
Trastuzumab IV C1 01:35 02:10 4 1 2 1 0 3
Trastuzumab IV C2 00:45 01:40 0 0 0 0 0 2
Trastuzumab C3+ 00:30 01:00 9 13 3 9 15 3
Trastuzumab SC C7+ 00:15 00:20 26 22 16 24 22 14
Breast Palliative Epirubicin Wkly 00:55 01:00 2 1 0 1 1 2
Epirubicin 3-Wkly 00:55 01:00 1 2 0 4 1 2
ONCOLOGY REGIMES Paclitaxel 01:00 02:10 12 8 12 13 9 8
Paclitaxel Including Cool Cap 01:00 05:10 1 0 0 0 0 0
Docetaxel 3 weekly 01:00 01:50 2 2 2 3 3 2
Docetaxel 3 weekly Including Cool Cap 01:00 03:20 3 6 2 3 5 7
Eribulin 00:55 01:00 2 7 10 2 5 8
Eribulin Including Cool Cap 00:55 03:00 1 0 0 0 0 0
Kadcyla - Trastuzumab Emtansine 00:45 02:20 4 2 2 4 3 2
Fulvestrant (sc) 00:15 00:15 0 0 0 0 0 0
30
Appendix B Sheffield Data Metric Return
Goseralin (sc) 00:15 00:15 0 0 0 0 0 0
Gem/Carbo 01:00 02:40 1 1 1 1 1 1
Lung Gem/Carbo 01:00 02:40 2 7 3 4 5 1
Carbo/Etoposide 00:55 03:10 4 7 4 3 8 3
CAV 00:55 01:15 0 0 0 0 0 0
Docetaxel 01:00 01:50 1 2 3 0 3 3
Pancreas Gemcitibine 00:35 01:20 7 5 6 7 5 6
Gynae Carboplatin 00:55 02:10 7 17 10 20 7 18
Carbo AUC 00:55 02:10 0 0 0 0 0 0
Paclitaxel + Carboplatin 00:40 03:10 2 2 3 2 1 5
Paclitaxel wkly 01:00 02:10 0 0 0 0 1 1
Prostate Docetaxel 01:00 01:50 3 3 3 2 5 5
Non-Chemo Blood Test 00:15 00:15 16 30 39 33 21 18
Hickman/PICC line care 00:20 00:20 50 44 39 52 41 37
HL/PICC line care + B/Test 00:30 00:30 12 18 19 14 18 17
PICC line Removal 00:40 00:40 2 3 3 1 1 1
Blood Transfusion x 1 00:30 02:50 0 0 0 0 0 0
Blood Transfusion x 2 00:35 03:50 0 0 0 0 0 0
Platelet Transfusion 00:30 01:30 0 0 0 0 0 0
Zoledronate 00:25 00:55 9 2 6 6 6 10
Denusumab 00:15 00:15 2 6 2 2 2 5
Cannula for Scan 00:15 00:30 0 0 0 0 0 0 204 223 212 234 203 203
31
Doncaster Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
Breast Adjuvant FEC 75 01:05 01:30 7 4 7 8 5 5
FEC 75 Including Cool Cap 01:05 04:00 2 4
FEC 100 01:05 01:30 2 1 1 2
FEC 100 Including Cool Cap 01:05 04:00
TAC 00:50 02:10 2 4 3 1 2 3
TCH 01:05 04:40 1 2 1 1
TCH C1 01:45 05:40 2 2 1 1
T-Cyclo 00:45 02:00 2 2 1 1 1 1
Docetaxel 01:00 01:50 1 2
Trastuzumab IV C1 01:35 02:10
Trastuzumab IV C2 00:45 01:40
Trastuzumab C3+ 00:30 01:00 4 1 7 5 1 7
Trastuzumab SC C7+ 00:15 00:20 7 11 7 4 2 3
Breast Palliative Epirubicin Wkly 00:55 01:00 2 2 2 2 2
Epirubicin 3-Wkly 00:55 01:00 1 1 ONCOLOGY REGIMES Paclitaxel 01:00 02:10 1 2 2 2 1
Paclitaxel Including Cool Cap 01:00 05:10 1 1
Docetaxel 3 weekly 01:00 01:50 1 1
Docetaxel 3 weekly Including Cool Cap 01:00 03:20
Eribulin 00:55 01:00 1 1 3 1 1 2
Eribulin Including Cool Cap 00:55 03:00
Kadcyla - Trastuzumab Emtansine 00:45 02:20 1 1
32
Doncaster Data Metric Return
Fulvestrant (sc) 00:15 00:15 1 1 3 1 1
Goseralin (sc) 00:15 00:15 4 3 1 4
Gem/Carbo 01:00 02:40 2 1
Lung Gem/Carbo 01:00 02:40 7 8 6 7 7 7
Carbo/Etoposide 00:55 03:10 7 1 7 6 2 4
CAV 00:55 01:15 2 1
Docetaxel 01:00 01:50 2 2
Pemetrexed 00:45 00:45:00 2 1 2 1
Pancreas Gemcitibine 00:35 01:20 3 3 1 4 3 2
Gynae Carboplatin 00:55 02:10 1
Carbo AUC 00:55 02:10 3 5 5 4 6 4
Paclitaxel + Carboplatin 00:40 03:10 2 1 1 1 3
Paclitaxel wkly 01:00 02:10
Prostate Docetaxel 01:00 01:50 1 1 1 4 1
Non-Chemo Blood Test 00:15 00:15 3 1 4 3 2 3
Hickman/PICC line care 00:20 00:20 3 3 3 1 2
HL/PICC line care + B/Test 00:30 00:30 1 1 1 1
PICC line Removal 00:40 00:40 2
Blood Transfusion x 1 00:30 02:50 1
Blood Transfusion x 2 00:35 03:50 5 8 4 7 1 5
Platelet Transfusion 00:30 01:30
Zoledronate 00:25 00:55 1 3 3 5 3 6
Denusumab 00:15 00:15 13 16 11 14 16 15
Cannula for Scan 00:15 00:30 2 1 87 88 88 92 78 84
33
Doncaster Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
EXAMPLE A REGIME A 01:00 01:30 10 5 6 11 14 5
ABVD 00:50 02:20 1 1 1
Ara-C s/c 00:00 00:30
Azacitidine 00:15 00:15 18 8 23 13 2 2
Bendamustine 00:35 00:50 1
Bendamustine-R 01:15 03:50 1
Brentuximab 00:35 01:20
Rheumi Cyclophosphamide 00:35 01:50 3 2 3 1 3
FC-R C1 01:05 05:20
FC-R C2+ 00:35 02:50 1
Idelasib + Rituximab 01:05 05:20
Mitoxantrone 00:35 01:20
Ofatumumab 00:35 05:20
Pamidronate 00:35 04:50 1 1
Pixantrone 00:35 01:50
HAEMATOLOGY REGIMES R-CVP - C1 01:05 06:10 1
R-CVP - C2+ 00:35 02:50 3 1 1 1 1 2
R-CHOP - C1 01:05 06:10 1 1 2 1
R-CHOP - C2 + 01:05 03:40 7 7 7 7 5 8
R-Chlorambucil C1 01:05 05:20
34
Doncaster Data Metric Return
R-Chlorambucil C2 + 00:35 02:40 1 1
Rituximab Maint IV 00:35 02:20 3 1 1 2 3
Rituximab Maint SC 00:15 00:15 2 1 1
VEDex 00:35 01:10 2 2 4 6 2 1
Velcade s/c 00:15 00:40 4 6 4 7 8 8
Zometa 00:25 00:55 12 12 13 14 11 15
Non-Chemo Blood Test 00:15 00:15 18 12 11 26 11 17
Blood Transfusion x 1 00:30 03:10 4 2 1 1 1
Blood Transfusion x 2 00:45 03:50 11 15 9 18 10 13
Blood Transfusion x 3 00:55 05:20 1
B/Test - Line Flush 00:30 00:30 4 3 2 1 1 2
Cannula Insertion 00:10 00:30 1
Cosmofer 00:25 03:50 1 2 1 3
Factor 8 00:15 00:15 2 2 2 1 2
IVIG's - maint 00:25 02:00 2 2 1 1 1 5
IVIG's Treatment Dose 01:30 06:00 1 11
Platelet Transfusion 00:25 01:30
Ritux Weekly 00:35 05:20 1 1 1 1 1
Venesection 00:30 01:00 11 10 11 13 11 15 111 89 98 115 87 100
35
Rotherham Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
07/09/2015 14/09/2015 21/09/2015 28/09/2015 05/10/2015 12/10/2015
Breast Adjuvant FEC 75 01:05 01:30 3 6 6 2 5 4
FEC 75 Including Cool Cap 01:05 04:00 0 0 0 0 0 0
FEC 100 01:05 01:30 0 0 0 0 0 0
FEC 100 Including Cool Cap 01:05 04:00 0 0 0 0 0 0
TAC 00:50 02:10 0 0 0 0 0 0
TCH 01:05 04:40
TCH C1 01:45 05:40 0 0 0 0 0 0
T-Cyclo 00:45 02:00 0 0 1 0 0 1
Docetaxel 01:00 01:50 0 1 0 0 3 2
Trastuzumab IV C1 01:35 02:10 0 1 0 0 1 1
Trastuzumab IV C2 00:45 01:40 0 0 0 0 1 0
Trastuzumab C3+ 00:30 01:00 1 0 0 1 0 0
Trastuzumab SC C7+ 00:15 00:20 5 7 6 6 7 7
Breast Palliative Epirubicin Wkly 00:55 01:00 0 0 0 0 0 0
ONCOLOGY REGIMES Epirubicin 3-Wkly 00:55 01:00 1 0 0 1 0 0
Paclitaxel 01:00 02:10 0 0 0 0 0 0
Paclitaxel Including Cool Cap 01:00 05:10 0 0 0 0 0 0
Docetaxel 3 weekly 01:00 01:50 1 2 0 0 3 2
Docetaxel 3 weekly Including Cool Cap 01:00 03:20 0 0 0 0 0 0
Eribulin 00:55 01:00
Eribulin Including Cool Cap 00:55 03:00
36
Rotherham Data Metric Return
Kadcyla - Trastuzumab Emtansine 00:45 02:20
Fulvestrant (sc) 00:15 00:15 0 1 1 0 0 1
Goseralin (sc) 00:15 00:15 2 1 0 0 1 2
Gem/Carbo 01:00 02:40 0 0 0 0 0 0
Lung Gem/Carbo 01:00 02:40 7 5 4 6 6 4
Carbo/Etoposide 00:55 03:10 0 2 1 1 1 1
CAV 00:55 01:15 0 0 1 0 0 0
Docetaxel 01:00 01:50 0 0 1 1 0 0
Pancreas Gemcitibine 00:35 01:20
Gynae Carboplatin 00:55 02:10
Carbo AUC 00:55 02:10
Paclitaxel + Carboplatin 00:40 03:10 0 0 0 0 0 0
Paclitaxel wkly 01:00 02:10 0 0 0 0 0
Prostate Docetaxel 01:00 01:50
Non-Chemo Blood Test 00:15 00:15 0 0 0 0 0 0
Hickman/PICC line care 00:20 00:20 4 4 5 2 1 1
HL/PICC line care + B/Test 00:30 00:30 4 4 8 2 1 1
PICC line Removal 00:40 00:40 1 0 0 1 1 0
Blood Transfusion x 1 00:30 02:50 0 0 0 0 0 0
Blood Transfusion x 2 00:35 03:50 0 1 0 0 0 0
Platelet Transfusion 00:30 01:30 0 0 0 0 0 0
Zoledronate 00:25 00:55 1 0 0 1 1 1
Denusumab 00:15 00:15 7 8 4 6 9 9
Cannula for Scan 00:15 00:30 0 0 0 0 0 0 VINORELBINE 39 43 40 32 42 39
37
Barnsley Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
Breast Adjuvant FEC 75 01:05 01:30 3 3 6 3 3 5
FEC 75 Including Cool Cap 01:05 04:00 1 1 2 2 1
FEC 100 01:05 01:30
FEC 100 Including Cool Cap 01:05 04:00
TAC 00:50 02:10
TCH 01:05 04:40
TCH C1 01:45 05:40
T-Cyclo 00:45 02:00 4 2 2 5 2 2
Docetaxel 01:00 01:50
Trastuzumab IV C1 01:35 02:10 1 1 1 1
Trastuzumab IV C2 00:45 01:40 1 1
Trastuzumab C3+ 00:30 01:00 1
Trastuzumab SC C7+ 00:15 00:20 5 5 4 5 5 5
Breast Palliative Epirubicin Wkly 00:55 01:00 1 1
Epirubicin 3-Wkly 00:55 01:00 1 2 ONCOLOGY REGIMES Paclitaxel 01:00 02:10
Paclitaxel Including Cool Cap 01:00 05:10
Docetaxel 3 weekly 01:00 01:50
Docetaxel 3 weekly Including Cool Cap 01:00 03:20
Eribulin 00:55 01:00
Eribulin Including Cool Cap 00:55 03:00
Kadcyla - Trastuzumab Emtansine 00:45 02:20
38
Barnsley Data Metric Return
Fulvestrant (sc) 00:15 00:15
Goseralin (sc) 00:15 00:15
Gem/Carbo 01:00 02:40 1 1 2 1 2 2
Lung Gem/Carbo 01:00 02:40 6 5 4 4 6 6
Carbo/Etoposide 00:55 03:10 4 5 4 3 2 4
CAV 00:55 01:15 1
Docetaxel 01:00 01:50 3 3 2 4
Pancreas Gemcitibine 00:35 01:20
Gynae Carboplatin 00:55 02:10
Carbo AUC 00:55 02:10
Paclitaxel + Carboplatin 00:40 03:10
Paclitaxel wkly 01:00 02:10
Prostate Docetaxel 01:00 01:50
Non-Chemo Blood Test 00:15 00:15 11 9 11 12 15 16
Hickman/PICC line care 00:20 00:20
HL/PICC line care + B/Test 00:30 00:30 2 2 2 3 3 3
PICC line Removal 00:40 00:40
Blood Transfusion x 1 00:30 02:50 1
Blood Transfusion x 2 00:35 03:50 1 2
Platelet Transfusion 00:30 01:30
Zoledronate 00:25 00:55 1 1 2 1
Denusumab 00:15 00:15 5 5 9 7 3 6
Cannula for Scan 00:15 00:30 1 1 1 45 45 55 47 52 55
39
Barnsley Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
EXAMPLE A REGIME A 01:00 01:30 10 5 6 11 14 5
ABVD 00:50 02:20 1
Ara-C s/c 00:00 00:30
Azacitidine 00:15 00:15 30 16 11 16 19 15
Bendamustine 00:35 00:50
Bendamustine-R 01:15 03:50
Brentuximab 00:35 01:20
Rheumi Cyclophosphamide 00:35 01:50 2 2 1
FC-R C1 01:05 05:20
FC-R C2+ 00:35 02:50
Idelasib + Rituximab 01:05 05:20
Mitoxantrone 00:35 01:20
Ofatumumab 00:35 05:20
Pamidronate 00:35 04:50
Pixantrone 00:35 01:50
HAEMATOLOGY REGIMES R-CVP - C2+ 00:35 02:50 1
R-CHOP - C1 01:05 06:10 2 2 3 1
R-CHOP - C2 + 01:05 03:40 2 3 2 2 5
R-Chlorambucil C1 01:05 05:20
R-Chlorambucil C2 + 00:35 02:40
40
Barnsley Data Metric Return
Rituximab Maint IV 00:35 02:20 Rituximab Maint SC 00:15 00:15 3 2 2
VEDex 00:35 01:10
Velcade s/c 00:15 00:40 5 4 5 3 6 7
Zometa 00:25 00:55 9 6 5 11 13 5
Non-Chemo Blood Test 00:15 00:15 17 13 15 4 14 14
Blood Transfusion x 1 00:30 03:10 1 1 1
Blood Transfusion x 2 00:45 03:50
Blood Transfusion x 3 00:55 05:20 10 5 9 5 5 8
B/Test - Line Flush 00:30 00:30 3 5 2 3 3 3
Cannula Insertion 00:10 00:30 1 1 3
Cosmofer 00:25 03:50 2 2 3 4 2 1
Factor 8 00:15 00:15
IVIG's - maint 00:25 02:00
Platelet Transfusion 00:25 01:30 1
Ritux Weekly 00:35 05:20 2 1 1 1 1 1
Venesection 00:30 01:00 13 19 12 10 11 14 98 77 72 62 80 80
41
Chesterfield Data Metric Return
Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Total Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
Breast Adjuvant FEC 75 01:05 02:30 3 6 1 3 7 3
FEC 75 Including Cool Cap 01:05 04:00 unable to quantite whether cool cap or not
FEC 100 01:05 02:30 1 1 1
FEC 100 Including Cool Cap 01:05 04:00 unable to quantite whether cool cap or not
TAC 00:50 02:10 1 1
TCH 01:05 04:40 1 1 1
TCH C1 01:45 05:40
T-Cyclo 00:45 02:00 1 1 2 1
Docetaxel 01:00 01:50 1 1 1 1
Trastuzumab IV C1 01:35 02:10
Trastuzumab IV C2 00:45 01:40
Trastuzumab C3+ 00:30 01:00
Trastuzumab sc cycle 1 or re-loading 00:30 06:00 1 1
Trastuzumab SC 00:30 00:30 3 10 5 3 7 4
Trastuzumab SC intermediate obs 00:30 01:30 1 ONCOLOGY REGIMES Trastuzumab SC C7+ 00:15 00:20
Breast Palliative Epirubicin Wkly 00:55 01:00
Epirubicin 3-Wkly 00:55 01:00 1 2 2 1
Paclitaxel 01:00 03:10 1
Paclitaxel Including Cool Cap 01:00 05:10 unable to quantitate whether cool cap or not
Docetaxel 3 weekly 01:00 02:50 1 1
Docetaxel 3 weekly Including Cool Cap 01:00 03:20 unable to quantitate whether cool cap or not
42
Chesterfield Data Metric Return
Eribulin 00:55 01:00
Eribulin Including Cool Cap 00:55 03:00
Kadcyla - Trastuzumab Emtansine 00:45 02:20
Fulvestrant (sc) 00:15 00:15 1 2 2
Goseralin (sc) 00:15 00:15
not on list: trastuzumab / pertuzumab 1 1
Gem/Carbo 01:00 02:40
Lung Gem/Carbo 01:00 02:40 2 2 2 2 1 2
Gem/Carbo Day 8 01:00 02:40 2 2 2 2 1
Carbo/Etoposide 00:55 03:10 2 1
CAV 00:55 01:15
Docetaxel 01:00 01:50 2 1 1 2 2
Pancreas Gemcitibine 00:35 01:20
Gynae Carboplatin 00:55 02:10
Carbo AUC 00:55 02:10
Paclitaxel + Carboplatin 00:40 03:10
Paclitaxel wkly 01:00 02:10
Prostate Docetaxel 01:00 01:50 2 2 1 2 3 1
Non-Chemo Blood Test 00:15 00:15
Hickman/PICC line care 00:20 00:20
HL/PICC line care + B/Test 00:30 00:30
PICC line Removal 00:40 00:40
Blood Transfusion x 1 00:30 02:50
Blood Transfusion x 2 00:35 03:50
Platelet Transfusion 00:30 01:30
Zoledronate 00:25 00:55 1 2 1 1 1
43
Chesterfield Data Metric Return
Denusumab 00:15 00:15 10 9 7 7 9 8
Cannula for Scan 00:15 00:30
Colorectal chemo Panitumumab 1 2 1
Oral (pharmacy only) Capecitabine colorectal 2 2 2 4 3 1
Capecitabine (breast) 5 5 5 3 6 1
Enzalutamide 1 4 3 4 1 1
Everolimus (breast) 1 0 0 0 1 1
Gefitinib 1 0 0 0 0 0
Pazopanib 1 1 0 0 1 2
Sunitinib 1 0 0 0 0 0
Erlotinib 0 1 0 0 1 0
Lapatinib 0 1 0 0 1 0 29 37 28 31 35 29
44
Chesterfield Data Metric Return
Total Total Total Total Total Total Nursing Chair Total Chair Attendances Attendances Attendances Attendances Attendances Attendances Disease Site Regime Time Time (Week 1) (Week 2) (Week 3) (Week 4) (Week 5) (Week 6)
Alemtuzumab IV 02:30 04:00 1 3 3 2
ABVD 00:50 02:20 1 1 1
Ara-C s/c 00:00 00:30
Azacitidine 00:15 00:15 7 7 14 4 5 17
Bendamustine 00:35 00:50 1 1 2 1 1
Bendamustine-R 01:15 03:50 1 1 1 1
Brentuximab 00:35 01:20
Carfilzomib 00:30 01:00 4 3 1 2
CHOP 01:30 02:30 1 1 2 1
Cyclophosphamide 00:35 01:50
FC-R C1 01:05 05:20
FC-R C2+ 00:35 02:50
Idelasib + Rituximab 01:05 05:20
Mitoxantrone 00:35 01:20
Ofatumumab 00:35 05:20 1
Pamidronate 00:35 04:50
HAEMATOLOGY REGIMES Pixantrone 00:35 01:50
R-CVP - C2+ (rapid) 00:35 02:50 1 2
R-CHOP - C1 01:05 06:10 1 2 2 2 1
R-CHOP - C2+ (rapid ritux) 01:05 03:40 3 2 4 2
R-CHOP C2+ (intermediate ritux) 05:30 05:30 2 1
R-Chlorambucil C1 01:05 05:20
45
Chesterfield Data Metric Return
R-Chlorambucil C2 + 00:35 02:40
R-GCVP (day 1, cycle 1) 02:00 06:00 1 1
R-GCVP (day 1, cycle 2+, rapid) 02:00 04:00 1
R-GCVP (day 8) 03:00 01:00 1 1
R-PMitCEBO, day 1 01:30 03:00 1
Rituximab 100mg split dose 03:00 06:10 1
Rituximab single agent (intermediate) 03:30 04:00 1
Rituximab IV (rapid) 00:35 02:20 1 2
Rituximab Maint SC 00:15 00:15 3 1 1 1 3
VEDex 00:35 01:10
Velcade s/c 00:15 00:40 6 4 5 2 6 9
Zometa 00:25 00:55
Non-Chemo Blood Test 00:15 00:15
Blood Transfusion x 1 00:30 03:10
Blood Transfusion x 2 00:45 03:50
Blood Transfusion x 3 00:55 05:20
B/Test - Line Flush 00:30 00:30
Cannula Insertion 00:10 00:30
Cosmofer 00:25 03:50
Factor 8 00:15 00:15
IVIG's - maint 00:25 02:00
Platelet Transfusion 00:25 01:30
Ritux Weekly 00:35 05:20
Venesection 00:30 01:00
Orals (pharmacy only)
Chlorambucil 1 1
46
Chesterfield Data Metric Return
CTD
CTDa 1 2 2
Dasatinib 1 1 1 2
Hydroxycarbamide 13 22 12 14 17 9
Ibrutinib 1 2 1
Idelalisib maint 1
Imatinib 1 1 4 3
Lenaldiomide +/-dex 5 3 5 3 7 1
Methotrexate low dose 1 1 1 1
MPT 2
Nilotinib 1
Pomalidomide 1 2 1
Ruxolitinib 1 2 1 2
Lenaldimide +/- vorinostat 1
RCD 1
RCDa
Thalidomide 1
Zoledronate (pharmacist review) 3 11 11 11 9 6 50 67 77 49 64 61
47
Appendix C
In September 2011, the NHS Information Standards Board has now granted Full Stage approval to the Systemic Anti-Cancer Therapy (SACT) Information Standard (Standard Number ISB Measure 1533). An Information Standard Notice has been circulated to the NHS. All relevant documents can be found on the ISB website.
1st April 2012 – Start of mandatory collection from trusts with e-prescribing systems. Target September 2012 - trusts without e-prescribing systems commence partial downloads. By April 2014, all trusts submitting full data
Source http://www.chemodataset.nhs.uk/home Time Period April 2014 – March 2015
The Systemic Anti-Cancer Therapy (SACT) Information Standard and phased implementation of national data collection applies to all organisations providing cancer chemotherapy services in or funded by the NHS in England. The standard relates to all cancer patients, both adult and paediatric, in acute inpatient, daycase, outpatient settings and delivery in the community. It covers chemotherapy treatment for all solid tumour and haematological malignancies, including those in clinical trials.
The national collection of all cancer chemotherapy information in the NHS in England commenced in April 2012. This is in line with the requirements of the Department of Health’s policy document Improving Outcomes: A Strategy for Cancer.
Number of patients Number of tumour records Number of regimens Number of cycles Number of drug records
Barnsley 134 134 794 800 2,144
Chesterfield 396 400 1,603 1,604 3,643
Doncaster & Bassetlaw 307 315 481 1,504 5,100
Rotherham 133 136 622 622 1,903
Sheffield Children’s 148 150 394 752 5028
Sheffield 5,447 5,502 27,951 27,954 56,713
48
Appendix D People diagnosed between 2010 and 2012
49
50
Appendix E
Patient Experience Patient given the name Staff told patient who to Patient finds it easy to No. of responses of the CNS in charge of contact if worried post contact their CNS their care discharge
Barnsley 153 88.7 82.2 99
Chesterfield 242 78.9 86.9 94.7
D & B 252 91.9 70.3 98.6
Rotherham 58 96.4 83.7 97.9
Sheffield 1711 89.5 73.6 96.1
Patient's GP given Patient Practice staff Saw GP Patient health got enough definitely definitely did once/twice thought they better or information No. of given enough everything before being were seen as remained about responses care from they could to told had to go soon as about the patient`s health or social support to hospital necessary same while condition and services patient waiting treatment Barnsley 153 78.1 84.7 80.5 64.8 96.5 68.8
Chesterfield 242 82.4 85.8 86.3 63.9 96.3 65.8
D & B 252 76.5 85.1 79.4 62.2 95.4 64.2
Rotherham 58 87.9 89.3 91.1 66.7 97.6 65.6
Sheffield 1711 77.6 84.9 80.5 60.2 94.2 64.8
Patient given Given easy to Patient given Hospital staff Hospital staff Hospital staff written understand written gave gave told patient No. of information written information information information on they could get responses about the type information about side about support getting free of cancer they about test effects groups financial help prescriptions had Barnsley 153 85.4 73.6 81 86.9 71.1 77.8
Chesterfield 242 84.1 73.1 77 88 44.4 76.7
D & B 252 85.9 75.2 78.8 84.1 48 82.5
Rotherham 58 80 70.4 82.7 76.9 25 66.7
Sheffield 1711 89.4 68.9 83.8 88.9 61.7 78
Given clear Patient given Patient did not Patient never written Given the right written think hospital thought they information amount of No. of responses information staff deliberately were given about what information about the misinformed conflicting should / should about condition operation them information not do post and treatment discharge
Barnsley 153 80 88.3 75.5 97.9 94.2
Chesterfield 242 78.6 91.7 85.3 88 88.2
D & B 252 72.2 91.9 90.6 86 89.2
Rotherham 58 77.6 88 94 93.6 88.2
Sheffield 1711 75.8 89.6 79 85.1 87.7
51
Title Strategy and Improvement Update
Report to: Board of Directors Date: 27 September 2016
Author: Dawn Jarvis – Director of Strategy and Improvement
For: Noting and consideration of escalated items Purpose of Paper: Executive Summary containing key messages and issues This paper provides updates on three things:- 1. CIP Programme 16/17 progress 2. Recovery and Financial sustainability plans 3. Strategic planning process led by the Directorate of Strategy and Improvement Recommendation(s) Board is asked to discuss the escalated items from Financial Oversight Committee in section 2.2 Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first By focusing on efficiency and financial stability to deliver care going forward Everyone counts – we treat each other with courtesy, honesty, respect and dignity By having clear and transparent processes and policies and by living our values Committed to quality and continuously improving patient experience By ensuring we are continuously improving our financial position Always caring and compassionate By protecting the future of the Trust by caring about how we become more efficient Responsible and accountable for our actions – taking pride in our work By having clear objectives and actions to improve our financial performance Encouraging and valuing our diverse staff and rewarding ability and innovation By ensuring everyone’s ideas count and everyone’s views are heard Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff Analysis of risks The main risk of not moving to a new way of working is that we will not have a credible and supported plan to deliver the savings necessary to reduce the financial deficit of the Trust. As a subset of this our key stakeholders and partners may lose faith in our ability to manage our own response to this issue and will take more direct ownership and control. Board Assurance Framework 1 Failure to achieve compliance with Monitor Risk Assessment Framework, CQC 5x4 = 20 and other regulatory standards, triggering regulatory action. 3 Failure to deliver financial plan. 5x5 = 25 4 Failure to deliver cost improvement plans 4x5 = 20 5 Failure to deliver turnaround/cost reduction programme 4x5 = 20
1 Introduction
1.1. This paper seeks to provide:- a) cumulative results at M5 of our 16/17 Cost Improvement Programme; b) an update on the delivery of our NHS Improvement plans; and c) an update on our strategic planning process.
2. 16/17 Cost Improvement Programme – Month 5 and cumulative delivery
2.1. The detail is shown in the enclosed power point slides attached as annex 1. In headline terms Board of Directors will want to note the following:-
The plan required delivery of £689k in M5 (Aug ‘16). Actual delivery in M5 was £833k, ahead of plan by £146k and ahead of stretch by £39k. YTD £2.943m plan, £3.632m actual, ahead of plan by £689k, and ahead of stretch by £75k.
2.2. As we enter September and a review of progress to half year we are starting to see some challenges. As previously reported some work streams are not progressing as fast as we would have hoped, but others are overachieving, hence the positive balance overall. The areas and work streams of concern are still:-
Financial support to prepare business cases for turnaround work streams – we have now agreed we will recruit additional support in the short term into Strategy and Improvement, this is underway.
Medical Productivity Workstream – deadlines for implementing the outcomes of the capacity and demand reviews are now slipping and a detailed response from Care Group Directors has been requested as to when the job planning meetings with teams and individuals are to take place. The Medical Director who is SRO for this work stream is attending the September FinOcc meeting.
Infrastructure Workstream – some projects are now re-planned and the new Director of Estates and Facilities is attending the September FinOcc meeting.
Income Workstream – the leadership of this has moved around several times in the finance function; ownership, accountability and stability is required to ensure the deadlines are met and the deliverables achieved. This has now settled directly with the Interim Finance Director who is attending September’s FinOcc to provide an update on the slippage.
Management and Corporate Services – this work stream is behind plan and some of the milestones for delivery are slipping, I have suggest a November return to FinOcc for the SRO and team.
2.3. A detailed review of the lines of spending for all areas of the Trust is currently taking place using M4 budget reports (Grip and Control Meetings) and we are using these meetings to assess whether any non-recurrent underspends can be removed from
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budgets (up to M4) and placed against some of the underperforming CIPS or in reserves. At time of writing we have completed less than half of the meetings and already have agreement to remove around £700k. We will run the Grip and Control meetings again in December and March by which point we will have developed a process of handover to a more sustainable methodology involving peer review.
3. Recovery Plans – timetable, content and sign off
3.1. We have agreed with NHS Improvement the following timetable for delivery of the various stages of plans; this needs to take account of the fast paced work on the South Yorkshire and Bassetlaw Sustainability and Transformation Plan (STP), which provides its next report in October.
3.2. We should agree at the Performance Review Meeting on 26 September whether or not the more sensible date for the submission of the 3-5 year plan in March, due to the changeover of CEO and Chair. We should also agree at the same meeting what requirements there will be for us to supply an additional operational plan (as required of all providers) alongside those already provided.
Date Submission Status 27 May 2016 Initial draft of short term recovery plan – to demonstrate Delivered on time – direction of travel and to seek initial informal feedback received and feedback/comments from NHSI being built into final plan for August 26 August Formal submission of two year recovery plan (FY16/17 and Delivered on time – 2016 FY17/18) – NHSI will review and provide formal feedback on feedback awaited this version. Should demonstrate that engagement with local partners has taken place. 26 October First draft of five year plan – again to demonstrate the On plan 2016 direction of travel, flesh out the likely content and provide detail of the work streams and governance arrangements that the longer term plan is likely to follow. December? 2 year operational plan TBC 5 January Formal submission of the five year plan (FY16/17-FY20/21) – On plan but challenging 2017 to demonstrate how this will fit in to STP; involve local partners in solution development and delivery; and how the trust will return to breakeven.
4. Strategic Development
4.1. As outlined above, there is a need to provide a “Financial Sustainability Strategy” as part of the conditions agreed with NHSI. We also need to revise our strategic framework in the current prevailing NHS, STP and Trust conditions. Board now has monthly sessions to plan and develop this starting at the Board Brief on 18 July, where the Directorate of Strategy and Improvement adopted the facilitation role, presenting a 25 week plan to enable the delivery of the 3-5 year plan which will be a key part of the new Strategic Framework.
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4.2. During August and September, Care Groups have provided us with their long term planning views: these are being collated and challenged at a series of Care Group and Exec meetings in September; at a large event on 3 October all Care Groups and Corporate Directorates will hear each other’s plans where further peer challenge will help refine them when set against the various measurement criteria previously agreed by the Board of Directors.
4.3. Following that meeting and following the timeline previously agreed by the Board of Directors, a series of options will be drawn up for discussion at the October Board Brief.
6. Summary
6.1. In summary:- M5 has been more challenging but we are still £689k ahead of the original plan and £75k ahead of the stretch plan. After a strong Q1, Q2 looks to have been just as strong, but at mid-year I recommend we have a more formal review of what is left to do and any lessons learned that we can make the most use of to deliver for the rest of 16/17, take forward into 17/18 and put in place to enable longer term planning and recovery. I would suggest that for the October meeting we focus much of the agenda on that more detailed review. But a positive first five months, from a difficult starting position.
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Executive Summary – DBH Improvement Programme 16/17
The Plan and Forecast for Month 5 - August 2016 Risks and Issues and mitigating actions (where required)
The planned delivery for the Improvement Programme for FY16/17 is £11.0m, Several schemes ramp up in delivery terms in October, extra with an internal stretch target to £13.0m. push needed now to ensure these work streams remain on The forecast outturn for the Improvement Programme (FOT) is now £12.119m track. a decrease since M1 of £296k from £12.415m. The plan required delivery of £689k in M5 (Aug ‘16). Actual delivery in M5 Recruitment of key personnel to S&I to support delivery; project was £833k, ahead of plan by £146k. YTD £2.943m plan, £3.632m actual, managers; financial support etc. ahead of plan by £689k, and ahead of stretch by £75k Smooth handover from Kingsgate at the end of October. Priorities (since the last report) have included: • Delivering the 2 year plan to NHSI on 26th August 2016 • Working with the leaders of the work streams that need extra support, or the projects that need additional resources • Receiving the strategic plans from the clinical services and agreeing the process and content for the October workshop with COO • Running round 3 of grip and control meetings • Pulling out non-recurrent underspends to add to reserve/local CIP Trust Total Monthly Delivery Trust Total Cumulative Delivery • Presenting to NHS Finance Directors on FIP experience at request of NHSI £1,600,000 • Recruiting project managers to cover some turnover Original Monitor plan £1,400,000 • Running Programme Board and Steering Groups Plan • Prepping for NHSI meeting £1,200,000 Actual / Forecast Priorities for the next month will include : £1,000,000 rd • Facilitating the clinical services planning meeting 3 October £800,000 • Planning Board Brief for October re decision points £600,000 • Ensuring delivery of themes remain on track via accountability meetings • Continuing to identify remainder of stretch target to £13.0 £400,000 • Continuing to drive plans for pipeline and 17/18 £200,000 • Responding to feedback on 2 year plan £0 • Working on 3-5 year plans 1 2 3 4 5 6 7 8 9 10 11 12 • Building on the communications activity with new round of meetings • Begin to map out Quality and Service Improvement Team after key meeting with STH 1 2016/17 Plan in Overview – total cumulative delivery and risk
Based on an original plan of £11m with an internal stretch to £13m, we are currently forecasting
16% or £2m of our plan is high risk but that £8m of the plan is, without any additional work, already delivering. Therefore 100% effort is going into 36% of the schemes to reach the £13m Efficiencies Summary Information Total Proportion of Efficiency total £000s % CIPs - High risk - red 2,032,975 16% CIPs - Medium risk - amber 1,802,019 14% CIPs - Low risk - green 8,284,453 64% Total needed to be identified 880,553 7% Total Efficiency 13,000,000 100%
2 2016/17 Plan in Overview – recurrence, category and development
Efficiencies Summary Information Total Proportion of Efficiency total £000s % Recurrent schemes 11,397,728 88% Non-recurrent schemes 721,719 6% Based on an original plan of £11m with an internal Total needed to be identified 880,553 7% stretch to £13m, we are currently forecasting Total Efficiency 13,000,000 100% • 88% of the £13m is made up of recurrent schemes Efficiencies Summary Information Total Proportion of which serves us well for carry through to 17/18. Efficiency total £000s % • 57% are pay related schemes with only 16% as Pay 7,403,800 57% income related which means we are not expecting to Non pay 2,573,400 20% “income” our way out of the deficit. Income 2,142,247 16% Total needed to be identified 880,553 7% • 65% of the schemes are fully developed using the Total Efficiency 13,000,000 100% NHSI definition Efficiencies Summary Information Total Proportion of Efficiency total
£000s % CIPs - Fully developed 8,433,626 65% CIPs - Plans in progress 2,045,298 16% CIPs - Opportunity 1,758,475 14% Total needed to be identified 762,601 6% Total Efficiency 13,000,000 100%
3 Improvement Programme Forecast Out turn 2016/17 – M5 position
Original Stretch Original Stretch Actual in Variance to Variance to Original Stretch Actual Variance to Variance Forecast Forecast Plan for the Plan for Plan in Plan in Month Original in Stretch in Plan YTD Plan YTD YTD Original to Stretch CYE (16/17) FYE (Recurrent) Year the Year Month Month Month Month YTD YTD £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Analysis by Workstream Theatres 443 520 0 0 39 39 39 0 0 126 126 126 671 1,039 Outpatient Productivity 287 259 19 20 17 -2 -3 64 91 77 13 -14 245 287 Medical Productivity 413 441 0 0 39 39 39 0 0 99 99 99 568 966 Non Medical Clinical 261 261 0 0 9 9 9 0 0 42 42 42 334 1,183 Management & Corporate Services Review 761 987 60 101 85 24 -16 293 339 285 -8 -54 869 1,035 Bed Plan / LOS 2,293 2,683 137 169 192 54 22 593 728 800 208 73 2,758 3,887 Procurement 1,901 2,003 97 151 151 53 0 471 718 719 248 1 2,163 2,687 Clinical Admin Review 250 250 0 0 0 0 0 0 0 0 0 0 250 250 Infrastructure 531 894 47 57 -7 -54 -64 93 162 121 28 -41 457 1,262 Income 1,058 1,325 99 60 77 -21 18 297 454 332 35 -122 1,176 1,509 Care Group & Corporate - Local 1,578 1,779 125 154 146 22 -8 623 663 619 -4 -44 1,620 1,437
Grip & Control 1,224 978 102 82 85 -17 3 510 402 412 -98 10 1,011 897 TOTAL 11,000 12,380 687 794 833 146 39 2,943 3,557 3,632 689 75 12,119 16,439
Rec 11,000 11,768 687 754 753 66 -1 2,943 3,144 3,284 341 140 11,398 16,439 Non rec 0 612 0 40 80 80 40 0 412 348 348 -64 722 0 11,000 12,380 687 794 833 146 39 2,943 3,557 3,632 689 75 12,119 16,439
4 Bed Plan / LOS Monthly Delivery Theatres Monthly Delivery Outpatient Productivity Monthly Delivery £350,000 £100,000 £45,000 Original Monitor plan Original Monitor plan £90,000 Original Monitor plan Stretch plan £40,000 £300,000 Stretch plan £80,000 Stretch plan Actual / Forecast £35,000 Actual / Forecast £250,000 £70,000 Actual / Forecast £30,000 £60,000 £200,000 £25,000 £50,000 £150,000 £20,000 £40,000 £15,000 £100,000 £30,000 £10,000 £20,000 £50,000 £10,000 £5,000
£0 £0 £0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Bed Plan / LOS Theatres Outpatient Productivity
Medical Productivity Monthly Delivery Non Medical Clinical Productivity Monthly Delivery Management & Corporate services review Monthly Delivery £120,000 £70,000 £120,000 Original Monitor plan Original Monitor plan Original Monitor plan Stretch plan £100,000 Stretch plan £60,000 £100,000 Stretch plan Actual / Forecast Actual / Forecast Actual / Forecast £50,000 £80,000 £80,000 £40,000 £60,000 £60,000 £30,000 £40,000 £40,000 £20,000
£20,000 £10,000 £20,000
£0 £0 £0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Medical Productivity Monthly Delivery Non Medical Clinical Productivity Monthly Delivery Management and Corporate services review
5 Procurement Monthly Delivery Clinical Admin Review Monthly Delivery Infrastructure Monthly Delivery £300,000 £90,000 £140,000 Original Monitor plan Original Monitor plan Original Monitor plan Stretch plan £80,000 Stretch plan £120,000 £250,000 Stretch plan Actual / Forecast £70,000 Actual / Forecast £100,000 Actual / Forecast £200,000 £60,000 £80,000
£50,000 £60,000 £150,000 £40,000 £40,000
£100,000 £30,000 £20,000
£20,000 £0 £50,000 1 2 3 4 5 6 7 8 9 10 11 12 £10,000 -£20,000
£0 £0 -£40,000 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Procurement Monthly Delivery Clinical Admin Review Monthly Delivery Infrastructure Monthly Delivery
Corporate & Care Group - Local Monthly Delivery Income Monthly Delivery Grip & Control Monthly Delivery £180,000 £250,000 £120,000 Original Monitor plan Original Monitor plan Original Monitor plan Stretch plan Actual / Forecast £160,000 Stretch plan Stretch plan £100,000 £200,000 £140,000 Actual / Forecast Actual / Forecast
£120,000 £80,000 £150,000 £100,000 £60,000 £80,000 £100,000 £60,000 £40,000
£40,000 £50,000 £20,000 £20,000
£0 £0 £0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Corporate & Care Group - Local Monthly Delivery Income Monthly Delivery Grip & Control Monthly Delivery
6
Title Amendment to the Procurement Strategy
Report to: Board of Directors Date: 27th September 2016
Author: Andrea Smith, Head of Procurement
For: Approval Purpose of Paper: To amend the Procurement Strategy to include the Carter requirements published in February of this year
The Board of Directors approved the Procurement Strategy in 2015. Since then Lord Carter of Coles produced the Report Operational productivity and performance in English NHS acute hospitals: Unwarranted variations in February 20161. Within the report there is a requirement for each Trust to develop a Procurement Transformation Plan (P2P). Because the Trust’s Procurement Strategy already covers many of the elements of the P2P it is recommended that the Procurement Strategy is amended to include two extra sections:
8) Lord Carter Recommendations (pg 19) and 9) Implementation of Lord Carter Recommendations (pg 20)
These additional sections clearly set out what the Lord Carter requirements are and how they will be met.
Recommendation(s)
Approve the amendments to the Procurement Strategy.
Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first Providing products and services that improve care Materials Management having stocking responsibility in full liaison with clinical staff. Everyone counts – we treat each other with courtesy, honesty, respect and dignity By introducing procurement principles into the procurement team. Including treating all customers with respect. Committed to quality and continuously improving patient experience By encouraging clinical engagement and innovation. Always caring and compassionate
1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_produ ctivity_A.pdf
1 By ensuring stocks are managed appropriately and freeing up clinical time to work with patients. Responsible and accountable for our actions – taking pride in our work By introducing a focus for the team and monitoring progress. Introducing a workplan to support the procurement strategy. Encouraging and valuing our diverse staff and rewarding ability and innovation By providing appropriate staff training and celebrating successes.
Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
The strategy does not introduce risks. It will enable the Trust to meet the Carter deadlines of board approval of the PTP by September 2016.
Board Assurance Framework 1 Failure to achieve compliance with financial performance aspects of the 5 x 4 = 20 Monitor Risk Assessment Framework and provider licence, triggering regulatory action 3 Failure to achieve compliance with performance and delivery aspects of Monitor 4 x 4 = 16 Risk Assessment Framework, CQC and other regulatory standards, triggering regulatory action 4 Inability to recruit right staff and ensure staff have the right skills to meet 4 x 3 = 12 operational needs.
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Contents 1) PURPOSE ...... 4 2) BACKGROUND ...... 5 3) VISION FOR PROCUREMENT ...... 7 4) NATIONAL AGENDA & PRIORITIES ...... 8 5) CURRENT POSITION ...... 9 6) ASPIRATIONS AND ACTIONS ...... 9 6.1. EFFICIENCY ...... 11 6.1.1. Efficiency Objectives ...... 11 6.1.2. Efficiency Actions ...... 11 6.2. LEADERSHIP ...... 12 6.2.1. Leadership Objectives ...... 12 6.2.2. Leadership Actions ...... 13 6.3. PROCESS ...... 13 6.3.1. Process Objectives ...... 14 6.3.2. Process Actions ...... 14 6.4. PARTNERSHIP ...... 15 6.4.1. Partnership Objectives ...... 15 6.4.2. Partnership Actions ...... 15 6.5. PEOPLE ...... 16 6.5.1. People Objectives...... 16 6.5.2. People Actions ...... 16 7) PROCUREMENT WORKPLAN ...... 17 8) LORD CARTER RECOMMENDATIONS ...... 19 9) IMPLEMENTATION OF LORD CARTER RECOMMENDATIONS ...... 20 10) REFERENCES ...... 21
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1) PURPOSE This Strategy provides the focus and actions that Procurement will take over the next three years aligning with the Trust Strategy ‘Looking Forward to Our Future’1. Procurement can add real value to the Trust not only in providing efficiencies and ensuring stock is in place to treat patients but in many more areas. Bringing together the innovation in the market with our clinicians can bring real change in the care pathway. The financial challenges the NHS face mean that cutting the cost of products alone can no longer provide the savings needed for the future. Changes in clinical practice are needed and procurement can be the catalyst to bring together suppliers and clinicians within a commercially focused partnership. NHS England has launched The Five Year Forward View2 highlighting a need to achieve a 2% – 3% net efficiency for the next 10 years to close the £30b funding gap in the NHS. Procurement is one of the solutions to assist in the ongoing efficiency requirements.
The Procurement Strategy is forward thinking and acts to strategically support the delivery of all four of the Trusts four Strategic Themes as well as National Procurement Policy and Guidance. It will provide the professional, commercial department required to ‘make it happen’ in an innovative but compliant manner that will lead the way. Figure 1 shows the strategic themes along with examples of how Procurement will support delivery.
Figure 1 - Strategy Themes
•Provide products and services that improve care Provides the safest, •Implementing processes to ensure trial and loan products are maintained , tested and made safe most effective care •Materials Management having stocking responsibility in full liaison possible with clinical staff. •Ensuring business continuity plans are in place with key suppliers
•Efficient & effective contracts that reduce patient pathway costs Control and reduce •Collaborating with acute 's & public sector organisations cost of providing •Utilising procurement hubs reducing duplication & time •Managing stock effectively incl. stock rotation & rationalisation healthcare •Managing supplier representitives effectively
•Bring supplier innovation combined with clinical engagement •Supplier days to encourage joint working and innovation Focus on innovation •Supplier portal to encourage engagement from all suppliers •Network with colleagues nationally and internationally to be aware and improvement of innovations •Develop Procurement staff to ensure they harness innovation
Develop responsibly, •Ensure simple electronic processes reducing admin burden and freeing up clinical time delivering the right •E-catalogues ensuring accuracy of ordering information and invoicing services with the right •Procurement process is made simple ensuring key stakeholders are staff involved at appropriate times during the process.
1 DBH Trust Strategy 2 NHS England 5 Year View 2) BACKGROUND
In 2014 the Trust restructured and six clinical care groups were formed plus corporate (See figure2). The table below shows the care groups and the annual spend per care group in 2013/143:
Figure 2 – 2013/14 Care Group & Corporate Spend
• Emergency Department, Medical and Surgical Assessment Units £7,337,067 Emergency •Respiratory Medicine
•Theatres & Anaesthetics, Critcal Care, Pain Surgical •gastro Intestinal, Endoscopy £10,675,319 •Ophthalmology, Oral Maxillofacial
•Trauma & Orthopaedic, Rehaibilitation Musculoskeletal •Care of Older People, Rhumatology £11,307,692 & Frailty
•Pathology, Pharmacy £8,463,966 Diagnostic & •Medical Imaging, Outpatients Pharmacy
•Obstetrics, Gynaecology Children & Famly •Paediatrics, Genitourinary Medicine £2,118,835 Services
•Cancer services £6,023,121 Seciality Services •Cardiovascular
•Estates & Facilities Management £28,709,488 Corporate •Catering •External Contracts
3 This is an estimate using previous cost codes as the care groups formed in July 2014. 5
Doncaster and Bassetlaw Hospitals Foundation Trust spent £74,635,488 in 2013/14 on Non-Pay spend and Agency (excluding drugs). The spend has been broken down in Figure 3 into clinical and non-clinical splits. Figure 4 shows the non-pay spend split by care group excluding Corporate.
Figure 3 - DBH Non Pay Split
Non Pay Expenditure Split
40% Clinical Goods and Services
Non-Clinical Goods and 60% Services
Figure 4 - DBH Spend by Care Group
Expenditure by Care Group
Children & Families Care Group Diagnostic & Pharmacy Care Group Emergency Care Group MSK & Frailty Care Group Specialty Services Care Group Surgical Care Group
5%
23% 18%
13% 16%
25%
The Trust has a supplier base of 2376 with 65% of spend with the top 30 suppliers. The majority of orders (98%) are placed via the Agresso finance system or NHS Supply Chain Electronic system. Although the statistic for electronic ordering is good, part of the procure to pay process is still heavily reliant on paper requisitions. The Supplies department receive nearly 10,000 paper requisitions per year. The Agresso finance system contains products and pricing for over 5000 products although this isn’t managed in a consistent manner leading to price queries within accounts payable.
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3) VISION FOR PROCUREMENT
To support the delivery of High Quality Patient Care through Strategic, Efficient and Innovative Procurement utilising appropriate levers such as collaboration and market engagement.
An account management approach to care groups will be introduced to ensure that the groups have the professional support and guidance required to realise the strategic priorities of the Trust.
The following procurement principles will apply in all our decision making, process and work ethics:
Communication We will communicate with internal customers promptly providing accurate information to support the Care Groups. We will communicate in a professional manner with internal and external stakeholders including suppliers and peers. Transparency Tender opportunities will be communicated on an e-tendering portal according to the thresholds outlined in the Standing Financial Instructions and Standing Orders (SFIs & SOs) Quotations will be carried out via the e-tendering portal according to the thresholds as outlined in the SFIs & SOs Engagement Procurement will work to gain suitable stakeholder engagement which may include clinicians, service users, external organisations and suppliers for each tender and project. Integrity Procurement will work in a professional manner at all times. Equality All suppliers will have an equal opportunity to win business with the trust. They will be evaluated in a fair and transparent manner. Consistency Procurement will follow the procurement process in a consistent manner. Innovation Procurement will encourage innovation from our suppliers and customers. Proportionality The tender process will be designed to meet the requirements taking into account the value, complexity and risk. Pre-qualification questionnaires will only be used for EU Procurements unless the market size requires it.
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4) NATIONAL AGENDA & PRIORITIES The Department of Health (DH) have launched a suite of strategies, guides and resources in recent years:
1. DH Procurement Strategy4 - (Better Procurement, Better Value, Better Care, 2013) 2. E- Procurement Strategy5 - (NHS e-Procurement Strategy, 2014) 3. NHS Procurement Standards6 - (NHS Procurement Standards, 2013) 4. NHS Procurement Dashboard7 - (NHS Procurement Dashboard, 2013) 5. NHS Procurement Transparency8 - (Procurement Transparency, 2014)
These have now been underpinned by a supporting Centre for Procurement Excellence (CPE) with the DH. The CPE are focusing on supporting Trusts with the following priorities:
Board level recognition and sponsorship of Procurement Executive authority and influence Organisational alignment Category management and sourcing strategies Supplier Relationship Management Risk management Operational Process Management Performance management Data, information and knowledge People strategy Excellence in governance, planning, programme and change management
This strategy aims to address the areas identified as priorities by the CPE. The strategy objectives and actions have been designed to align with the DH guidance and fall within four main themes. Refer to section 6.2 to 6.5 for specific actions in these four themes:
Leadership People
Partnership Process
4 DH Procurement Strategy 5 NHS e-procurement strategy 6 NHS Procurement Standards 7 NHS Procurement Dashboard 8 NHS Procurement Transparency 8
5) CURRENT POSITION The North of England Commercial Procurement Collaborative (NOECPC) carried out an independent review of the Supplies function in July 2014 (NOECPC, 2014).
The review highlighted the need for improvements in the following areas:
Strategic Procurement Structure Leadership Staff development Systems and process Governance Communications The Trust has also carried out a self-assessment against the NHS Procurement Standards. These standards are best practice procurement standards that guide Trusts in how to benchmark their procurement function against what ‘good’ procurement looks like. Each Trust should aim to achieve a green or amber status in most areas. The results for each procurement standard are detailed in figure 6. The actions to improve these standards are detailed within the strategy.
6) ASPIRATIONS AND ACTIONS
The Supplies department will become The Procurement Department with a focus on the end to end procurement process. The department will achieve varying levels of the NHS Procurement Standards detailed in Figure 6 by March 2017. Not all NHS procurement standards are suitable for all Trusts and there are standards where achieving a green would not be suitable for DBH. This does not mean however that the particular standards objectives will not be met it just means the Trust will achieve it in a slightly different way. Examples of this are:
1. Partnership Standard 3.4 -Ensure that opportunities to supply exist for “encouraged enterprises” SME Development – whilst the Trust will baseline the number of SME’s the Trust engage with and will allow all suppliers including SME’s to bid for future work through an electronic tendering portal, the Trust will also be working in collaboration with other Trusts to reduce costs and standardise. This means that the collaborative groups will be looking for contracts based on larger volumes and these are often not suitable for SME’s. 2. Partnership Standard 1.5 - Advertise all opportunities over £10k. There is no benefit to the Trust in advertising all opportunities over £10k with the objective of encouraging smaller businesses. The Trust can achieve an improved level of engagement with business through a new procurement portal where it can publish and carry out quotations. This will be a much simpler process for both the Trust and the Supplier. The portal will be free of charge for suppliers to register and will be used for quotations and tenders in the future. This will achieve the aim of the particular standard but in a different way.
These examples above show that whilst the Trust may not reach green in all areas there is still potential to do more than the current status to improve performance in all areas. The Department of Health recognise that not all standards will be suitable to be met in full by all organisations.
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Figure 5 - DBH Self-Assessment of the Procurement Standards & Targets for March 2017
1) People
People 2017 Red People 14/15 Amber Green StandardAssessed 0 2 4 6 Total Number of Standards and Levels for People
2) Partnerships
Partnerships 2017 Red Partnerships 14/15 Amber Green 0 2 4 6 8 10 12 StandardAssessed Total Number of Standards and Levels for Partnerships
3) Process
Process 2017
Red
Process 14/15 Amber
StandardAssessed Green
0 3 6 9 12 15 18 Total Number of Standards and Levels for Process
4) Leadership
Leadership 2017 Red Leadership 14/15 Amber Green StandardAssessed 0 3 6 9 12 15 18 Total Number of Standards and Levels for Leadership
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6.1. EFFICIENCY
The Procurement Department will spearhead the Trusts procurement related Cost Improvement Programme (CIP). The new department will have a stretching target for savings and improvement over the next three years. This will be a blend of cashable savings within care groups, other procurement savings, cost avoidance and non-cashable benefits.
The method for achieving savings is becoming more complex as it requires much more than reducing the cost of a product. Future cashable efficiencies can be achieved through innovation, standardisation and collaboration. This can only be achieved by having a professional, motivated Procurement Team with a focus on the Trusts objectives and team’s vision and shared objectives. Investment in the team will be required to continue to make efficiencies and to improve on the efficiencies.
By achieving at least 18% of the Trusts overall CIP target the team will produce cashable and other procurement savings of at least £7m over the next 3 years. This will be achieved through a range of projects including standardisation, rationalisation, substitution, demand management, contract monitoring, collaboration and market testing.
Efficient and effective processes and procedures will be put in place making the procurement process fully electronic in the future.
6.1.1. Efficiency Objectives Contribute £7m to the Trust CIP target over the next 3 years. Contribute non-cashable efficiencies to the Trust including professional procurement resource to new projects and innovation. Have a fully documented audit trail of efficiency savings that have the support of the Care Groups. Ensure the Director of Finance is kept briefed on the progress of the Procurement CIP.
6.1.2. Efficiency Actions Develop and jointly agree with finance savings definitions. Develop and implement an efficiency database to hold both cashable and non-cashable savings. Ensure procurement CIP projects are reported to care groups along with other CIP schemes. Develop joint working between procurement and care group finance leads. Develop a regular report to the Director of Finance on the Procurement CIP progress.
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6.2. LEADERSHIP
To achieve the aspirations over the next 3 years requires a change in behaviours. Procurement can no longer rely entirely on negotiating the cost of products and services down. The scale of financial challenge means that the Trust has to be receptive to changes in product, specifications and demand management. This requires leadership support from the Board and Procurement.
The Director of Finance and Infrastructure is the Board level member responsible for Procurement. A Non-Executive Director has been appointed as the Non-Executive Procurement Sponsor from 2014.
The board will give support for the Head of Procurement to build a stronger procurement function over the next 3 years to ensure that the changes required to achieve the aspirations have Executive Support.
The Head of Procurement was appointed in August 2014 to lead the department and implement the recommended strategy and changes. The procurement team in the future will lead procurement across the Trust, supporting and challenging the care groups to ensure the best opportunities are identified hand in hand with clinicians and are implemented effectively.
6.2.1. Leadership Objectives Board engagement in the Procurement Strategy and Plans are reviewed in line with the Trust Strategy. Introduce strong procurement leadership. Transform the procurement function from operational to strategic. Proactively engage with the market to ensure procurement is the first contact with the Trust. Clinical engagement is considered for every clinical procurement project. Introduction of a Category Management approach within Procurement. Trust Wide visibility of stock and patient level costing. National procurement leaders engage with the Trust. Trust staff outside of the procurement department has efficiency related objectives. Business continuity plans are in place for key suppliers to the Trust. Transparency of spend and opportunities are clearly visible. Innovation focusing on patient care and efficiencies are encouraged and supported by Procurement. Procurement influence all spend above the tender threshold. Care Groups benefit from Procurement Account Management. Key stakeholders including clinicians and suppliers are kept informed on Procurement developments and opportunities. All major clinical procurement projects will have a Senior Clinical Sponsor. SME’s are able to trade easily with the Trust. 12
6.2.2. Leadership Actions Develop a business case for the transformation of Procurement. Re-structure the department with a focus on category management and care group account management. Report procurement performance annually to Trust Board. Brief the Executive and Non-Executive lead on procurement issues quarterly. Review, recommend and implement changes to stock management systems. Introduce a procurement handbook for staff induction and guidance. Introduce procurement systems (further details within section 6.3 on process) to enable transparency of contracting and purchasing. Introduction of internet and intranet systems to provide procurement communication. Enable SME information to be captured in a supplier management system. Ensure a Senior Clinical Sponsor is appointed for all major clinical procurement projects. Have a procurement lead focusing on communications.
6.3. PROCESS
In May 2014 the Department of Health launched an e-procurement strategy9 for the NHS. The ambition of the strategy is for all NHS purchase-to-pay transactions and all category management activities to be undertaken by electronic means to cover all non-pay expenditure. Use of master data across the NHS will assist in benchmarking and catalogue content. The GS1 system enables a single global source of master data to be created, captured and shared across supply chains, from the brand owner through to the end user GS1 codes are easily recognisable on products as Bar Codes. The standard acute contract now instructs all Provider Trusts to comply with the NHS E-Procurement strategy.
The Trust has already started the journey of an electronic procure to pay process and has an element of inventory management throughout the hospital sites utilising the Supply Chain EDC Materials Management system. The e-procurement plans will be developed further and will incorporate electronic processes from the development of specifications and adverts through to contract management. There has never been as much need for electronic auditable systems as there is now due to the litigious nature of the supplier market. The EU requires that all public bodies use electronic means for the advertisement and receipt of tenders. This will become UK law in 2015.
Although 98% of the orders are placed via the Agresso finance system or NHS Supply Chain Electronic system electronically the requisitioning element of the process remains on paper.
9 NHS E-Procurement Strategy https://www.gov.uk/NHS_eProcurement_Strategy.pdf 13
The Agresso finance system contains products and pricing for over 5000 products. This will need to be built up significantly if electronic requisitioning and ordering is to be effective.
Figure 6 - Current Ordering Statistics
30,275 Supply Chain Electronic Orders
9,428 Paper Requisitions
14,268 Department Direct Aggresso Orders 10,476 Supplies Aggresso Orders (from Paper Req's)
55,019 Electronic Orders placed
6.3.1. Process Objectives
Tendering, Evaluation and Contract management will be carried out via fully auditable electronic systems. Paperless procure to pay systems in place working effectively and efficiently. Regularly stocked items are available via electronic catalogues allowing for efficiency of scale and reliable spend reports. Trust wide view of stock is in place linked to patient level costing. E-procurement systems are compliant with the latest DH e-procurement strategy requirements. The Trust reports on the DH Procurement Dashboard on a quarterly basis. A procurement handbook is in place for all Trust staff to guide them easily through the process. Sustainability is baselined and targets set. The trust is GS1 compliant and has implemented throughout the Trust. The trust has introduced global standards for Purchase Order, Advice Note, invoicing and messaging (PEPPOL). No orders will be sent via fax or post. Ensure every invoice has a purchase order number for payment. Ensure full visibility of spend for procurement and care groups and have the ability to benchmark with others. The Procurement Dashboard reporting tool will be in place and reported to Trust Board annually. Sustainability will form part of the category strategy and evaluation criteria.
6.3.2. Process Actions
Procure and implement tendering and contract management systems. Redesign the procure to pay process to ensure a paperless system throughout the Trust. Increase product range and manage the internal catalogue. Procure and implement a trust wide inventory management solution to enable GS1 coding to be used and provide Patient level costing data. Develop reporting capability and report via the procurement dashboard.
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Reject invoices with no Purchase order number. Procure and implement a spend analytics tool. Introduce a gateway for transmitting orders and e-invoices that enables PEPPOL compliance. Develop the systems required to ensure the procurement dashboard reporting can be achieved. Standard documents will be developed that include sustainability.
6.4. PARTNERSHIP
It is well understood that individual trusts cannot always achieve best value on their own. The Trust has developed a number of excellent working relationships with other organisations in order to aggregate spend and achieve efficiencies. It will continue to work with others on procurement initiatives with an increased focused on a structured plan and key deliverables.
The trust is a full member of the North of England Commercial Procurement Collaborative (NOECPC) and will work with the NOECPC to influence their future workplans.
6.4.1. Partnership Objectives
Have a structured workplan with collaborative groups including but not exclusive: a) North Of England Commercial Procurement Collaborative (NOECPC) b) Working Together Group made up of 7 Yorkshire Trusts c) Yorkshire Procurement Managers Group d) Northern Lincolnshire & Goole NHS FT and United Lincolnshire Hospitals NHS Trust Project focused clinical procurement groups in place for all major clinical procurements. Clinical Procurement Groups established and led by the Clinical Procurement Specialist. The groups will be chaired by a senior clinician relevant to the products or services being reviewed. Key suppliers are performance managed and have regular performance reviews. The Head of Procurement liaises with the DH on national procurement initiatives.
6.4.2. Partnership Actions Procurement pipeline/workplan established with collaborative groups to ensure no duplication exists. Clinical Procurement Specialist is tasked with establishing clinical procurement groups. A Contract management system is procured and implemented. The Head of Procurement is an active member of the Centre for Procurement Excellence. Supplier relationships are developed that encourage innovation and efficiency. A recording method will be introduced to enable the Trust to capture spend with SME’s. A baseline will be set for the % of business carried out with SME’s.
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6.5. PEOPLE Effective Procurement requires a whole team approach. The team should be appropriately trained and have the environment and systems required to carry out their role effectively. Investment will be required within the department for staff, systems and training. A business case is being developed to support delivery of this strategy.
6.5.1. People Objectives Develop and present a business case to support delivery of this strategy. Have a future-proof structure in place that achieves the Trust and procurement strategy objectives. Support the care groups with an account management approach. Manage the market with a category management approach. Have a working environment that is fit for purpose for now and in the future. Have a team of professional Procurement staff motivated and achieving personal and team objectives. Are customer and patient focused at all times. Become a valued department that the Trust engages with during business planning and prior to any procurement process commencing.
6.5.2. People Actions Develop a structure and recommend within the Procurement Business Case. Ensure the structure has category management and business intelligence capability. Provide staff training utilising: a) Academy of Procurement Excellence (APEX) b) Chartered Institute of Management and Supplies (CIPS) c) Mentoring d) Shadowing e) System Training Redesign the receipts and distribution area making it fit for purpose to allow for future direct deliveries from a wider range of suppliers. Introduce regular staff meetings with hot topics to focus on procurement innovation and development. Ensure the whole team are focused on Trust and Procurement Objectives. Develop a procurement handbook and provide procurement training to non-procurement staff. Develop an account management approach for the Care Groups. Form closer working relationships with the Care Group Finance Leads.
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7) PROCUREMENT WORKPLAN Mar-15 Jun-15 Sep-15 Dec-15 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 1 2 3 4 5 6 7 8 9 Infrastructure Strategy Approval Business Case Development & Approval Restructure of Supplies Department Stock management system review, business case and tender Stock management implementation Receipts and Distribution area re-design and improvement Procurement office re-design and improvement Efficiencies Develop and jointly agree with Finance savings definitions Develop and implement an efficiency database to hold both cashable and non-cashable savings. Have a fully documented audit trail of efficiency savings that have the support of the Care Groups. Ensure procurement CIP projects are reported to Care Groups along with other CIP schemes. Develop joint working between procurement and care group finance leads. Increase the efficiency target for Procurement to fund Business Case. Develop a regular report to the Director of Finance on the Procurement CIP progress. Leadership Board approval of the Procurement Strategy. Head of Procurement to engage in National Procurement initiatives Introduction of a Category Management approach within Procurement. Provide the Board with a procurement update annually. Brief the Executive and Non-Executive lead on procurement issues quarterly. Implement an account management structure for care groups. Develop and introduce a procurement handbook for staff induction and guidance. Staff development requirements identified and appropriate training provided.
Mar-15 Jun-15 Sep-15 Dec-15 Mar-16 Jun-16 Sep-16 Dec-16 Mar-17 1 2 3 4 5 6 7 8 9 Process Procure and implement an e-tendering and contract management system. Work with finance to ensure Trust Funds ordering and finances are on Agresso. Introduce products and Contracts onto Agresso master file and manage proactively. Web requisitioning is introduced Trust wide. Trust wide view of stock is in place linked to patient level costing. E-procurement systems are compliant with the latest DH e-procurement strategy. The Trust reports on the DH Procurement Dashboard on a quarterly basis. Sustainability is baselined and targets set. The Trust is GS1 compliant and has implemented throughout the Trust. Introduce a gateway for transmitting orders and e-invoices that enables PEPPOL compliance. Ensure every invoice has a purchase order number raised upfront and is matched for payment. Reduce confirmation orders by 50%. Groups have the ability to benchmark with others by implementing a spend analytics tool. Develop reporting capability and systems to enable reporting via the procurement dashboard. Integration with Agresso and EDC complete. Partnership
Procurement pipeline/workplan established with collaborative groups to ensure no duplication exists.
Clinical procurement groups in place for all major clinical procurements. Clinical Procurement Groups established and led by the Clinical Procurement Specialist. The groups will be chaired by a senior clinician relevant to the products or services being reviewed. Key suppliers are performance managed and have regular performance reviews. A recording method will be introduced to enable the Trust to capture spend with SME’s. A baseline will be set for the % of business carried out with SME’s. People Define role training requirements and recommend within the Business case.
Carry out training for staff. All staff to have regular 1-1's Personal objectives to be set and monitored as part of a regular appraisal. Introduce regular staff meetings Ensure the whole team are focussed on procurement objectives. Develop a procurement handbook and provide procurement training. Develop an account management approach for the Care Groups Form closer working relationships with the Care Group finance leads. Ensure the team has category management and business intelligence capability. 8) LORD CARTER RECOMMENDATIONS As published in the Lord Carter Report February 2016, the Trust will be implementing the following recommendations:
1. Produce a Every Trust should have a local Procurement Transformation Plan in place by October 2016 covering plans to meet the model hospital Procurement benchmarks, collaboration with other Trusts and the national solutions such as NHS Supply Chain . Trusts should consider the role Transformation collaborative procurement hubs could play in helping them achieve their model hospital benchmarks but without competing with the al Plan national provider 2. Publish Metrics Trusts focusing on the measure of key procurement metrics and being responsible for driving compliance to the following targets by September 2017: 80% addressable spend transaction volume on catalogue, 90% addressable spend transaction volume with a purchase order, 90% addressable spend by value under contract. 3. Collaboration Collaboration (i.e. sharing data and resources ) designed to modernise the procurement function with Trusts accelerating collaboration with with others to other Trusts to develop aggregated sourcing work plans to reduce variety (including NHS Supply Chain for their categories) for 2016-17 and improve in 2017-18 including contributing to clinically driven product testing and evaluation, and adopting the outcome pf these processes, Procurement switching products where appropriate, unless a clinically agreed exception exists 4. National Spend NHS Improvement providing a national spend analysis and benchmarking solution from high quality spend data to be fully operational by analysis and April 2107. This will include a purchasing pricing index staring with an initial basket of 100 products with immediate effect. NHS Benchmarking Improvement will hold trusts boards to account in performance against the index from October 2016. 5. Ensure effective All Trusts to prioritise the role of procurement on ensuring effective system control and compliance, building supply chain capability in system Control, terms of both inventory management systems and people. Trusts to aim to work in collaboration both with national procurement compliance and strategies and other trusts to explore common systems adoption e.g. efficient electronic catalogues using retail systems standards, building supply enhancing current purchase to pay systems, adopting (GS1) and Pan European Procurement Online (PEPPOL) standards detailed in the chain capability eProcurement Strategy, and to align with NHS Supply Chain on category initiatives. 6. Embrace the Trusts embracing the adoption and promotion of the NHS Standards of Procurement with the support of the new skills Development NHS Standards Networks, with those that have already achieved Level 1 achieving Level 2 of the standards by October 2018; and those trusts that are yet to of Procurement attain level 1 achieving that level by October 2017. All trusts to produce a self-improvement plan to meet their target standard by March 2017. 7. Align to NHS He plans are expected to be agreed with NHS Improvement and ideally Lord Carter would like to see alignment with NHS Improvement’s Improvement’s proposed regional structure. regional structure
9) IMPLEMENTATION OF LORD CARTER RECOMMENDATIONS The following table indicates when who and how the recommendations will be recommended:
# Carter Carter How When Who How Recommendation Objective Monitored or Reported 1 Produce a Procurement A local PTP by A published and disseminated PTP covering By October Head of Published Transformational Plan October 2016 plans to meet the model hospital 2016 Procurement document benchmarks, shared with others through collaboration with details of how we intend to improve service 2 Publish Metrics Measure key Using the NHS Procurement Dashboard By October Head of Quarterly procurement Reporting template to report monthly 2017 Procurement updates to metrics progress on doing it Well, Doing it Efficiently DOF and doing it Right. Targets by September 2017 An annual 80% addressable spend transaction report to the volume on Catalogues Board of 90% addressable spend transaction Directors volume with a PO 90% addressable spend by value under Contract 3 Collaboration with Collaboration to Sharing data, time and expertise with other From April Head of Publish others to improve improve Trusts and Hubs. Developing an aggregated 2016 Procurement Workplan on Procurement sourcing work plans where feasible, and the Intranet sharing our own work plans ( with NHS Supply Chain, NOECPC and CCS) Also working with ‘Working Together Group’ on joint procurement initiatives. 4 National Spend analysis Providing data Submitting all of our spend data to NHS From July E Procurement Data records and Benchmarking for the national Improvement (through our links with NHS 2016 Manager online spend analysis Supply Chain) Via PPIB (Uploading & benchmarking data onto
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(by April 2017) PPIB website of PO spend 5 Ensure effective system Ensuring The Trust aim to work in collaboration with By April 2017 Head of NHS Control, compliance and effective system both the national procurement strategy and Procurement Procurement building supply chain control and other trusts to explore common system Dashboard & capability compliance, adoption, and with the upcoming Carter model building supply implementation of the NHS SBS system to Hospital chain capability, explore common functionality it can provide. metrics in terms of both inventory mgt., By implementing the Genesis Stock system Commenced systems and and GHX catalogue system, moving to be April 16 people compliant with GS1 and PEPPOL. To include Stock management functionality.
6 Embrace the NHS Adoption and Produce a self-improvement plan to Head of By Standards of promotion of Procurement attainment Procurement the NHS Attain Level 1 October 2016 of the Standards of Attain Level 2 October 2017 Standard Procurement Attain Level 3 October 2018
Plan to include Using the Procurement Skills Development Network to improve the longer term resilience, leadership and capability of the Procurement Department 7 Align to NHS See alignment The Trust is already a member of NOEPC and tbc Head of tbc Improvement’s regional with NHS the Working Together Group. Continue with Procurement structure improvement’s these links and feed back into work carried proposed nationally by the NHS Customer Board to regional improve NHS Procurement structure (not yet published) REFERENCES
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(2013). Better Procurement, Better Value, Better Care. England: Department Of Health.
(2013). NHS Procurement Dashboard. England: Department of Health.
(2013). NHS Procurement Standards. England: Department of Health.
(2014). NHS e-Procurement Strategy. Engalnd: Department of Health.
(2014). Procurement Transparency. England: Department of Health.
(2014). Five Year Forward Review. England, NHS England
NOECPC. (2014). Overview of the Supplies Department at Doncaster & Bassetlaw Hospitals NHS Foundation Trust. NOECPC.
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Title Financial Performance – August 2016
Report to: Board of Directors Date: 27 September 2016
Author: Jeremy Cook (Interim Director of Finance)
For: Approval Purpose of Paper: Executive Summary containing key messages and issues
To update the Board on the financial position for the Month of August 2016. Recommendation(s) The Board is asked to NOTE that the reported financial position is a deficit of £7.6m.
The variance against plan for Month 5 is £2.8m favourable.
CIP performance is £3.6m year to date and is marginally above plan against the YTD stretch CIP target and £0.7m above original CIP target
Delivering the Values – We Care Not applicable Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
Due to the deficit the Trust is in breach of its license with Monitor
Board Assurance Framework 1 Failure to comply with the Monitor Risk Assessment Framework, 5 x 4 = 20 CQC and other regulatory standards, triggering regulatory action. 2 Failure to deliver the financial plan 5 x 5 = 25
3 Failure to deliver the cost improvement plan 4 x 5 = 20
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Finance Performance Board Report
Financial Year 2016/17 Month 5 (August 2016)
1 Content 1.1 Finance Overview 1.2 Finance Dashboard 1.3 Summary of Key Trends 1.4 Summary of Comprehensive Income 1.5 Income and Expenditure by Care Group 1.6 Summary Statement of Financial Position 1.7 Sources and Applications of Funds
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1.1 Finance Overview
The Trust submitted a revised annual plan to NHS Improvement in June showing a deficit of £24.7m. It is now forecasting to reduce this deficit by £8.7m to £16.0m by year end. The Month 5 financial position is £7.6m deficit against a revised planned deficit of £10.4m – a favourable variance of £2.8m. The position includes a £2.3m provision in expenditure to match planned YTD cost pressures that have yet to materialise. The key metrics are contained below in the Finance Dashboard. The key points to note in the Month 5 year to date (YTD) finance position are: • £0.9m under performance against the income plan. This includes £0.2m over performance in clinical income mainly due to A&E (£0.4m), maternity (£0.2m), Emergency (£0.2m) and other (£0.4m) offset by OP follow up caps penalty (£0.7m) and under performance against OP Procedures (£0.3m). Other income is underperforming by £1.1m mainly due to recharges (£0.8m) which is offset by underspend in expenditure and internally generated income (£0.3m) • £3.7m under spend against operational expenditure budgets compared to £2.6m in Month 4. This is mainly due to the improvement in run rate in pay (improvement in variance of £0.3m) and the management of reserves (improvement in variance of £0.7m) • £3.6m achievement of CIP YTD, an over performance of £0.7m against original YTD target and an over performance of £0.1m against the stretch target. This equates to CIP delivery of £8.7m in year and £8.9m full year effect. • Agency Spend in Month 5 was £5.6m YTD compared to YTD budget of £6.3m a favourable variance of £0.7m. The ceiling set by NHSi for this Trust is £13.5m for the year and a pro-rata of this to Month 5 YTD is £5.6m – equating to £29k spend below ceiling • The total Care Groups’ net budget position is favourable by £3.0m with the exceptions of MSK and Frailty with a net adverse variance of £0.6m, Specialty Services with a net adverse variance of £0.2m and Surgical with a net adverse variance of £0.2m in the main due to underperformance against clinical income plan to date. • Cash balance at the end of August was £5.0m. This is higher than the minimum cash balance of £1.9m due to the receipt of the 1st tranche of the Sustainability and Transformation Funding of £2.9m in August. The cash drawn down in August was £2.0m in line with the plan. Cumulatively the Trust has drawn down £10.6m against our plan of £10.3m. • Capital expenditure YTD is £4.2m against a plan of £4.6m. The slippage of £0.5m is due to Estates Investment (£0.4m) and Medical Equipment (£0.4m), other (£0.2m) offset by IT spend above plan (£0.7m) • Trade debtors at the end of August over 90 days overdue total to £2.7m. This has increased from last month by £0.4m. 3 1.2 Finance Dashboard (1)
Cumulative Cumulative Month 5 vs Plan to Actual to Variance to Variance to Month 4 Run Month 5 Month 5 Month 5 Month 4 Rate £'m £'m £'m £'m Deficit before technical adjustment (10.4) (7.6) 2.8 2.1 +ve Income 157.0 156.0 (0.9) (0.5) -ve Operating expenditure (inc CIP) (161.4) (157.8) 3.7 2.5 +ve Agency expenditure (6.1) (5.6) 0.5 0.6 +ve CIP performance against stretch target* 3.6 3.6 0.1 0.0 -ve Financing costs (4.7) (4.6) 0.1 0.1 +ve Cash balance 1.9 5.0 3.1 0.0 +ve Cash draw down (10.3) (10.6) (0.4) (0.4) - Capital expenditure (4.6) (4.2) 0.4 1.2 -ve Value to Value to Movement Month 5 £'m Month 4 £'m £'m Underlying deficit -8.7 -6.8 -1.9 -ve
Key Above plan with +/- 5% tolerance Greater than 5% below plan
* CIP performance against original target is £0.7m overperformance
4 1.2 Finance Dashboard (2)
Target Score Actual Score Variance Financial sustainability risk rating 1 2 1 Downside Upside £'m Base Case £'m £'m
Sensitivity analysis of deficit before technical adjustment -12.9 -16.0 -19.0 Annual Plan Forecast Forecast £'m Outturn £'m variance £'m Non recurrent consultancy costs -3.1 -2.3 0.8 Value to Balance Annual Plan Month 5 £'m available £'m Reserve funding 15.2 9.0 6.2 Value to Value to Movement Month 4 vs Month 5 £'m Month 4 £'m £'m Month 5 Run Trade debtors overdue greater than 90 days 2.7 2.3 0.4 -ve Trade creditors overdue greater than 90 days 0.0 0.0 0.0 - Month 4 vs Value to Value to Movement Month 5 Run Month 5 £'m Month 4 £'m £'m Rate Outpatient cap -0.7 -0.5 -0.2 -ve
5 1.3 Summary of Key Trends
6 1.4 Summary of Comprehensive Income
Month 5 2015/16 YTD vs. Forecast 2015/16 2016/17 Month 5 2016/17 Month 5 YTD 2016/17 2015/16 2016/17 Year End Outturn Plan Plan Actual Variance Plan Actual Variance Actual Variance Actual £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Income Clinical income 321,011 334,299 28,042 27,771 -271 140,120 140,178 58 133,958 6,220 335,419 Other income 26,712 30,441 2,264 2,210 -54 12,695 12,521 -174 6,450 6,071 29,123 Income recharges 9,848 10,294 830 698 -132 4,149 3,327 -822 4,169 -842 8,575 Total income 357,571 375,034 31,136 30,679 -456 156,964 156,026 -938 144,577 11,449 373,117
Expenditure Pay -247,909 -251,994 -20,953 -20,611 341 -105,112 -103,253 1,859 -102,253 -1,000 -245,976 Drugs -32,493 -33,348 -2,744 -2,647 98 -13,400 -13,162 239 -12,914 -248 -32,907 Clinical supplies & services -29,988 -28,592 -2,331 -2,392 -61 -11,651 -11,861 -211 -12,893 1,031 -28,926 Other non pay -57,616 -58,366 -4,836 -4,736 100 -24,158 -23,903 255 -23,722 -181 -57,787 Contingency and Reserves -664 -2,193 -564 -18 546 -2,959 -2,256 703 3,898 -6,155 0 Recharges -9,848 -10,294 -833 -696 137 -4,165 -3,324 841 -4,169 845 -8,535 Total expenditure -378,518 -385,338 -32,261 -31,099 1,162 -161,445 -157,758 3,686 -152,052 -5,707 -374,131
EBITDA -20,947 -10,304 -1,125 -420 705 -4,480 -1,733 2,747 -7,475 5,742 -1,565 Finance costs -15,410 -14,386 -1,189 -1,177 12 -5,890 -5,824 66 -6,381 557 -14,435 Impairment -10,382 0 0 0 0 0 0 0 -4,326 4,326 0 Deficit for the year -46,739 -24,690 -2,314 -1,597 716 -10,370 -7,557 2,813 -18,181 10,624 -16,000
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1.5 Income and Expenditure by Care Group
Income Expenditure
Net Budget August 2015 Budget to Actual to Budget to Actual to Position Reported Care Groups date date Variance date date Variance Variance Variance £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Children & Families Care Group 21,435 21,543 107 15,950 15,365 585 692 -675 Diagnostic & Pharmacy Care Group 5,621 5,852 231 13,892 14,027 -135 96 -77 Emergency Care Group 25,574 27,762 2,187 19,859 20,115 -256 1,931 -2,063 MSK & Frailty Care Group 30,334 29,516 -817 23,769 23,551 218 -600 -314 Specialty Services Care Group 26,487 25,645 -842 18,885 18,202 684 -158 -610 Surgical Care Group 28,768 27,801 -967 29,410 28,678 731 -236 -2,268 Corporate Directorates 3,660 3,555 -105 32,555 32,239 316 472 2,144 Recharges & Contingency 15,084 14,351 -732 7,124 5,580 1,544 812 3,179 Trust Total 156,963 156,025 -938 161,445 157,758 3,686 3,009 -685
8 1.6 Summary Statement of Financial Position
Cash 31 March As at 31st August 2016 2016 The cash balance at the end of Month 5 was £5.0m, higher than Actual Plan Actual Variance the planed £1.9m minimum cash balance required under the £'000 £'000 £'000 £'000 Non-current assets conditions of the cash support Intangible assets 2,937 2,446 2,302 (144) Property, plant and equipment 188,652 189,384 189,689 305
• The cash drawdown in August was £2.0m compared to the Trade and other receivables 1,592 1,601 1,592 (9)
plan of £2.0m. YTD variance is £0.4m more than planned. Total non-current assets 193,181 193,431 193,583 152
• The 2016/17 plan includes £29.1m of cash support from Current assets NHSI and is based on the Trust achieving the revised Inventories 5,474 5,500 6,280 780 Trade and other receivables 15,676 17,417 18,886 1,469 £24.7m control total. However, this requirement is Cash and cash equivalents 2,169 1,900 4,993 3,093 expected to drop by £8.7m to £20.4m in line with the Total current assets 23,319 24,817 30,159 5,342
Trust’s forecast outturn Non-current assets held for sale 300 - 300 300
Current liabilities Trade and other payables (32,029) (34,615) (37,267) (2,652) Property, Plant and Equipment (Capital) : Borrowings (2,775) (2,775) (2,775) - Variance has moved £0.65m in month resulting from the Provisions (524) (524) (524) - • Total current liabilities (35,328) (37,914) (40,566) (2,652) unplanned IT expenditure. Total assets less current liabilities 181,472 180,334 183,476 3,142
Non-current liabilities Debtors are above plan due to : Borrowings (59,037) (68,273) (68,659) (386) Provisions (728) (728) (666) 62 • Amounts due from the Charitable Fund including the Total non-current liabilities (59,765) (69,001) (69,325) (324)
Ophthalmology development. The Charity are continuing Total assets employed 121,707 111,333 114,151 2,818 with the planned phased disposal of their investments enabling payment to be received by the Trust. Financed by (taxpayers equity) Public dividend capital 128,780 128,780 128,780 - Revaluation reserve 29,939 29,939 29,939 - Creditors are above plan due to : Income and expenditure reserve (37,012) (47,386) (44,558) 2,828 Total taxpayers equity 121,707 111,333 114,161 2,828 • The provision in expenditure to match planned YTD cost pressures that have yet to materialise. 9
1.7 Source and Applications of Funds
The cash balance at the end of Month 5 was £5.0m. This is higher As at 30th August 2016 than planned due to the receipt of the 1st tranche of Sustainability and Transformation Funding (STF) of £2.9m, given Plan Actual Variance the uncertainty regarding the timing of the receipt this was £'000 £'000 £'000 ignored when requesting NHSi cash support as per their Sources guidance. Cash Support £10,250 £10,634 £384
Capital Expenditure is £0.4m lower than plan, this position Sources of Cash £10,250 £10,634 £384 includes £1.3m of accruals. Higher in month expenditure on Applications Microsoft Licences (£0.3) and the disputed Scanners (£0.2m), Surplus \ (Deficit) (£10,370) (£7,557) £2,813 both of which were unplanned, have offset the continuing underspends in Estates and Medical Equipment. Depn £3,766 £3,756 (£10) Capital programme (£4,586) (£4,184) £402 Financing Repayments (£1,263) (£1,296) (£33) The disposal of properties owned by the Trust is running behind PDC - - - the original plan. Disposal Proceeds £475 - (£475) Financing Activities (£1,608) (£1,724) (£116) The Creditors position includes the provision in expenditure to match planned YTD cost pressures that have yet to materialise Movement in Stock (£26) (£806) (£780) Movement in Debtors (£1,728) (£1,777) (£49) together with the capital accrual. The positive impact of these Movement in Creditors £2,750 £5,176 £2,426 higher accruals has been partial negated by the advanced Movement in Charitable Fund Debtor - (£1,433) (£1,433) payment of National Insurance in month. Other Movements £466 £311 (£155) Working Capital £1,462 £1,471 £9
The Charity are continuing with the planned phased disposal of Applications of Cash (£10,516) (£7,810) £2,706 their investments with over £2.0m requested in September to cover current and future cash demands. Amounts due from the Net Movement in Cash (£266) £2,824 £3,090 Charitable Fund include the impact of the Ophthalmology development and general admin costs. 10
Title Business Intelligence Report
Report to: Board of Directors Date: 27.09.2016
Author: David Purdue, Chief Operating officer Sewa Singh, Medical Director Richard Parker, Director of Nursing, Midwifery and Quality
For: Approval Purpose of Paper: Executive Summary containing key messages and issues The Business intelligence report highlights the key performance and quality targets required by the Trust to maintain Monitor compliance. The report focuses on the 4 main performance area for Monitor Compliance Cancer, measured on average quarterly performance 4hr Access, measured on average quarterly performance 18 weeks measured on monthly performance against active waiters, performance measured on the worst performing month in the quarter Infection Control based on an annual trajectory
The quality report focuses on the key indicators of infection control, mortality and gives specific focus into best practice tariffs, complaints and serious incidents.
The report reviews the actions being taken to address for all performance and quality indicators.
Recommendation(s)
To approve Delivering the Values – We Care (how the values are exemplified by the work in this paper)
We always put the patient first By ensuring the correct capacity and pathways are in place to allow for treatment in the right place, first time. To ensure quality care is at the centre of all we do to provide the most efficient service. Everyone counts – we treat each other with courtesy, honesty, respect and dignity By ensuring that all parties have contributed to the planning and delivery of services Committed to quality and continuously improving patient experience By delivering new ways of working across health and social care to ensure compliance withal quality indicators Always caring and compassionate
1 By ensuring staff are committed to working with partners to improve services. Responsible and accountable for our actions – taking pride in our work By being accountable for delivery of the efficient and effective services Encouraging and valuing our diverse staff and rewarding ability and innovation By ensuring engagement in planning and delivery of services Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks Resource – Key financial issues related to additional funding streams to support planning for surge capacity. Governance – The Trust needs to maintain compliance framework with monitor Equality and Diversity – No known issues or risks. PR and Communications – Need for continued appropriate communication to ensure ongoing performance Patient, Public and Member Involvement – Public attendance at System Resilience Groups Risk Assessment – The risks to the Trust’s performance are very high 2015/16, at this stage especially in relation to 4hr access NHS Constitution - Rights and Pledges – No known issues or risks.
Board Assurance Framework 1 Failure to achieve performance and compliance targets and processes 4x3 = 12
2 Failure to match capacity with demand, particularly during winter 4 x 4 = 16
3 Failure to maintain appropriate organisational corporate governance systems 5x 4 = 20
2 Doncaster and Bassetlaw Hospitals NHS Foundation Trust Board of Directors Meeting Performance - August 2016 - (Month 5)
Sewa Singh Medical Director Richard Parker Director of Nursing David Purdue Chief Operating Officer Jeremy Cook Interim Director Of Finance
Executive summary - Performance - August 2016
The performance report is against operational delivery in July/August 2016 Provide the safest, most effective care possible
Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to Treatment, which includes diagnostic waits and Cancer Targets. The targets are all monitored quarterly, both 4hr access and cancer are averaged over the quarter but referral to treatment is monitored each month of the quarter and must be achieved each month. The business intelligence report also highlights key National and local targets which ensure care is being provided effectively and safely by the Trust.
4hr Access The target is based on the number of patients who are treated within 4hrs of arrival into the emergency department and set at 95 and reported Quarterly as an average figure. This target is for all urgent care provided by the Trust for any patient who walks in. We have 2 type 1 facilities, ED at BDGH and DRI and 1 type 3 facility at MMH. The Trust does not count any GP admissions areas within its target. The rules on reporting changed in month and any breaches which occur after midnight are now classed on the day they breached rather than on the day of arrival. August Performance Trust 91.8% Quarter 2, 93.28%, currently 28th Nationally out of 138, National performance in August 88.9%
Key issues related to 2 main issues The continued increases in attendances August 2016 saw 811 more patients than in 2015. Acuity remains high with a conversion rate of 20.8% August changeover of staff severely affected performance in the first week of August particularly at the DRI site. Additional consultant time was made available by reducing elective work but additional trainees meant that areas were short.
DRI achieved 88.03%, if MMH were included Doncaster achieved 90.19%. 987 patients failed to be treated within 4hrs. 578 patients failed due to internal ED waits, 245 failed due to bed waits. 113 patients required to wait in the department due to their condition. 12% of patients were transferred to the urgent care centre in August. This equates to 20.7% of patients who arrived by FDASS.
Bassetlaw achieved 95.92%, 169 patients failed to be treated within 4hrs. 130 patients failed due to internal ED waits. On average 150 shifts are put out to locums each week for both EDs which shows the shortfall against establishments in the departments.
DRI hosted the 2nd NHSi improvement event on the 5th of September. Following this NHSi have requested the Trust to deliver a master class in patient flow and discharge pathways for the North of England. NHSi are also attending the Trust on the 5th of October to review the innovative smart ER concept devised by the lead for the Emergency Departments.
Ambulance Handover times though showing breaches continue to be the best performing in the South Yorkshire Trusts despite the increase in Ambulance attendances.
Referral to Treatment The target is now measured against incomplete pathways only at 92%. Fines for RTT have been lifted for 2016/17.
The PTL is in the process of being revalidated after the launch of CAMis
August, achieved 92.01% 4 specialities failed the target; General Surgery, 88.8% Urology 89.6% T&O 89.8% Medicine 91%
Individual action plans are in place for all 4 specialities to improve the position. Urology is as a result of a 17% increase in referrals General surgery, T&O and medicine is as a result of capacity.
The Trust is working as part of the SDIP, to ensure demand and capacity plans are in line with expected RTT performance.
2 patients identified in July with pathways over 52 weeks remain active at the end of August due to both wanting further delays in their treatments.
Diagnostic waits ended at 98.96% against the target of 99% The numbers waiting over 6 weeks was 78, the target was achieved in all radiology areas. The breach is a result of sickness issues in Audiology with an unprecedented 25 patients waiting over 6 weeks. The Trust target was missed by 2 breaches.
Cancer Performance All key cancer targets have been achieved in July New guidance for 28 day diagnosis is being worked up for each cancer pathway. Electronic referral pathways have been agreed for both lung and urology with STH.
Stroke The Stroke pathways have been reviewed against the income related to Best practice Tariff and the Trust is now receiving the correct income. Of the 40 discharged strokes in the month, 33 received the highest income stream with all patients receiving elements of best practice performance.
Cancelled Operations Cancelled operations performance, is those patients cancelled on the day of the procedure and is split into theatre and non-theatre cancellations. Theatre cancellations were impacted mainly in the month due to staff availability. Cancellations due to bed availability reduced to 8 across both sites.
David Purdue Chief Operating Officer August 2016
At a Glance -August 2016 (Month 5) Month Standard (Local, Current Month Actual Page Indicator Month Actual Data Quality RAG Rating Page Indicator Current Month Actual Month Actual (BDGH) National Or Monitor) Month (DRI) (TRUST) 31 day wait for second or subsequent treatment: surgery 94.0% M 100.0% % of patients achieving Best Practice Tariff Criteria Aug-16 61.7% 53.1% 80.0%
31 day wait for second or subsequent treatment: anti cancer drug treatments 98.0% M 100.0% Best Practice Criteria
31 day wait for second or subsequent treatment: radiotherapy 94.0% M 100.0% 36 hours to surgery Performance 70.2% 59.3% 93.3% 62 day wait for first treatment from urgent GP referral to treatment 85.0% M 86.6% 72 hours to geriatrician assessment Performance 91.4% 90.6% 100.0% 4-5 Jul-16 19 62 day wait for first treatment from consultant screening service referral 85.0% M 100.0% % of patients who underwent an MDT assessment 100.0% 100.0% 100.0%
FracturedNeck Femurof Aug-16 31 day wait for diagnosis to first treatment- all cancers 96.0% M 100.0% % of patients who underwent a falls assessment 97.8% 100.0% 93.0% Two week wait from referral to date first seen: all urgent cancer referrals (cancer 93.0% M 94.5% % of patients receiving a bone protection medication assessment 100.0% 100.0% 100.0% suspected) Two week wait from referral to date first seen: symptomatic breast patients (cancer 93.0% M 92.5% Mortality-Deaths within 30 days of procedure 0.00% 0.00% 0.00% not initially suspected)
Standard (Local, Page Indicator Current Month Month Actual Data Quality RAG Rating National Or Monitor) A&E: Maximum waiting time of four hours from arrival / admission / transfer / 6-7 95.0% M Aug-16 91.9% discharge (Trust) 4 Per Month for 20 Infection Control C.Diff Qtr 2 - 45 full M 1 year Aug-16
Monitor Compliance Framework Infection Control MRSA 0 L 0
Maximum time of 18 weeks from point of referral to treatment- incomplete pathway 92.0% M 92.0% 18 HSMR (rolling 12 Months) 100 N Jun-16 93.64
Never Events 0 L Aug-16 0 8-9 Aug-16 Safe VTE 95.0% N Jul-16 95.0%
% of Patients waiting less than 6 weeks from referral for a diagnostics test 99.0% N 98.96% 12 Per Month Pressure Ulcers L 5 144 full Year 20 2 Per Month 23 Total time in A&E: 4 hours (95th percentile) HH:MM 04:00 N 05:48 Falls that result in a serious Fracture L 0 full Year Aug-16 A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 09:58 Catheter UTI Snap shot audit 0.91% A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 03:59 Aug-16 A&E: Time to treatment decision (median) HH:MM 01:00 N 00:57
6-7 A&E unplanned re-attendance rate % 5.0% N 0.3% Page Indicator Current Month Rag Rating
A&E: Left without being seen % 5.0% N 4.0%
Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes 739 A&EPerformance Indicators Complaints received (12 Month Rolling) 554 Ambulance Handovers Breaches-Number waited over 30 & under 60 Minutes N Jul-16 40
Ambulance Handovers Breaches -Number waited over 60 Minutes 4 Proportion of patients scanned within 1 hour of clock start (Trust) 48.0% N 52.5% Proportion of patients directly admitted to a stroke unit within 4 hours of clock start Concerns Received (12 Month Rolling) 920 90.0% N 70.0% (Trust) Percentage of eligible patients (according to the RCP guideline minimum threshold) 90.0% N 100.0% given thrombolysis (Trust) Proportion of applicable patients receiving a joint health and social care plan on 90.0% N 77.1% 10-12 discharge (Trust) May-16
Stroke Percentage of patients treated by a stroke skilled Early Supported Discharge team 40.0% N 67.6% (Trust) Complaints Performance 29 Percentage of those patients who are discharged alive who are given a named 95.0% N 73.0% 21 Aug-16 person to contact after discharge (Trust) & Claims Complaints Implementation of Stroke Strategy - TIA Patients Assessed and Treated within 24 60.0% N 60.5% Hours Cancelled Operations 0.8% N 1.2% Clinical Negligence Scheme for Trusts (CNST) awaiting data Cancelled Operations-28 Day Standard 0 N 3 13 Aug-16 Out Patients: DNA Rate L 9.1% Liabilities to Third Parties Scheme (LTPS) awaiting data
L Out Patients: Hospital Cancellation Rate 6.4% Total number of open and active claims with the NHSLA (as at 31 May 2015) awaiting data Theatres & Outpatients L
e Emergency Readmissions within 30 days (PbR Methodology) L May-16 4.4% Claims per 1000 occupied bed days awaiting data Effectiv Monitor Compliance Framework: Cancer - July 2016 (Month 4)
Context Cancer targets are reported quarterly as an average position. Guidance for 62 day pathways has been published which clarifies internal transfer as day 38 for classic 62 day pathways. Performance measures are reported a month behind due to validation and National uploads.
Reasons for Success/Failure Two week wait and 62 day classic pathways achieved the standard at a Trust level but failed for Bassetlaw CCG. The Two week wait fail was as a result of patient choice, despite the processes in place to relay the importance of attending to the patients GP practice.
Actions being taken to address any issues The Trust reports weekly at the PTL all 62 day target performance Electronic system flags delays in individul pathways to the relevant consultant, MDT coordinator and performance manager are in place flagging at day 28. 30 and 50 Individual breach reports are discussed with the MDTs to ensure learning is in place Urology pathways follow Gold Standard Framework, internal processes for MRI and OPD booking reviewed and identified clinics and slots now in place Electronic transfer protocols now agreed with STH for transfer in Lung and Urology Improved access to diagnostics and cancer patients flagged through the diagnostic system. Changes to access from the NICE guidance has led to redesigned referral proformas and guidance to GPs Process mapping carried out on two week wait administration pathways to optimise the system. Patients being contacted when they delay their appointment outside of 14 days
QTR 1 2016- Indicator Standard Jul-15 May-16 Jun-16 Jul-16 17 31 day wait for second or subsequent treatment: surgery 94.0% 95.7% 100.0% 100.0% 100.0% 100.0% 31 day wait for second or subsequent treatment: anti cancer drug treatments 98.0% 100.0% 100.0% 100.0% 100.0% 100.0% 31 day wait for second or subsequent treatment: radiotherapy 94.0% 100.0% 100.0% 100.0% 100.0% 100.0% Tumor Type Breast 100.0% 100.0% 100.0% 100.0% 100.0% Gynaecological 100.0% 92.6% 100.0% 75.0% 81.8% Haematological 83.3% 100.0% 100.0% 100.0% 80.0% Head & Neck 80.0% 61.5% 50.0% 83.3% 0.0% Lower Gastrointestinal 71.4% 73.7% 85.0% 61.5% 64.3% 62 day wait for first treatment from urgent GP referral to treatment Lung 85.0% 80.0% 69.2% 40.0% 80.0% Other 100.0% 100.0% 100.0% Sarcoma 50.0% 66.7% 66.7% 0.0% Skin 96.6% 97.6% 100.0% 100.0% 100.0% Upper Gastrointestinal 73.3% 100.0% 100.0% 100.0% 85.7% Urological 70.3% 76.4% 79.1% 72.7% 78.6% All Cancers 84.0% 87.7% 89.7% 86.0% 86.6% Tumor Type Breast 100.0% 100.0% 100.0% 100.0% 100.0% Gynaecological 100.0% 100.0% Haematological Head & Neck Lower Gastrointestinal 83.3% 100.0% 100.0% 100.0% 62 day wait for first treatment from consultant screening service referral Lung 85.0% Other Sarcoma Skin Upper Gastrointestinal Urological All Cancers 100.0% 97.9% 100.0% 100.0% 100.0% 31 day wait for diagnosis to first treatment- all cancers 96.0% 98.6% 99.1% 99.4% 98.6% 100.0% Two week wait from referral to date first seen: all urgent cancer referrals (cancer suspected) 93.0% 93.2% 93.4% 93.1% 94.0% 94.5% Two week wait from referral to date first seen: symptomatic breast patients (cancer not initially suspected) 93.0% 93.1% 94.2% 95.8% 93.8% 92.5% Monitor Compliance Framework: Cancer - Graphs - July 2016 (Month 4) Monitor Compliance Framework: A&E - August 2016 (Month 5)
Context Trust achieved 91.8% in August, National Performance in August was 89%, Year to date position stands at 93.26%, which is the 28th best performing Trust out of 138.
Reasons for Success/Failure DRI performance ended at 88.03%, 987 patients failed to be treated in 4 hrs Bassetlaw performance ended at 95.92%, 169 patients failed to be treated within 4hrs Activity continues to increase with August seeing 811 more patients in 2016 than in August 2015.
Actions being taken to address any issues Patient flow processes have been reviewed following the Perfect Week to improve early discharge and improve flow out of the EDs The A number of initiatives are underway to improve staffing levels including training roles and overseas recruitment. A new consultant has been appointed who commences on the 26th of September. The MOU for agency cap breaks now agreed and signed with working together Trusts. Holt services commence on the 1st of October to improve locum availability. Medical rotas have been reviewed to match capacity and additional support staff put in place to improve flow in the department. Streaming from FDASS is being audited to identify pathways which can go directly to assessment areas and out of the hospital. Improved Trustwide escalation plans for internal ED processes have been agreed following process mapping in the department. Symphony in ED has been simplified to improve productivity of the medical staff in the department. Electronic discharge summaries are now in place for GP follow up. Ambulance delays have improved and joint working with both YAS and EMAS continues. The National A&E recovery plan, has been launched. A 90 day improvement methodology has started, with 4 learning events planned in the next 3 months.
Indicator Standard Aug-15 Qtr 1 2016-17 Jun-16 Jul-16 Aug-16 A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Trust) 94.5% 93.5% 92.3% 92.8% 91.9% A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Bassetlaw CCG) 96.1% 95.0% 94.0% 94.5% 95.4% 95.0% A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Doncaster CCG) 92.2% 91.9% 90.6% 91.0% 89.3% Total time in A&E: 4 hours (95th percentile) HH:MM 04:00 05:09 05:23 05:42 05:34 05:48 A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00 08:15 09:05 09:18 10:06 09:58 A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00 03:54 03:58 03:58 03:57 03:59 A&E: Time to treatment decision (median) MM 01:00 00:52 00:57 01:03 00:58 00:57 A&E unplanned re-attendance rate % 5.0% 0.4% 0.7% 0.3% 0.4% 0.3% A&E: Left without being seen % 5.0% 3.6% 3.7% 3.9% 3.8% 4.0% Indicator Standard Jul-15 Qtr 1 2016-17 May-16 Jun-16 Jul-16 Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes 699 2206 753 773 739 Ambulance Handovers Breaches -Number waited over 30 & under 60 Minutes 185 226 76 75 40 Ambulance Handovers Breaches -Number waited over 60 Minutes 10 147 12 11 4 Monitor Compliance Framework: A&E - Graphs - August 2016 (Month 5) Monitor Compliance Framework: 18 Weeks & Diagnostics -August 2016 (Month 5) Context
National reporting changes for RTT have come into effect from October 2015 are: 1. Removal of the submission of Admitted Adjusted Clock Stops (only Non-Admitted and Admitted (Unadjusted) are submitted but no target applies). 2. Additional item submitted on the number of “Incomplete Pathways with a Decision to Admit for Treatment” (no target applies) 3. Additional item submitted on the number of “New RTT Periods” in the month (number of clock starts in the month).
Reasons for Failure (if applicable) Incomplete pathways in August ended at 92.01% 4 specialities failed to meet the 92% target, Gen Med 91% General Surgery 88.8% Urology 89.6% T&O 89.8% 2 patients waited over 52 weeks, these are both patients who were over 52 weeks in July and have continued to request delays in their treatment. Diagnostic waits failed at 98.96%, radiology acheived the target at 99.3%. The failure is a result of increased breaches in Audiology due to sickness. Actions being taken to address any issues General medicine is related to gastroenterology capacity gaps. A review of current pathways is being undertaken with both CCGs General Surgery performance has been adversely affected by the lack of junior medical staff at BDGH, which meant the reduction in operting capacity on the Bassetlaw site. A first assistant is now appointed which will increase elective surgery at BDGH. A review of orthopaedic productivity is underway, detailed work with the commissioners in in progress to review orthopaedic pathways Urology demand has been raised with the commissioners and alternative pathways are being reviewed to increase internal capacity The validation of the illogical pathways is down at 40 weeks with no further patients currently identified.
Expected date to meet Indicator Standard Jun-15 Qtr 1 2016-17 Jun-16 Jul-16 Aug-16 standard Maximum time of 18 weeks from point of referral 92.0% 93.50% 92.80% 92.80% 92.60% 92.01% Standard Met to treatment- incomplete pathway Expected date to meet Indicator Standard Jun-15 Jun-16 Jul-16 Aug-16 standard
% of Patients waiting less than 6 weeks from 99.0% 99.40% 99.60% 99.23% 98.96% referral for a diagnostics test Standard Met Diagnostics Waits 35 33 56 78 Monitor Compliance Framework: 18 Weeks & Diagnostics -August (Month 5) Stroke -May 2016 (Month 2) Context
Stroke Targets are now reported against the SSNAP data, and 90% on a stroke unit is no longer collected
Reasons for Failure (if applicable)
The key pathway remains direct admission to a stroke unit, this months performance levels are based on 48 discharges in the month. 29 patients were directly transferred within 4hrs, an additional 5 patients were admitted within 4hrs.20mins and a further 6 within 4hrs 50mins. 5 patients were admitted after 10 hrs as their presenting symptoms were not suggestive of a stroke then 93.8% would have been admitted.
Actions being taken to address any issues The new assessment beds on the stroke unit are in operation. The overall number of stroke beds has increased to 49 across the Trust Improved teaching in ED, to identify the key signs of strokes Pathways for the stroke service out of the hospital to MMH and early supported discharge are being reviewed to ensure adequate bed capacity
Indicator Standard Jun-15 Qtr 1 2015-16 Apr-16 May-16 Jun-16
Proportion of patients scanned within 1 hour of clock start (Trust) 48.0% 43.4% 42.9% 52.5% Proportion of patients directly admitted to a stroke unit within 4 hours of clock start 90.0% 88.7% 69.6% 70.0% (Trust) Data Percentage of eligible patients (according to the RCP guideline minimum threshold) given 90.0% N/A Data currently 100.0% 100.0% currently thrombolysis (Trust) unavailable, still unavailable, Proportion of applicable patients receiving a joint health and social care plan on discharge 90.0% N/A undergoing 87.5% 77.1% still (Trust) validations undergoing Percentage of patients treated by a stroke skilled Early Supported Discharge team (Trust) 40.0% N/A 73.6% 67.6% validations
Percentage of those patients who are discharged alive who are given a named person to 95.0% N/A 79.2% 73.0% contact after discharge (Trust)
Implementation of Stroke Strategy - TIA Patients Assessed and Treated within 24 Hours 60.0% 73.9% 66.4% 66.7% 60.5% 71.8% Stroke - Graphs May 2016 (Month 2) Stroke - Graphs South Yorkshire January - March 2016
January - March 2016 is the latest available data. Theatre & Outpatients -August 2016 (Month 5) DNA Rate: Benchmarking data taken from Healthcare Evaluation Data (HED) (May 2015 to April 2016)
Qtr 1 Indicator Standard Aug-15 Jun-16 Jul-16 Aug-16 2016-17
Cancelled Operations (Total) 0.8% 1.7% 1.3% 1.4% 1.2% 1.1% Cancelled Operations (Theatre) 1.1% 1.0% 0.9% 0.9% 0.8% Cancelled Operations (Non Theatre) 0.7% 0.3% 0.6% 0.3% 0.2% Cancelled Operations-28 Day Standard 0 1 9 2 1 3 Outpatients: DNA Rate Total (Refreshed Each 9.14% 9.20% 10.27% 9.11% 9.01% Month) Outpatients: DNA Rate First (Refreshed Each 9.63% 9.29% 10.08% 9.40% 9.24% Month) Outpatients: DNA Rate Follow Up (Refreshed Each 8.94% 9.16% 10.36% 8.97% 8.90% Month) Outpatients: Hospital cancellation Rate (Refreshed N/A 10.42% 6.77% 6.40% 6.99% Each Month) Outpatients: Patient cancellation Rate (Refreshed N/A 11.81% 10.18% 10.71% 9.89% Each Month) Outpatients: Patient died cancellation Rate N/A 0.00% 0.00% 0.00% 0.00% (Refreshed Each Month) * Please note cancellation data has changed to reflect cancelltions made within 14 days of the appt. Facility unavailable in McKesson PAS so comparative data will not be available until Oct 16 * Did not wait data is currently unavailable Bed Plan 2016/17
Bed capacity has been difficult at times at DRI. Escalation beds have been used appropriately to manage flow with a number of closed beds open on occasion to manage capacity. Work continues with the wider system to review admission avoidance schemes. The intermediate care review is looking initially at emergency admissions to identify key pathways were admission to a secondary care bed can be avoided. April May June July August Sept Oct Nov Dec Jan Feb March DRI
Bed requirement for medical and care of the elderly patients based on current length of stay per month, statistical process control methodology used to review special cause variation. 248 253 267 239 236 241 259 243 279 273 266 239
Bed capacity is based on the Trust achieving length of stay reductions in line with benchmarked Trusts 235 235 235 235 235 235 235 235 235 235 235
Specialty medicine bed requirement ( Cardiology, stroke, Renal, Diabetes, Haematology) 72 67 66 74 64 71 90 69 64 78 68 72
Specialty beds available 90 90 90 90 90 90 90 90 90 90 90 90
Total medical patient beds required 310 320 357 313 300 312 349 312 343 353 334 311
Beds position against funded 15 5 -22 12 25 13 -24 13 -18 -28 -9 14
Surgical Bed requirements, includes new pathways for Bassetlaw patients 75 69 72 73 87 70 76 77 76 74 75 76
Surgical beds capacity 79 79 79 79 79 79 79 79 79 79 79 79
Specailty surgical bed requirements urology and vascular 32 34 35 37 31 33 35 29 31 26 27 31
Specialty bed capacity 39 39 39 39 39 39 39 39 39 39 39 39
Total surgical bed requirements 107 103 107 110 118 103 111 106 107 100 104 107
Bed position against funded 11 15 11 8 0 15 7 12 11 18 14 11
Orthopaedic Bed requirements 60 62 60 56 59 58 56 57 51 48 59 55
Total beds available taking into consideration of the new models of care 70 70 70 62 62 62 62 62 62 62 62 62
Bed position against funded 10 8 10 6 3 4 6 5 11 14 3 7
Gynaecology bed requirement including breast services 13 12 12 11 12 14 13 11 11 11 11 15 Gynaecology beds available including daycase 24 24 24 24 24 24 24 24 24 24 24 24 Beds against funded 11 12 12 13 12 10 11 13 13 13 13 9
Total adult bed requirement against funded beds 47 40 11 39 30 42 0 17 27 17 22 44
Paediatric bed requirement 16 22 17 17 14 13 13 17 20 18 15 16
Paediatric Beds Available 39 39 39 39 39 39 39 39 39 39 39 39
Bed against funded 23 17 22 22 25 26 26 22 19 21 24 23
Bassetlaw Medicine bed requirements 101 86 99 95 94 94 103 98 108 90 97 98 Medical beds available 104 104 104 104 104 104 104 104 104 104 104 104
Beds against funded 3 18 5 11 10 10 1 6 -4 14 7 6
Surgical Elective Requirements 7 7 8 10 11 11 10 11 10 12 11 10 Surgical beds open Monday to Saturday am 16 16 16 16 16 16 16 16 16 16 16 16 Beds agsinst funded 8 4 9 6 5 5 8 4 10 8 5 5
Orthopaedic bed requirements 18 24 23 23 25 19 21 23 22 19 21 24 Orthopaedic beds available 31 31 31 31 31 31 31 31 31 31 31 31 Beds against funded 13 7 8 8 6 12 10 8 9 12 10 7
Bed total available 126 117 130 128 130 124 134 132 140 121 129 132
Bed difference against beds 25 34 21 23 21 27 17 19 11 30 22 19
Paediatric bed requirements for inpatient care 7 9 7 7 6 8 9 10 11 9 8 8 Paediatric beds available 14 14 14 14 14 14 14 14 14 14 14 14 Beds against funded 7 5 7 7 8 6 5 4 3 5 6 6 Medical Outliers by Specialty -August 16 (Month 5)
Most Sleepers-out in Least Sleepers-out Daily average July 2016 in July 2016 Medicine to Ortho 6 18 0 Medicine to S12 3 6 1 Medicine to Surgery 12 19 6 Medicine to Gynae 6 11 3
Executive summary - Safety & Quality - August 2016 (Month 5)
HSMR: Rolling 12 month HSMR at the end of June 2016 remains below expected at 93.6. However, there has been an increase in elective HSMR in the month of June which we are investigating. Rolling 12 month elective HSMR remains below 100. Rolling 12 month SHMI at the end of March 2016 remains at 100.
Fractured Neck of Femur: Overall Trust achievement of BPT remains at 60% with BDGH performing better than DRI. The issue at DRI is theatre capacity. Mortality compares favourably with the national benchmark.
Serious Incidents: There were no SIs reported in August as aresult of falls and the Trust remains on trajectory to achieve a reduction in SIs this year.
Executive Lead: Mr S Singh
Hospital Acquired Pressure Ulcers : Performance continues to be ahead of trajectory and significantly better than at the same point in 2015/ 2016
C.Diff: Performance continues to be ahead of trajectory and better than at the same point in 2015/ 2016 Fall resulting in significant harm: Performance is ahead of trajectory and is now slightly ahead of the position in 2015/ 2016
Complaints and concerns: Response rates continue to be below the expected standards and improvement work is continuing as the restructuring of the Patient Safety and Experience Teams is completed. Friends & Family Test: Work to improve response rates in ED are continuing.
Executive Lead: Mr R Parker Hospital Standardised Mortality Ratio (HSMR) - June 2016 (Month 3)
Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months) 110 110 110 97 100 105 105 90
80 100 100 70
93.64 60 95 95 50 93.58 90 90 40 Jul 15 - Jun Jul 15 - Jun 16 Jul 15 - Jun 16 Aug 14 - Jul 15 Aug 14 - Jul 15 Feb 15 - Jan 16 Aug 14 - Jul 15 Jan 15 - Dec 15 Feb 15 - Jan 16 Oct 14 - Sep 15 Apr 15 - Mar16 Apr 15 Jan 15 - Dec 15 Oct 14 - Sep 15 Feb 15 - Jan 16 Nov Oct14 15 - Sep 14 - Aug 15 Jan 15 - Dec 15 Oct 14 - Sep 15 Nov Oct14 15 - Sep 14 - Aug 15 Jun 15 - May 16 Dec 14 - Nov 15 Mar 15 - Feb 16 Apr 15 - Mar 16 May 15 - Apr 16 Jun 15 - May 16 Nov Oct14 15 - Dec 14 - Nov 15 Mar 15 - Feb 16 Sep 14 - Aug 15 May 15 - Apr 16 Apr 15 - Mar 16 Jun 15 - May 16 Dec 14 - Nov 15 Mar 15 - Feb 16 May 15 - Apr 16
HSMR Trend (monthly) Crude Mortality (monthly) - August 2016 (Month 5) (number of deaths/number of patient discharged) Crude Mortality Crude Mortality 0.022 (DRI) 2014 2015 2016 (Trust) 0.019 January 115.45 116.80 99.91 2.0% 0.016 0.013 February 99.11 99.94 97.71 0.01 March 102.91 90.54 98.44 1.8% April 110.49 105.91 91.84
1.6% Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May 90.93 101.15 100.07 May-16 June 113.74 80.27 91.20 1.4% July 109.94 92.56 Crude Mortality August 120.18 100.27 1.2% 0.025 (BDGH) September 110.10 90.26 1.0% 0.015 October 106.58 90.29 November 106.84 88.98 0.005 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15
December 115.87 82.30 Aug-16 Nov-15 Mar-16 May-16 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May-16
Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trust 1.32% 1.34% 1.31% 1.52% 1.78% 1.79% 1.76% 1.36% 1.49% 1.31% 1.43% 1.39% Doncaster 1.50% 1.40% 1.42% 1.66% 1.94% 1.99% 1.74% 1.51% 1.51% 1.36% 1.64% 1.61% Bassetlaw 1.21% 1.55% 1.26% 1.49% 1.69% 1.62% 2.12% 1.33% 1.82% 1.48% 1.22% 1.17% NHFD Best Practice Pathway Performance - July 2016 (Month 4)
Best Practice Criteria Performance 36 Hours to Surgery Performance MDT Assessment Performance
100% 100% 100% 90% 80% 80% 90% 70% 60%
60% 40% 80% 50% Jul-16 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Jan-16 Aug-16 Jun-16 Nov-15 Oct-15 Apr-16 Mar-16 Sep-15 Feb-16 Dec-15 May-16 Aug-16 Nov-15 Mar-16 40% May-16 Trust DRI BDGH Trust DRI BDGH 30% 20% 72 Hours to Geriatrician Assessment Performance Falls Assessment Performance 10% 0% 100% 100%
80% Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May-16 90% 60% % achieving best practice tariff criteria (Trust) 40% 80% % achieving best practice tariff criteria (DRI) Jul-16 Jul-16 Jan-16 Jun-16 Oct-15 Jan-16 Apr-16 Sep-15 Feb-16 Jun-16 Dec-15 Oct-15 Aug-16 Apr-16 Nov-15 Sep-15 Feb-16 Dec-15 Mar-16 Aug-16 Nov-15 May-16 Mar-16 % achieving best practice tariff criteria (BDGH) May-16 Trust DRI BDGH Trust DRI BDGH
Bone Protection Medication Assessment Deaths within 30 days of procedure (Rolling 12 months) 8% 100% 7%
90% 6% 5% 80% 4%
Jul-16 3% Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May-16
Trust 2% 1% 0% Jul 15 - Jun 16 Aug 15 - Jul 16 Feb 15 - Jan 16 Jan 15 - Dec 15 Oct 14 - Sep 15 Nov Oct14 15 - Sep 15 - Aug 16 Sep 14 - Aug 15 Apr 15 - Mar 16 Jun 15 - May 16 Dec 14 - Nov 15 Mar 15 - Feb 16 May 15 - Apr 16
Trust (rolling 12 months) DRI (rolling 12 months) BDGH (rolling 12 months) Trust Benchmark Data Serious Incidents - August 2016 (Month 5) (Data accurate as at 08/09/16) Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed. Overall Serious Incidents
Number Serious Incidents Reported Serious Incidents per 1000 occupied bed days (Trust & Care Group) 0.9 25 0.8 20 0.7
15 0.6 0.5 10 0.4 5 0.3 0 0.2 0.1 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May-16 0 Emergency Care Group MSK & Frailty Care Group Surgical Care Group Children & Family Services Diagnostic & Pharmacy Speciality Services Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Feb-16 Sep-15
Number Reported SI's Number Reported SI's - Previous years performance Dec-15 Aug-16 Nov-15 Mar-16 May-16
Current YTD reported SI's (Apr 16 -Aug 16) 29 Number reported SI's (Apr 15 - Jun 15) 68 Reported Si's per 1000 occupied bed days Reported Si's per 1000 occupied bed days - Previous years performance Current YTD delogged SI's (Apr 16 - Jun 16) 5 Number delogged SI's (Apr 15 - Jun 15) 27 Themes Serious Falls Care Issues Pressure Ulcers - Category 3 & 4 (HAPU)
0.09 0.4 0.3 0.08 0.35 0.25 0.07 0.3 0.06 0.2 0.25 0.05 0.2 0.15 0.04 0.15 0.03 0.1 0.02 0.1 0.05 0.01 0.05
0 0 0 Jul-16 Jul-16 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Sep-15 Feb-16 Jan-16 Dec-15 Jun-16 Jan-16 Aug-16 Oct-15 Jun-16 Apr-16 Nov-15 Sep-15 Feb-16 Oct-15 Mar-16 Apr-16 Dec-15 Sep-15 Feb-16 Aug-16 Dec-15 May-16 Nov-15 Aug-16 Mar-16 Nov-15 Mar-16 May-16 May-16
Serious Falls per 1000 occupied bed days Care Issues per 1000 occupied bed days Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days Monitor Compliance Framework: Infection Control C.Diff - August 2016 (Month 5) (Data accurate as at 14/09/2016)
Standard Q1 Jul Aug YTD 2016-17 Infection Control - C-diff 40 Full Year 7 3 1 11 2015-16 Infection Control - C-diff 40 Full Year 9 3 1 13 2016-17 Trust Attributable 12 0 0 0 0 2015-16 Trust Attributable 12 3 0 0 0
C-diff 2016-17 Trust Attributable C-diff 2016-17 50 15 40 10 30 20 5 10 0 0 Jul Jul Jan Jun Oct Apr Jan Sep Feb Jun Dec Oct Aug Apr Sep Feb Nov Dec Mar Aug Nov May Mar May
2016-17 C-diff Cumulative total 2015-16 C-diff Cumulative total Standard 2016-17 Trust Attributable Cumulative Total 2015-16 Trust Attributable Cumulative Total Standard
Pressure Ulcers & Falls that result in a serious fracture - August 2016 (Month 5) (Data accurate as at 09/08/2016)
Falls that result in a serious fracture 15
Standard Q1 Jul Aug YTD 10 2016-17 Serious Falls 19 Full Year 1 2 0 3 2015-16 Serious Falls 20 Full Year 3 0 1 4 5 0 Please note: At the time of producing this report the number of serious falls reported are prior to Jul Jan Jun Oct Apr Sep Feb Dec Aug Nov Mar the RCA process being completed. May
2016-17 Falls Cumulative Total 2015-16 Falls Cumulative Total Standard
Pressure Ulcers (Ungradeable, Cat 3 & Cat 4) 90 75 60 45 Standard Q1 Jul Aug YTD 30 15 2016-17 Pressure Ulcers 60 Full Year 7 1 5 13 0
2015-16 Pressure Ulcers 82 Full Year 29 Jul Jan
22 5 2 Jun Oct Apr Sep Feb Dec Aug Nov Mar May
Please note: At the time of producing this report the number of pressure ulcers reported are prior to the RCA process being completed. 2016-17 Pressure Ulcer Cumulative Total 2015-16 Pressure Ulcer Cumulative Total Standard Complaints & Claims - August 2016 (Month 5) (Data accurate as at 15/08/2016) Complaints Complaints Received Concerns Received 90 120 August2016 Year to Date 80 100 Complaints Recieved Complaints Recieved 70 Risk Breakdown Risk Breakdown 60 80 50 60 40 30 40 Low Risk 20 Moderate Risk 20 10 High Risk 0 0 42552 42583 42552 42583 Jul 2014 Jul 2015 Jul 2014 Jul 2015 Jan 2015 Jan 2016 Jun 2014 Jun 2015 Jun 2016 Jan 2015 Jan 2016 Oct 2014 Oct 2015 Jun 2014 Jun 2015 Jun 2016 Apr 2014 Apr 2015 Apr 2016 Sep 2014 Feb 2015 Sep 2015 Feb 2016 Oct 2014 Oct 2015 Dec 2014 Dec 2015 Apr 2014 Apr 2015 Apr 2016 Sep 2014 Feb 2015 Sep 2015 Feb 2016 Aug 2014 Aug 2015 Dec 2014 Dec 2015 Nov 2014 Nov 2015 Aug 2014 Aug 2015 Mar 2015 Mar 2016 Nov 2014 Nov 2015 Mar 2015 Mar 2016 May 2014 May 2015 May 2016 May 2014 May 2015 May 2016 Complaints Mean UCL LCL Concerns Mean UCL LCL Complaints - Resolution Perfomance Parlimentary Health Service Ombusdman (PSHO) (% achieved resolution within timescales)
Complaints Resolution Performance Number of cases 70% Month referred for Number Currently Oustanding investigation 60% August 0 5 50% Number referred for 40% Outcomes investigation YTD 30% YTD Fully / Partially Upheld 3 20% Not Upheld 4 2015/16 14 No further Investigation 10% 1 Case Withdrawn 1 0% Fully / Partially Upheld 0 Not Upheld 0 2016/17 0
Jul-16 No further Investigation Jan-16 Jun-16 0 Oct-15 Apr-16 Sep-15 Feb-16 Dec-15 Aug-16 Nov-15 Mar-16 May-16 Case Withdrawn 0 Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over deadlines are excluded data. Claims Number of Claims per 1000 Occupied bed days Current Month Month Actual YTD 0.9 0.8 0.7 Awaiting data Clinical Negligence Scheme for Trusts (CNST) Aug-16 Awaiting data 0.6 0.5 0.4 Liabilities to Third Parties Scheme (LTPS) Aug-16 Awaiting data Awaiting data 0.3 0.2 0.1 0 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Feb-16 Sep-15 Dec-15 Aug-15 Nov-15 Mar-16 May-16 Friends & Family - August 2016 (Month 5) (Data accurate as at 13/08/2016) Inpatients
Please note: At the time of producing this report no further benchmarking data is available from NHS England.
Response Rates (%) Likely to recommend (%) 40% 0.975 0.97 30% 0.965 0.96 20% 0.955 10% 0.95 0.945 0% 0.94 Jul-16 Jul-16 Jan-16 Jan-16 Jun-16 Jun-16 Oct-15 Oct-15 Apr-16 Apr-16 Feb-16 Sep-15 Feb-16 Sep-15 Dec-15 Dec-15 Aug-16 Aug-15 Nov-15 Nov-15 Mar-16 Mar-16 May-16 May-16 Trust England Trust England
Accident & Emergency
Please note: At the time of producing this report no further benchmarking data is available from NHS England.
Response Rates (%) Likely to recommend (%) 16% 0.95 14% 12% 0.9 10% 8% 0.85 6% 4% 0.8 2% 0% 0.75 Jul-16 Jul-16 Jan-16 Jun-16 Oct-15 Apr-16 Feb-16 Sep-15 Jan-16 Dec-15 Jun-16 Aug-15 Oct-15 Nov-15 Apr-16 Feb-16 Sep-15 Mar-16 Dec-15 Aug-16 May-16 Nov-15 Mar-16 May-16 Trust England Trust England
Title Nursing Workforce Information
Report to: Board of Directors Date: 27 September 2016
Author: Richard Parker - Director of Nursing, Midwifery and Quality Moira Hardy – Deputy Director of Nursing, Midwifery and Quality
For: Information Purpose of Paper: Executive Summary containing key messages and issues
This paper updates the Board of Directors on key issues relating to the Nursing Workforce, using information from the September 2016 UNIFY return which relates to August actual and planned hours:
Workforce information and variances between planned and actual hours worked Care Hours Per Patient Day (CHPPD) implementation as set out in Lord Carter’s report; Operational productivity and performance in English acute hospitals: Unwarranted variations Update Workforce information and Quality and Safety profile meeting requirements of NHS England (NHSE), including How to ensure the right people, with the right skills, are in the right place at the right time (2013) and Safe staffing for nursing in adult inpatient wards in acute hospitals (2014) relating to Hard Truths Update of Trust position regarding safe nurse staffing and efficiency (Agency Capping) from TDA, Monitor, NHSE, CQC and NICE Key issues and actions
Recommendation(s)
The Board of Directors is asked to NOTE the content of this paper and SUPPORT the actions identified to ensure that the risks associated with inappropriate nurse staffing levels are appropriately managed.
Delivering the Values – We Care (how the values are exemplified by the work in this paper)
We always put the patient first By delivering safe and effective care by providing staff who can be responsive and well led Everyone counts – we treat each other with courtesy, honesty, respect and dignity By listening to staff and patients when developing and evaluating quality and safety of care. Monitoring that care is delivered with compassion Committed to quality and continuously improving patient experience By developing and monitoring safe staffing levels and the quality of care provision Always caring and compassionate By providing staff with the right skills and ensuring that they are in the right place at the right time. We monitor care is delivered with compassion Responsible and accountable for our actions – taking pride in our work By assuring ourselves that the quality of care meets the CQC standard. Having escalation processes in
2 place when staffing, safety and quality vary from optimum levels Encouraging and valuing our diverse staff and rewarding ability and innovation By setting up systems and processes that avoid duplication and reward good practice Related Strategic Objectives
Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement Develop responsibly, delivering the right services with the right staff
Analysis of risks
Risks associated to the inability to recruit to establishment and develop staff to provide harm free care, delivered with compassion and of appropriate quality.
Risk associated with not meeting regulatory and commissioner requirement.
Board Assurance Framework 3 Failure to deliver financial plan. 4 x 5 = 20
13 Inability to recruit the right staff and ensure that staff have the right skills to meet 4 x 3 = 12 operational needs.
3 1. INTRODUCTION
This paper provides the Board of Directors with detailed information relating to the Nursing Workforce; highlighting issues which may impact upon the Trusts ability to provide appropriate staffing levels and skill mixes. It also updates the Board of Directors on the implementation on Care Hours per Patient Day (CHPPD), which has been a required national return since 01 May 2016 and the data submitted to UNIFY.
This report also provides the Board of Directors with the Trust position in relation to the agency and frameworks caps from TDA, Monitor, NHSE, CQC and NICE.
2. BACKGROUND
This paper provides the DBHFT Board of Directors with the relevant information to consider staffing levels and skill mixes across the Trust. It provides the planned and actual workforce information, along with the Care Hours per Patient Day (CHPPD) for August 2016, which has been submitted to the UNIFY system, with additional information relating to the August Quality Metrics dashboard for each ward, focusing on those areas that require improvement.
3. WORKFORCE INFORMATION
The workforce data submitted to UNIFY provides the actual hours worked in August 2016 by registered nurses and health care support workers compared to the planned hours. The Trusts overall planned versus actual hours worked in August was 98%; the same as July.
3a. Actual versus planned staffing levels (based on daily data capture)
The actual staffing levels for August were collected manually, mostly contemporaneously, and validated by the Matrons and Heads of Nursing (HoNs) retrospectively. The Matrons based the planned levels on the agreed planned staffing levels in the 2016/2017 funded establishments. The planned hours are adjusted each month to account for the number of days in the month. The fill rate includes shifts used to support escalation and closed beds.
Data collection for the planned staffing levels for intensive care, paediatric and midwifery areas has led to planned staffing levels being based on actual acuity and dependency requirements on a day by day basis to reflect occupancy levels.
The data for August 2016 (Appendix 1) demonstrates that the actual available hours compared to planned hours were; within 5% for 21 Wards (50%), 2 more than in July between 5% – 10% for 15 Wards (36%) 1 more than in July surpluses over 10% for 3 Wards (7%) 1 less than in July deficits over 10% for 3 Wards (7%) 2 less than July.
The 3 Wards where there were surpluses in excess of 10% of the planned hours; 25, 17 and Rehab 2, had higher than planned staffing levels due to;
provision of enhanced care in all three areas, with escalation and closed beds also being open on Ward 17 and 25
4 The 3 wards where there were deficits in excess 10% of the planned hours were; Labour Ward at Bassetlaw Hospital, B6, and ITU at BDGH. The lower than planned staffing levels were due to;
Acuity and dependency of patients on ward B6 allowed staff to be safely moved to support other clinical areas. Increased level of long term sickness absence in ITU at BDGH. Labour Ward at BDGH has long-term sickness issues as well as vacancies.
3b. Care Hours Per Patient Day (CHPPD)
The Lord Carter Review highlights the importance of ensuring that workforce and financial plans are consistent in order to optimise delivery of clinical quality and use of resources. The review recommended that care hours per patient day (CHPPD) data is collected monthly and for this to be collected daily from April 2017.
From 01 May 2016, CHPPD has become the principle measure of nursing and healthcare support worker deployment; and a similar approach will be introduced for medical staff and Allied Health Professionals (AHPs) to be in place by April 2017 (excluding non-acute areas). Measurement of AHPs is to ensure the right teams are in the right place at the right time, providing high quality, safe effective care.
Whilst previous measurements have informed the evidence base for staffing models, they may not have reflected varying staff allocation across the day, or included the wider multidisciplinary team. CHPPD provides a single consistent way of recording and reporting deployment of staff working on inpatient wards and is calculated by adding the hours of registered nurses to the hours of healthcare support workers, and dividing the total by every 24 hours of inpatient admission (or approximating 24 patient hours by counts of patients at 23:59hrs). To ensure skill mix and care needs are met CHPPD reports split out registered nurses and healthcare support workers.
Utilising actual versus planned staffing data submitted to UNIFY in August 2016 and applying the CHPPD calculation the care hours for August 2016 are;
Care Hours Per Patient Day (CHPPD) – August 2016 Site Name Registered midwives/ nurses Care Staff Overall BASSETLAW HOSPITAL 5.1 3.4 8.5 DONCASTER ROYAL INFIRMARY 4.2 2.9 7.1 MONTAGU HOSPITAL 2.3 2.4 4.7 TRUST 4.2 3.0 7.2
5 The CHPPD care hours data for the first four months of data collection (May 2016 – August 2016) is consistent;
The model ward portal will allow the Trust to compare our CHPPD to other trusts within a specialty and by ward to identify how we can improve our staff deployment and productivity. We have requested to be a pilot for this work.
3c. Safe Staffing and Efficiency
A cap of agency expenditure for registered general and specialist nursing staff, midwives and health visitors has been in place since October 2015. The annual ceiling for DBHFT has been set at the lowest level of 3% which is a reflection of the relatively low level of bank and agency usage when compared to the national picture. The August figure was slightly higher at 1.38% compared to the July position of 1.05%, but still well within the 3% cap.
Information relating to the use of off-framework, high cost nursing agency staff continues to be reported to NHSI on a weekly basis, as does the work to eliminate the use of off framework agencies so that the Trust is compliant with the guidance, with minimal breaches being reported each week.
3d. Nurse Manager Clinical Time
To ensure that the HoNs and Matrons have a visible presence in the clinical areas HoNs have identified that they are aiming to work at least one clinical shift a month in one of their clinical areas, with the Matrons working two clinical shifts a month. This information is collected as part of the monthly Hard Truths returns. In addition senior sisters/charge nurses are expected to have 2 days per week as managerial/supernumerary time and this information is also being recorded monthly.
The Clinical and Supervisory Time in August 2016 was:
Care Group HoN Clinical Time Matrons Clinical Time Ward Supervisory Time Surgical MSK and Frailty Specialty Service Emergency Obstetrics and Gynae Children’s
The majority of HoN’s and Matrons have undertaken their clinical time in order to support ward areas clinically, where this has not been achieved it has been due to annual commitments and cover arrangements.
6 The majority of senior sisters/charge nurses have been unable to completely maintain their 2 days a week supernumerary time as they have been working clinically due to staffing pressures.
3e. Quality and Safety Profile
The Quality Metrics (appendix 1) for adult wards include 15 indicators that cover each of the five CQC Key Assessment Criteria (safe, effective, caring, responsive and well led). These were agreed by the HoNs in April 2015, and remain the same for 2016/17, but with an adjusted baseline based on outturn in 2015/16 and revised trajectories for CDI, PU, falls with harm and multiple falls. Two wards have been assessed as red for quality in July; Ward 25 with the Respiratory Unit remaining red again this month.
Ward 25 has triggered red against the following quality metrics; multiple falls, FFT positivity and negativity of response, LoS, appraisal and SET. Pressure ulcers have also triggered amber. The respiratory unit has triggered red against the following quality metrics; falls resulting in harm, SI’s, FFT response rate, appraisal and SET. Safety thermometer, multiple falls and pressure ulcers have also triggered amber.
A quality summit was held for the respiratory unit last month with the Deputy Director of Quality and Governance and Matron and an action plan has been formulated and is being monitored. Some changes to systems and processes following the merger of Ward 26 and Ward 27 are required and the unit was 92% actual against planned staffing in August due to vacancies, which is felt to have impacted on quality. This position should improve in September when new registrants come into post.
A quality summit for Ward 25 will be undertaken by the Deputy Director of Quality and Governance with the Matron and Ward Manager who will formulate an action plan to address the quality areas.
Following discussions with the deputy Director of Quality and Governance and Head of Nursing regarding their quality metrics, ATC, who triggered red last month on the quality metrics have improved their rating to amber this month.
4. PLANNED ACTIONS AND KEY RISKS
The major issue facing most acute hospitals nationally, and locally, continues to be the challenge of filling qualified vacancies. The actions to mitigate the risks which have been detailed in previous papers are continuing, along with systems and processes to meet the expectations outlined in the safe staffing and efficiency correspondence. These are:
The Trust has put measures in place to reduce use of non-framework agencies and to minimise the breaching of the price cap Monitoring and use of escalation processes are in place to tightly control use of registered and non- registered agency usage Continue to progress the Non-Medical workforce utilisation programme as part of DBH Strategy and Improvement programme utilising enabling tools e.g. Calderdale Framework, including; . Challenging and reviewing skill mix to make better use of Non-registered staff exploring the development of extended roles . Reviewing the non-ward staff roles and responsibilities Provide comparison CHPPD data as this becomes available nationally
5. RECOMMENDATION
The Board of Directors is asked to NOTE the content of this paper and SUPPORT the identified actions.
7 APPENDIX 1: HARD TRUTHS September 2016 Paper Workforce /Quality/Safety Profiles August 2016 Data
WQAT annual WQAT annual Safe Effective Caring Responsive Well led Profile assessment 2015/6 assessment 2016/17
No of Quality Care Group Matron Ward Funded Total Total Total Total Total Workforce Rating Rating Dashboard Beds
Surgical NS B6 16 Jan-16 NS 20 27 Dec-15 NS 21 27 Jan-16 LM S12 20 Apr-16 RF SAW 21 Feb-16 LC ITU DRI 20 na Nov-15 LC ITU BDGH 6 na Jan-16
MSK and Frailty SS A4 24 Mar-16 SS B5 30.7 Feb-16 AH St Leger 35 Mar-16 AH 1&3 23 Nov-15 SS Mallard 16 Nov-15 SS Gresley 32 Feb-16 SS Stirling 16 Oct-15 KM Adwick (rehab2) 29 Feb-16 KM Wentworth (rehab1) 29 Feb-16
Specialty Service JP 18 12 Nov-15 JP 18 CCU 12 Oct-15 AW 32 18 Nov-15 AW 16 24 Nov-15 RM 17 24 Feb-16 JP CCU/C2 18 Nov-15 RM S10 20 Nov-15 RM S11 19 Dec-15
Emergency MH ATC 21 Dec-15 SS AMU 40 Feb-16 MH A5 16 Jan-16 MH C1 24 Dec-15 SC 24 24 Nov-15 SC 25 16 Nov-15 SC Respiratory unit 56 Nov-15
Children and Families AB SCBU 8 na na n/a AB NNU 18 na na n/a AB CHW 18 na n/a AB A3 14 na n/a AB COU/CSU 21 na n/a SS G5 24 Apr-16 SS M1 26 Nov-15 SS M2 18 Nov-15 SS CDS 14 na Oct-15 SS A2 18 May-16 SS A2L 6 na May-16
Trust Position
Footnote: Paediatrics undertake a patient experience survey but will move to utilising FFT
Title NHS Improvement Undertakings Tracker
Report to: Board of Directors Date: 27 September 2016
Author: Matthew Kane, Trust Board Secretary
For: Review and noting Purpose of Paper: Executive Summary containing key messages and issues
On 22 March 2016, it was reported to the Board that Monitor (now NHS Improvement) had concluded that there had been a breach of license and therefore enforcement action to remedy the breach was in order.
Monitor/NHS improvement therefore decided to accept undertakings from the Trust in relation to a number of areas, as well as adding an additional license requirement requiring the Trust to ensure it has sufficient and effective board, management and clinical leadership capacity and capability as well as appropriate governance systems and process to enable it to address breaches of its license and comply with the undertakings.
The attached tracker provides a breakdown of these undertakings, and a summary of progress against each one, providing the Board with oversight and highlighting any exceptions or concerns.
Recommendation(s)
To review and note the attached.
Delivering the Values – We Care (how the values are exemplified by the work in this paper)
We always put the patient first Through our commitment to demonstrating good standards of corporate governance at all levels of the organisation, and by planning to support the delivery of sustainable services. Committed to quality and continuously improving patient experience By ensuring that we implement best governance and compliance practice, from planning through to delivery. Responsible and accountable for our actions – taking pride in our work By ensuring that our governance arrangements support effective challenge and accountability at board level.
Related Strategic Objectives
Control and reduce the cost of healthcare Develop responsibly, delivering the right services with the right staff
1
Analysis of risks
Further breach of the Trust’s license, or of any of the undertakings, may result in enforcement action by NHS Improvement.
Board Assurance Framework 1 Failure to achieve compliance with financial performance aspects of the Monitor 5 x 4 = 20 Risk Assessment Framework and provider license, triggering regulatory action 2 Failure to deliver accurate financial reporting underpinned by effective financial 4 x 4 = 16 governance 3 Failure to deliver financial plan 4 x 4 = 16 4 Failure to deliver Cost Improvement Plans 4 x 5 = 20 5 Failure to deliver turnaround / cost reduction programme 3 x 5 = 15 9 Failure to achieve compliance with performance and delivery aspects of Monitor 4 x 4 =16 Risk Assessment Framework, CQC and other regulatory standards, triggering regulatory action 13 Inability to recruit right staff and ensure staff have the right skills to meet 4 x 3 = 12 operational needs
2
NHS Improvement Undertakings Tracker
RAG rating key: B Black - Complete G Green - On track to be achieved A Amber - Significant work to be done (i.e. not on track, not all milestones hit) R Red - Obstacles to achievement (i.e. likelihood that objective will not be achieved unless obstacles are addressed)
Ref Undertaking Management commentary Lead Timescale Progress 1 Sustainability 1.1 Take all reasonable steps to deliver the Trust's services on a clinically, operationally and financially - Grip & Control DJ Ongoing sustainable basis, including but not limited to the actions in paragraphs 1.2. to 1.10 below. As part - Turnaround programme & workstreams of this, the Licensee will take all reasonable steps to improve its financial position and minimise its - CIP Plans G external funding requirement, as measured by any extent or benchmark which may be specified The Trust was £2.1m ahead of plan in M4. by NHSI.
1.2.1 Develop and submit to NHSI a Short Term Recovery Plan comprising: 2 year plan delivered in August. 3-5 year plan to be DJ / JC 31/08/2016 - a recovery plan for 2016/17 to be submitted to NHSI by 29 April 2016, or such other date as may delivered in draft end September in final end December, be agreed with NHSI; and this is a tight timescale and will be challenging but the G - a recovery plan for 2017/18 to be submitted to NHSI by 15 July 2016, or such other date as may timescales will be kept under continuous close review as be agreed with NHSI. the work moves forwards.
1.2.2 Develop and submit to NHSI a strategy for financial sustainability and an associated longer-term, 3-5 year plan to be delivered in draft end September in DJ / MP 31-Dec-16 five year financial plan (“the Strategic Plan”), to be submitted to NHSI by 30 September 2016, or final end December. G such other date as may be agreed with NHSI. 1.3 Either deliver, or if NHSI so specifies, demonstrate to NHSI that it can deliver, each of the plans Ongoing DJ Ongoing G referred to in paragraph 1.2. 1.4 In relation to the development of both the short term recovery plan and the strategic plan, Several meetings including a QPIA panel already held. DJ 31-Dec-16 consult with its commissioners and ensure that the plans reflect appropriately the views of its Both CCGs are on the panel and on the Programme G commissioners. Steering Group 1.5 Modify the plans if needed in response to any input from NHSI after NHSI has received and Ongoing DJ 31-Dec-16 considered the plans, whether such input is provided before or after receipt of the assurance G specified in paragraph 1.6. 1.6 Obtain assurance that the plans and their delivery will enable the Trust to comply with paragraph To be factored into internal audit plan if appropriate and DJ 31-Mar-17 1.1. The source, scope and timing of that assurance will be agreed with NHSI, and the assurance NHSI deem necessary. G will be provided to NHSI if NHSI so requests.
Page 1 Ref Undertaking Management commentary Lead Timescale Progress 1.7 Develop and agree with NHSI Key Performance Indicators (“KPIs”) to assess the effective delivery For future agreement DJ / JC tbc and impact of the short term recovery plan and strategic plan, by such date as to be agreed with N/a NHSI. 1.8 Commission, at any point, the level of external support considered necessary by NHSI to assist the FIP phase 1 still under discussion, other providers will be MP Ongoing Licensee in the development and delivery of the plans, the scope and the identity of the provider necessary for niche or specialist support. G of that support to be agreed with NHSI. 1.9 Ensure that the Trust has the necessary personnel, systems and processes to enable it to deliver Recruitment ongoing, majority of posts filled. MP Ongoing the short term recovery plan and the strategic plan, including demonstrating that it has sufficient A executive and senior management capacity and expertise to enable delivery.
1.9.1 Consult and agree with NHSI the appointment and scope of any key advisors in relation to the Ongoing (see comments re: FIP) MP / CS Ongoing plans described above, in addition to external support referred to in paragraph 1.8 above. G
1.9.2 Consult and agree with NHSI executive capacity to support the delivery of the plans described Ongoing as appropriate. MP / CS Ongoing G above, including key executive appointments. 1.9.3 Consult and agree with NHSI finance department capacity to support the delivery of the plans Proposals for changes to finance team approved August JC Ongoing described above. 2016. NHSI to be consulted moving forwards. G
1.1 Keep the short term recovery plan and the strategic plan, and their delivery, under review. Where Ongoing, through reporting to NHSI. MP / DJ Ongoing matters are identified which materially affect the Licensee’s ability to deliver sustainable services, / JC whether identified by the Licensee or another party, the Licensee will notify NHSI as soon as possible and update and resubmit the short term recovery plan and/or the strategic plan within a timeframe to be agreed with NHSI.
2 Financial Governance 2.1 Take all reasonable steps to address the weaknesses in its financial governance, including but not KPMG recommendations are being implemented in full. JC 31-Dec-16 limited to the actions in paragraphs 2.2 to 2.5 below. Management Response & action plan being monitored through Financial Oversight Committee, to be completed G Dec 2016. Grip and Control actions implemented.
2.2 Develop an action plan to address the findings and recommendations arising from KPMG’s Action plan agreed, implementation is underway, JC 31-Dec-16 Financial Misreporting Investigation. This action plan will be agreed with NHSI. The Licensee will monitored through Financial Oversight Committee. G implement the action plan, unless otherwise agreed with NHSI.
Page 2 Ref Undertaking Management commentary Lead Timescale Progress 2.3 Commission a wider governance review, the scope and timing of which is to be agreed with NHSI. Wider governance review planned for 2016/17, in MP 31-Dec-16 If required by NHSI, develop an action plan to address any findings and recommendations arising accordance with Well Led framework. from this review. This action plan will be agreed with NHSI. The Licensee will implement the action G plan, unless otherwise agreed with NHSI.
2.4 Following implementation of the action plans referred to in 2.2 and 2.3 above, if required by NHSI, Tbc if required by NHSI MP Tbc commission a follow up review from a source and according to a scope and timing to be agreed with NHSI to test whether the actions are implemented. If such a review is commissioned, provide N/a copies of the draft and final reports to NHSI within a week of receiving them.
2.5 If required by NHSI, commission an assurance review of the Trust’s 2015/16 financial baseline Tbc if required by NHSI MP / JC Tbc position, with the scope and timing to be agreed with NHSI. Following this review, if required by NHSI, develop an action plan to address any findings and recommendations arising. This action N/a plan will be agreed with NHSI. The Licensee will implement the action plan, unless otherwise agreed with NHSI. 3 Distressed Financing and Sustainability and Transformation Fund 3.1 Where interim support financing or planned term support financing is provided by the Secretary All terms and conditions will be complied with. Indeed JC Ongoing of State to the Licensee pursuant to section 40 of the NHS Act 2006, or the Licensee receives compliance with such has been integrated into the trust's payments under the Sustainability and Transformation Fund, the Licensee will comply with any financial, operational and other plans. G terms and conditions which attach to the financing or payments.
3.2 Comply with any reporting requests made by NHSI in relation to any financing to be provided to All reporting request will be complied with as required. JC Ongoing the Licensee by the Secretary of State pursuant to section 40 or 42 of the NHS Act 2006 or G payments made under the Sustainability and Transformation Fund. 3.3 Comply with any spending approvals that are deemed necessary by NHSI. All requests will be complied with as and when required. JC Ongoing G 4 General 4.1 Implement sufficient programme management and governance arrangements to enable delivery Turnaround programme management arrangements DJ Q4 2015/16 of these undertakings. established, repoorting via Financial Oversight B Committee. 4.2 Such programme management and governance arrangements must enable the Board to: Turnaround programme repoorting to Board via monthly DJ Q4 2015/16 - obtain clear oversight over the progress in delivering the undertakings; Financial Oversight Committee. Workstream SROs are - obtain an understanding of the any risks to the successful achievement of the undertakings and held to account by FinOC. B ensure appropriate mitigation of any such risks; and - hold individuals to account for the delivery of the undertakings.
Page 3 Ref Undertaking Management commentary Lead Timescale Progress 4.3 Provide regular reports to NHSI on its progress in meeting the undertakings set out above, in a Weekly telephone meetings taking place, alongside MP / DJ Ongoing format to be agreed between the Licensee and NHSI, including reporting against the KPIs agreed monthly reports and NHSI visits. / JC G pursuant to paragraph 1.7. 4.4 Attend meetings, or, if NHSI stipulates, conference calls, as required, to discuss its progress in Weekly telephone meetings taking place, alongside MP / DJ Ongoing meeting those undertakings. These meetings will take place once a month unless NHSI otherwise monthly reports and NHSI visits. / JC G stipulates, at a time and place to be specified by NHSI and with attendees specified by NHSI.
4.5 Provide NHSI with the assurance relied on by its Board in relation to its progress in delivering On request. MP / CS On request N/a these undertakings, upon request. 4.6 Provide to NHSI direct access to its advisors, the Licensee’s board members, and any other Regular NHSI contact with Chair & other board members. MP / CS Ongoing members of the Licensee’s staff considered necessary by NHSI, as needed in relation to the NHSI meetings with governors scheduled. NHSI has G matters covered by these undertakings. access to relevant advisors / consultants (SS, CM, KPMG).
4.7 Comply with any additional relevant reporting or information requests made by NHSI. On request. MP / CS On request N/a
Page 4
Title Single Oversight Framework
Report to: Board of Directors Date: 27 September 2016
Author: Matthew Kane, Trust Board Secretary
For: For noting Purpose of Paper: Executive Summary containing key messages and issues The purpose of this report is to provide an overview of the new NHS Improvement Single Oversight Framework which sets out the method by which NHSI will provide support to deliver high quality, sustainable healthcare services.
It replaces the Monitor Risk Assessment Framework and the TDA Accountability Framework and will be implemented from 1 October 2016. A copy of the full document has not been produced with the papers but can be found at: https://improvement.nhs.uk/resources/single-oversight-framework
Recommendation(s) The Board is requested to NOTE the briefing on the Single Oversight Framework.
Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first By ensuring excellent quality of care Committed to quality and continuously improving patient experience By ensuring we are continuously improving our financial position and use of resources Responsible and accountable for our actions – taking pride in our work By ensuring we have capable leadership and are well led
Related Strategic Objectives Provide the safest, most effective care possible Control and reduce the cost of healthcare Focus on innovation for improvement
Analysis of risks
Not applicable as this report is provided for information only.
Board Assurance Framework
This report relates to all the risks contained within the Board Assurance Framework.
Single Oversight Framework
NHS Improvement published its Single Oversight Framework on 13 September 2016. It will provide an integrated approach to overseeing NHS foundation trusts and trusts and help to identify the support they need to deliver high quality, sustainable healthcare services. It aims to help providers attain and maintain CQC ratings of ‘good’ and ‘outstanding’.
The benefits of the Single Oversight Framework are: to provide one framework for providers, irrespective of their legal form; to help NHSI identify potential support needs, by theme, as they emerge; to allow NHSI to tailor support to the specific needs of providers in the context of their local health systems; and to be based on the principle of earned autonomy.
Oversight themes
In carrying out its role NHS Improvement will oversee and assess providers’ performance against five themes:
Segmentation
NHS Improvement will segment providers into four groups based on the extent of support needs identified through the oversight process and performance against the above measures. Segmentation will be based on:
All available information on providers – obtained directly and from third parties. Identifying providers with a potential support need in one or more of the above themes.
2
Relationship knowledge and/or findings of formal or informal investigations, or analysis, consideration of the scale of the issues faced by a provider and whether it is in breach or suspected breach of licence conditions (or equivalent for NHS trusts).
The four segments are as follows:
The segment a provider is placed in determines the level of the support NHSI provides but not the precise support package. On the basis that Doncaster and Bassetlaw is in breach of its licence but not in special measures, it is likely it will be placed in segment three (mandated support).
3
Use of metrics
NHSI will be introducing agency spend into the ‘finance and use of resources’ theme and where providers have not agreed a control total this will have an implication for their score, particularly if they are planning a deficit.
Following the approach set out in the recent Strengthening financial performance and accountability document and the introduction of financial special measures, NHSI will be expanding their value for money approach by considering pay-bill growth, consolidation of back office and pathology services and addressing unsustainable services where necessary through consolidation or change of transfer to a neighbouring provider.
Use of the EBITA metric has been removed and NHSI will instead revert to using a provider’s income and expenditure margin as a measure of financial efficiency. Likewise, capital controls have been removed while NHSI undertake more work in this area.
Implementation
The Framework will be introduced on 1 October 2016 and replace the Monitor Risk Assessment Framework and the TDA Accountability Framework which will no longer formally apply. The sector’s segmentation is likely to be publicly available from November 2016. A shadow segmentation process has already begun and providers will be discussing their shadow segment with NHS Improvement regional teams over the coming weeks.
4
REF: CORP/EMP 14 v.5
RAISING CONCERNS: ‘We Care, We Listen, We Act’
This Procedural document supersedes: Whistleblowing Policy - Voicing your Concerns - CORP/EMP 14 v.4
Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours.
Author/reviewer: (this L Robinson, Staff Governor version) Date revised: September 2016 Approved by: Board of Directors Date of approval: 27 September 2016 Date issued: Next review date: September 2019 Target audience: Trust Wide
Page 1 of 16 REF: CORP/EMP 14 v.5
Amendment Form
Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.
Version Date Issued Brief Summary of Changes Author Version 6 September Policy title renamed following the National L. Robinson 2016 Whistleblowing policy and reference to Freedom to Speak Up Guardian role
Version 5 3 April 2014 Amended in line with Enterprise and Diane Culkin Regulatory Reform Act 2013 that amended the Employment Rights Act 1996. This document has also been reviewed in line with Trust APD document and should be read in full.
Version 4 January NHS constitution H Selvidge 2011 Speak up for the NHS Changes to organisation Non executive Director identified
Version 3 Dec 08 The policy has been re-drafted and will J Lang need to be re-read in full
Version 2 May 2005 Addition of paragraph on “sexual H Selvidge behaviour” following the Ayling Inquiry
Page 2 of 16 REF: CORP/EMP 14 v.5
Contents
Page Section No. 1 Introduction 4 2 Purpose 5 3 Duties and Responsibilities 5 4 Procedure – Deciding Whether to Raise a Concern 6 5 Anonymous Concerns 8 6 Independent Advice 8 7 Training/Support 8 8 Monitoring Compliance with the Procedural Document 8 9 Equality Impact Assessment 9 10 Associated Trust Procedural Documents 9 11 References 9
Appendices: Appendix 1 Questions to Consider if Deciding Whether to Blow the Whistle 10 Appendix 2 Whistleblowing – How to Raise your Concerns 11 Appendix 3 Equality Impact Assessment 14 Appendix 4 Raising Concerns – Your Local Guardians 16
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1. INTRODUCTION
1.1. Doncaster and Bassetlaw Hospitals NHS Foundation Trust (DBH) is committed to providing the highest standard of care and governance. For this standard to be maintained the Trust actively encourages a climate of open communication, transparency and candour about matters of concern, and supports implementation of Sir Robert Francis’s recommendations following the Mid Staffordshire investigation.
1.2. At one time or another we all may have concerns about things that are happening at work and usually these concerns can be easily resolved. However, when the concern feels serious because it is about a possible danger, professional misconduct or financial malpractice that might affect patients, colleagues, or the Trust itself, it can be difficult to know what to do.
1.3. This policy has been developed to provide guidance on how to raise concerns in a responsible and constructive manner, without fear of victimisation, ensuring that these issues are dealt with in a fair, timely and consistent manner across the Trust. It should be read in conjunction with any relevant professional code of conduct/guidelines which it is intended to complement.
1.4. Issues of concern that may be raised through this policy include:-
Healthcare matters such as suspected negligence, mistreatment or abuse of patients or issues relating to the quality of care provided. Concerns about the professional or clinical practice or competence of colleagues, other members of staff or other workers, including those members of staff who have non-clinical roles. Malpractice involving immoral, illegal, or unethical professional conduct or neglect of a professional duty. The treatment of other staff, including suspected harassment, discrimination or victimisation. Health, safety and environment issues. Suspicion or knowledge of theft, fraud, corruption, bribery or other financial malpractice. Employment standards and/or working practices. Criminal offences or miscarriages of justice. Failure to comply with any other legal obligation. Deliberate concealment of any of the above.
1.5 This policy applies to all employees, and all areas of the Trust, including permanent, temporary and bank employees. The staff of our contractors (including agency workers) and volunteers may also raise concerns using this policy without fear of recrimination.
1.6 Under the 2016 terms and conditions for doctors and dentists in training the role of Guardian for Safe Working Hours has been established. This role will ensure that issues of
Page 4 of 16 REF: CORP/EMP 14 v.5 compliance with safe working hours are addressed as they arise and will provide assurance to the Board of Directors that doctors’ working hours are safe.
2. PURPOSE
2.1 The purpose of this policy is to encourage and enable staff to raise clinical and other concerns within the Trust in a constructive and positive manner, rather than overlooking a problem or “whistle blowing” elsewhere.
2.2 By its use, the Trust aims to encourage an open culture, and to reassure staff that concerns raised correctly under this policy will be listened to and acted on appropriately. It has been developed in response to the Public Interest Disclosure Act 1998, whereby employees who raise legitimate concerns that they reasonably believe are in the public interest are protected from adverse treatment by the Trust or from suffering a detriment, such as bullying and harassment from another worker. This policy sets out the responsibility of employees and other workers and enables managers to demonstrate accountability.
2.3 The policy is intended to address concerns promptly where the interests of others, or of the Trust itself are at risk. It does not address individual or collective issues, which are more properly dealt with under the Trust’s other policies, such as the Grievance and Dispute Procedure or Fair Treatment for All Policy.
3. DUTIES AND RESPONSIBILITIES
3.1 The Chief Executive is ultimately responsible for ensuring there is an effective system in place for employees to raise issues relating to Raising Concerns (Whistleblowing).
3.2 Local Freedom to Speak up Guardian – this role has been established to provide confidential advice to staff who may not know who they should raise their concern with, and to ensure that anyone who does raise a concern is appropriately supported and not subject to any detrimental treatment.
3.3 These functions are delegated to all Executive Directors who have responsibility for: Ensuring this Policy is adhered to; The provision of advice and information relating to Raising concerns (Whistleblowing).
3.4 All Trust managers have a duty to: Develop and create a culture where employees can discuss concerns. Take the employee’s concerns seriously and understand the difficult position they may be in. Evaluate the basis of any concerns brought to their attention, taking prompt action to resolve the concern or to refer to an appropriate person. Seek appropriate advice
Page 5 of 16 REF: CORP/EMP 14 v.5 Keep the employee informed of the process. Monitor and review the situation. Inform appropriate members of the Trust i.e. the Director of People and Organisational Development.
3.5 All employees are responsible for: Raising their concerns as soon as possible in an objective and factual way, in line with this policy and the accompanying procedure. Keeping records, where possible, of any incidents and potential witnesses Co-operating with any investigation, if appropriate, including being available for interview, providing a statement and/or documentation. Maintaining the confidentiality of patients and staff. All reported concerns will be dealt with complete confidence and can be defined broadly as “protected disclosure”.
4. PROCEDURE – DECIDING WHETHER TO RAISE A CONCERN
4.1 This can be a hard decision. You might feel it’s not your business, or someone else will do something, or you don’t have any evidence, or you are being disloyal to your colleagues, or you will be victimised. Or you might have seen someone else raising a concern and experiencing some of the issues above.
4.2 However, you must always consider the needs of our patients, and your responsibility to them as your first priority. You should also remember that it is your duty to raise issues so others can investigate them and sort them out. And finally consider what might happen if you don’t raise the issue and something does go wrong. Some questions which may be helpful in reaching this decision can be found in Appendix 1.
4.3 If you raise genuine concerns under this policy that you reasonably believe are in the public interest, the Trust will support you. This means that you will not be at risk of reprisal, victimisation, discrimination or any form of disciplinary sanction as a result of raising your concerns. Nor will your continued employment, opportunities for future training or promotion be prejudiced because you have raised a legitimate concern. If you are subsequently found to be mistaken, this does not matter and you will still be protected.
4.4 Whilst the Trust encourages the raising of genuine concerns, this must be exercised with proper regard to individual’ and patients’ rights to confidentiality and by observing the appropriate procedure for raising such concerns.
4.5 You are, therefore, reminded of your duties of confidentiality and responsibilities to the Trust. However, this does not preclude you from expressing concerns about misconduct, malpractice, risks or potential incidents. Whilst areas of concern may be raised with external bodies without first raising them with the Trust, if such disclosures are not justified under the Public Interest Disclosure Act, the action taken could be regarded as a breach of duty and may lead to disciplinary action.
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4.6 If you raise an issue, as far as possible, your confidence will be protected. However, where disciplinary/criminal action follows, you might need to give a statement and therefore reveal your identity, but you will be informed and supported.
4.7 Unauthorised disclosure of information, particularly information relating to the care and treatment of individual patients, will be regarded as a most serious matter and will normally warrant disciplinary action.
4.8 Process flowchart for raising concerns
Page 7 of 16 REF: CORP/EMP 14 v.5
5. ANONYMOUS CONCERNS –
5.1 The Trust cannot ignore anonymous concerns and will therefore take all reasonable steps to investigate anonymous reports. However, anonymous reports are more difficult to deal with, and there can be no real report back on what has happened as a result. We would want to encourage open reporting, but it is better to anonymously report something than not report it at all. If you feel you need to make an anonymous report, it may not be dealt with under this policy specifically, but it will be investigated as thoroughly as possible and a separate log of anonymous reports will be kept in People and Organisational Development (P&OD) or in the Complaints Management Team, depending on whether it involved specific staff or not. Any action taken and outcome will be filed in these two places for future reference.
6. INDEPENDENT ADVICE
6.1 Free, independent and confidential advice on whether and how to raise a concern about serious malpractice at work can be obtained at any stage from:
NHS Whistleblowing Helpline on: 08000 724725 or online at www.wbhelpline.org.uk or via email at [email protected] - the website offers specific advice for NHS staff. Additionally, advice can be sought from the relevant Trade Union or Professional Associations.
Advice can also be sought from:-
Care Quality Commission on 03000 616161 or via email at: [email protected]. The website offers further advice at www.cqc.org.uk
7. TRAINING/SUPPORT
7.1 Staff will receive instruction and direction regarding Whistleblowing advice and information from a number of sources:
Trust Policies and Procedures Line manager Fraud Awareness Training Other communication methods (e.g. Staff Brief/Team Meetings)
Page 8 of 16 REF: CORP/EMP 14 v.5
8. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT
8.1 Awareness and compliance with this policy will be monitored annually by the responses to the Staff Survey.
8.2 Any concern raised by an employee under this policy must be reported, anonymously if appropriate to the Director of People and Organisational Development (P&OD). P&OD will log the name of the manager notifying the concern, the nature of the concern and the date. P&OD Case Management Team will monitor resolution of the concern and monitor trends across the Trust of such concerns.
8.3 The Director of P&OD will be responsible for monitoring that this procedure is followed and may be consulted at any stage through the process to offer advice to those involved.
9. EQUALITY IMPACT ASSESSMENT
An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment For All Policy (CORP/EMP 4). A copy is attached at Appendix 3.
The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified.
10. ASSOCIATED TRUST PROCEDURAL DOCUMENTS
Key policies for you to refer to are:- Disciplinary Procedure – CORP/EMP 2 Fraud Policy and Response Plan – CORP/FIN 1 (D) Grievance and Dispute Procedure – CORP/EMP 3 Information Management & Technology (IM&T) Security Policy – CORP/ICT 2 Fair Treatment for All Policy- CORP/EMP 4 Policy for Supporting Staff Involved in Incidents, Complaints and Claims - CORP/RISK 4 v.3 Risk Management Strategy – CORP/RISK 10 Serious Incidents (SI) Policy – CORP/RISK 15 v.3 Standing Financial Instructions, including Gifts, Hospitality & Sponsorship - CORP/FIN 1 B Standing Orders – CORP/FIN 1 A
11. REFERENCES
Francis Report – Duty of Care Order
Page 9 of 16 REF: CORP/EMP 14 v.5 Public Concern at Work, “Speak up for a Healthy NHS” http://www.pcaw.org.uk/files/SpeakupNHS.pdf Public Interest Disclosure Act 1998 – www.legislation.gov.uk
APPENDIX 1
QUESTIONS TO CONSIDER WHEN DECIDING TO RAISE A CONCERN (WHISTLE BLOW)
The following questions have been compiled by the charity Public Concern at Work to help individuals who are unsure whether or how to raise a concern:
Is someone (e.g. a patient) unaware that they are being exposed to a risk that you would not take or expose your loved ones to?
If the tables were turned and someone had a concern about your clinical practices, how would you want them to raise the issue?
How can the risk be addressed so that the least damage is caused to the colleague involved?
Have you talked to your colleagues or your team (if not, why not)?
Can you find a solution within your team?
Is there a trusted senior colleague or friend you can discuss the issue with first?
If you have known of the risk for some time, why are you minded to raise the issue now?
What do you think would be a satisfactory outcome?
What obstacles are there to it?
What is your motivation?
Do you know that you can contact the NHS Whistleblowing Helpline to discuss in confidence whether or how to raise a concern on 08000 724725 or via www.wbhelpline.org.
IF IN DOUBT – RAISE IT!
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APPENDIX 2
HOW TO RAISE YOUR CONCERNS
1.1 The Whistleblowing Policy provides four different steps in raising a concern that falls within the scope of this policy. You can be accompanied by a companion who may be a Trade Union Representative or professional association representative or a work colleague not involved in the issue/area which is causing concern.
1.2 Step One - In the first instance, you should raise this with your work team or line manager, verbally or in writing.
1.3 Step Two - If you feel unable to approach your line manager for any reason or feel that they have not investigated the issue thoroughly under Step One, you should raise the matter with the Matron, Business Manager, Clinical Manager , Head of Nursing, General Manager, Care Group Director a Senior Manager responsible for the Directorate or Care Group. You should do this in writing within five days of Step One and indicate whether or not you wish to raise the matter in confidence so that appropriate arrangements can be made.
1.4 Step Three - If Steps One and Two have been followed, or you can’t raise the matter with any of the people in Step Two for any reason and you still have concerns or feel that the matter has not been dealt with, you should write to either the Chief Executive or responsible Executive Director.
1.5 Step Four - If you wish to raise a concern internally but do not feel happy using the normal management chain for any reason you should write to, or e-mail the Director of People and Organisational Development, the Freedom to Speak up Guardian at [email protected] or a Non-Executive Director via the Chairman’s office, Doncaster Royal Infirmary.
2. OUR RESPONSE TO YOUR CONCERNS
2.1 Arranging the Initial Meeting. The aim is for a meeting between you and whoever you chose to raise the concern with to take place within 5 working days of making a verbal or written request. The relevant manager will make the arrangements to meet promptly, with due regard to confidentiality and discretion. The option of being accompanied or represented by a trade union representative or colleague will be offered to provide support. Further contact will then be at a mutually agreed time.
2.2 The Initial meeting. At the first meeting, the manager should: Thank you for raising the issue, regardless of the circumstances Remind you that moral support is available from your trade union or professional association
Page 11 of 16 REF: CORP/EMP 14 v.5 Ask if you have a personal interest in the matter, in case the matter might be better dealt with as a grievance or appeal for example. Ask for your view on how the concern may best be resolved. Make notes which all parties involved in the initial meeting will be asked to sign as confirmation that they are an accurate reflection of the meeting that has taken place. Inform the Director of People and Organisational Development that the concern has been raised (anonymously if appropriate).
2.3 Initial response. The manager will take a decision on what action to taken and agree this with you. This may take the form of an informal review, an internal inquiry or a more formal investigation involving outside bodies such as the Police or NHS Protect. If a formal investigation is launched then the Trust’s Disciplinary Policy will be followed. An initial response to the individual who has raised a concern (whistleblower) will be made in writing within 5 working days of the discussion. The response will summarise the concern and set out the planned action, including who is handling the matter.
2.4 Looking into a concern. We are committed to responding in an open and transparent way. Everyone involved should feel that matters have been dealt with thoroughly and fairly. The investigating manager may seek advice from any Executive Director depending on the nature of the concern.
2.5 Feedback to the person(s) raising concerns. In the spirit of developing a learning culture, at the conclusion of the investigation, you will be asked for their opinion on how the concern was handled. You will also be given as much feedback as appropriate in respect of the outcome, as long as this does not infringe on the a duty of confidence owed to someone else.
2.6 Dissatisfaction with the Trust’s Response. Through this policy, we will try to respond to concerns in an open and transparent way. If you are dissatisfied with the response, you can go to other levels within the Trust, the NHS Whistlblowing Helpline (www.wbhelpline.org.uk) the relevant trade union or professional body, or the external bodies detailed below.
2.7 Informing Other Agencies/Bodies. Whilst we encourage the raising of concerns internally, we also recognise that there may be circumstances where it is appropriate to report matters to outside agencies, including regulators or the police. We would prefer you to raise matters internally, but it is much better to raise a concern with the appropriate regulator than not at all, as long as this is in good faith and there is evidence to back up the concern. Public Concern at Work or the relevant Trade Union will be able to give advice on the circumstances in which an outside body can be contacted safely.
2.8 The regulatory bodies relevant to the NHS include:
Care Quality Commission www.cqc.org.uk NHS Improvement www.improvement.nhs.uk NHS Protect www.nhsprotect.nhs.uk The Audit Commission www.audit-commission.gov.uk
Page 12 of 16 REF: CORP/EMP 14 v.5 HM Revenue & Customs www.hmrc.gov.uk Health & Safety Executive www.hse.gov.uk The Charity Commission www.charity-commission.gov.uk The Occupational Pensions Regulatory Authority www.opra.gov.uk
2.9 Reporting Fraud & Corruption. The Trust must comply with NHS Provider Standards in respect of allegations of Fraud & Corruption and a separate policy entitled ‘The Fraud, Bribery and Corruption Policy & Response Plan’ exists to detail the specific action required of staff in respect of concerns of this type. Any member of staff or manager presented with a concern about fraud or corruption must at the earliest opportunity report their concerns in the first instance directly or indirectly to either:
The Local Counter Fraud Specialist (LCFS) The Director of Finance, Information and Procurement NHS Fraud & Corruption Reporting Line on: 0800 028 40 60 Online at: www.reportnhsfraud.nhs.uk
2.10 The Public Interest Disclosure Act 1998 will not protect an employee who makes a rash disclosure. A rash disclosure includes reporting to the media a concern that falls within the scope of this policy that could and should have been raised within the Trust.
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APPENDIX 3 - EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING
Service/Function/Policy/ CSU/Executive Directorate and Assessor (s) New or Existing Date of Assessment Project/Strategy Department Service or Policy? CORP/EMP 14 v 5 Department of People and Diane Culkin Existing 11th March 2014 Whistleblowing Policy – Organisational Development Voicing your Concerns 1) Who is responsible for this policy? Department of People and Organisational Development 2) Describe the purpose of the service / function / policy / project/ strategy? The policy sets out the appropriate process for ‘workers’ to raise concerns about unlawful conduct, financial malpractice or dangers to the public or environment. The aim of the policy is to protect workers who raise concerns in good faith and make sure their concerns are listened to without fear that their job will be at risk for making the disclosure. 3) Are there any associated objectives? The policy is in line with the ‘Public Interest Disclosure Act 1998’ 4) What factors contribute or detract from achieving intended outcomes? – Detract - Staff lack of awareness of the policy and appropriate action to take. Contribute – Staff awareness, evidence of effective use of policy 5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership, maternity/pregnancy and religion/belief? No – open to all ‘workers’ which includes contractors, agency workers or any other health care worker who has a contract of service or similar with the Trust If yes, please describe current or planned activities to address the impact N/A 6) Is there any scope for new measures which would promote equality? Monitoring of issues raised through the policy could be undertaken. 7) Are any of the following groups adversely affected by the policy? Protected Characteristics Affected? Impact a. Age No Nil b. Disability No Nil c. Gender No Nil d. Gender Reassignment No Nil
Page 14 of 16 REF: CORP/EMP 14 v.5 e. Marriage/Civil Partnership No Nil f. Maternity/Pregnancy No Nil g. Race No Nil h. Religion/Belief No Nil i. Sexual Orientation No Nil 8) Provide the Equality Rating of the service/ function/policy /project / strategy Outcome 1 X Outcome 2 Outcome 3 Outcome 4 *If you have rated the policy as having an outcome of 2, 3 or 4, it is necessary to carry out a detailed assessment and complete a Detailed Equality Analysis form in Appendix 4 Date for next review: March 2017, or earlier if changes to policy required Checked by: Ruth Cooper Date: 12 March 2014
Page 15 of 16 REF: CORP/EMP 14 v.5
APPENDIX 4 – RAISING CONCERNS - YOUR LOCAL GUARDIANS
Page 16 of 16
Title Annual Statement of Compliance Against NHS England Core Standards for Emergency Preparedness Resilience and Response (EPRR) 2016/17 Report to: Board of Directors Date: 27 September 2016
Author: Jean Yates, Emergency Planning Lead on behalf of David Purdue, Chief Operating Officer and Accountable Emergency Officer (AEO)
For: Approval Purpose of Paper: Executive Summary containing key messages and issues
This report provides a review of the Trust performance and compliance against the National Core Standards for Emergency Preparedness, Resilience and Response (EPRR) 20176/17
DBH is a Category 1 Responder under the Civil Contingencies Act 2004 (CCA 2004), and therefore has a statutory duty to respond to, manage and recover from any incident which has the capability of causing the Trust to implement special measures over and above ‘business as usual’ to manage the incident. This is usually described as, but not limited to, a major incident or a significant business continuity disruption, which has the capability to significantly impact on normal service delivery.
NHS England developed the Core Standards for Health Category 1 and 2 Responders, based on statutory duties within the Civil Contingencies Act 2004. The standards were first introduced in 2013 and have been reviewed and revised annually since. The Trust has to respond to 47 of the standards; 33 generic EPRR standards and 14 standards relating to the response to incidents involving either hazardous materials or chemical, biological, radiation or nuclear (HazMat/CBRN) incidents. Since 2014, NHS England introduced an additional set of standards, which focus on a key theme for the year. This process is described in the Standards as a ‘Deep Dive’ into a specific EPRR process.
This year, the deep dive focuses on five Business Continuity standards, and in addition, into fuel requirements to maintain critical services, in the event of loss of fuel. This latter requirement is not part of the assessment process, therefore is not counted in compliance: organisations have been asked to undertake an estimated fuel summary to support the revision of the National Emergency Fuel Plan (NeFP).
The Accountable Emergency Officer is required to present the findings and the outcome of the self- assessment NHS England (North) at a confirm and challenge extraordinary meeting of the Local Health Resilience Partnership on 25 October 2016.
It should be noted that this year, the national definition for full compliance has changed from:
“The plans and work programme in place appropriately address all the core standards that the
1 organisation is expected to achieve”.
To: “Arrangements are in place that appropriately addresses all the core standards that the organisation is expected to achieve. The Board or Governing Body has agreed with this position statement.
In previous years we, along with our neighboring trusts, have been able to declare full compliance because any amber or red ratings were accompanied by an action plan.
In accordance with this change, this year, the Trust will declare that our compliance rating is SUBSTANTIAL, since four of the standards have been rated at AMBER.
Recommendation(s)
The Board of Directors is asked to APPROVE the Compliance Report and associated action plan
Delivering the Values – We Care (how the values are exemplified by the work in this paper) [delete as appropriate]
We always put the patient first By ensuring that the Trust has emergency plans and processes in place which protect and prioritise patient care during an emergency or significant service disruption
Responsible and accountable for our actions – taking pride in our work Ensuring that the Trust has plans and processes in place to respond to emergency and significant service disruptions, reducing the impact on patient, staff and the public and maintaining the Trusts reputation.
Related Strategic Objectives [delete as appropriate]
Provide the safest, most effective care possible Develop responsibly, delivering the right services with the right staff
Analysis of risks Resource – staff need time to participate in development and attendance at training and exercises Governance – The Trust needs to maintain compliance with statutory and regulatory bodies and guidance. As a minimum meet NHS England Core Standards for EPRR Equality and Diversity – No known issues or risks. PR and Communications – No known issues or risks Risk Assessment – the risk lies in lack of compliance with the Core Standards and either not having emergency plans in place, or having a plan that is inadequate to enable the Trust to
2 fulfil its duties as a category1 Responder under the Civil Contingencies Act 2004 NHS Constitution - Rights and Pledges – No known issues or risks.
Board Assurance Framework 1 Failure to have a plan in place, or have an inadequate plan which enables the 1x5 = 5 Trust to meet its statutory and regulatory obligations
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BOARD OF DIRECTORS
ANNUAL STATEMENT OF COMPLIANCE
AGAINST
NHS ENGLAND CORE STANDARDS FOR EMERGENCY PREPAREDNESS RESILIENCE AND RESPONSE (EPRR)
2016/17
David Purdue, Chief Operating Officer and AEO
September 2016
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1. Introduction
National Core Standards for Emergency Preparedness, Resilience and Response (EPRR) were introduced by NHS England in 2013. They have been revised and refined year on year, and the 2016 version was released in June 2016, with a submission date no later than 18 October 2016.
Each year, the Acute Trusts are required to self-assess and declare compliance against 48 core standards; 34 of these are generic standards relating to EPRR, and 14 relate specifically to the Trust’s capability to respond to incidents involving hazardous materials (HazMat) , and chemical, biological radiological and nuclear threats (CBRN).
In 2014, a new process was introduced which identified a specific area to look more closely at. In 2014, the focus was HazMat/CBRN; in 2015, the focus was pandemic influenza and this year the deep dive is focusing on business continuity, with an element looking at fuel demand in an emergency or significant business continuity disruption, which will also support the 2016 revision of the National Emergency Fuel Plan (NeFP).
2. Statutes and Guidance underpinning EPRR
The Trust is a category 1 responder under the Civil Contingencies Act 2004, which means we have a key role in preparing for and responding to a range of emergency situations and significant service disruptions. The CCA (2004) places statutory duties on Category 1 responders, and the core standards assess our preparedness and response capabilities to those duties and also to other statutory and regulatory requirements.
The key documents are:
Civil Contingencies Act 2004 NHS Act 2006 (as amended by Health and Social Care Act 2012 - S.46 and 47) NHS England Emergency Preparedness Framework 2015 National Standard Contract S.30 NHS Improvement Care Quality Commission
3. Process and timetable
The timetable for assurance and compliance 2016 has been brought forward this year, usually starting in October, this year the standards were released in July. The Accountable Emergency Officer (AEO) , supported by the Emergency Planning Lead, has undertaken a self-assessment of the Trusts EPRR arrangements against the core standards, and is presenting the Trust position to the Board of Directors including any action plan required where any of the standards are not met in their entirety. The Board are required to sign off the compliance statement.
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The AEO will then present the Trusts compliance statement and Board report to a specially convened meeting of South Yorkshire and Bassetlaw Local Health Resilience Partnership, (LHRP), and take questions from both NHS England North, and health peer group colleagues. The purpose of this meeting is to put in place a confirm and challenge process to all parties and seek confirmation that the self-assessment process has been undertaken with rigour and evidence is available to support the compliance statement if so required.
Timeline
Date Process July/August 2016 DBH self –assessment against 2016 core standards and production of report 8 September 2016 SY&B Mental Health, Acute and FTs Emergency Planning Leads undertake a local agreement to peer review self- assessments prior to submission 15 September AEO reviews Trust self- assessment and signs off self -assessment and level of 2016 compliance report 23 September AEO presents assurance report and statement of compliance to Board of 2016 Directors 18 October 2016 Trust submission of compliance assurance to LHRP 25 October 2016 South Yorkshire and Bassetlaw LHRP confirm and challenge meeting to present statement of compliance and improvement plans December 2016 Regional confirm and challenge meetings February 2017 National confirm and challenge meetings 1 April 2017 NHS England Board receive national assurance report
4. Review of 2015/16 Core Standards
Table 1 shows compliance levels for the 2015/6 round of assurance with the deep dive focusing on pandemic influenza preparedness:
Level Compliance Compliance against ‘Deep Dive’ Total against generic HazMat/CBRN standards Pandemic standards influenza standards 31 14 3 48 2 0 1 3 0 0 0
We declared Amber in three standards, one of which was part of the pandemic deep dive. Of these, one standard remains outstanding and has been declared as AMBER for this year:
Standard 36: Demonstrate organisation wide (including on-call personnel) appropriate participation in multi-agency exercises.
Reason: The challenge with this standard relies on accessing appropriate multi-agency exercises which can also be used to test our on-call managers and executives. Acute partners within the South Yorkshire and Bassetlaw footprint have the same challenge with
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S.36. Exercises this year that the Trust had arranged to participate in, had been planned for dates which later coincided with the junior doctors industrial action.
However, the Trust has been able to demonstrate capability at a senior level, responding to power outage; switchboard failure and junior doctors’ industrial action, working closely with local partners. Real events count towards standard 36.
It was agreed that local partners would work together to develop appropriate multi-agency exercises that met health’s needs as well hose of as multi-agency partners.
5. Performance against the Core Standards 2016
The standards applicable to the Trust in 2016 are:
33 generic standards: Which relate to emergency preparedness and business continuity. These remain unchanged from last year and are based on the duties of category 1 Responders under the Civil Contingencies Act (CCA) 2004. These duties are: - Assess the risk of emergencies occurring and use this to inform contingency planning - Put in place emergency plans; - Put in place Business Continuity Management arrangements; - Put in place arrangements to make information available to the public about civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency; - Share information with other local responders to enhance co-ordination; - Co-operate with other local responders to enhance co-ordination and efficiency;
The Trust is fully compliant with all generic standards except Standard 36 ( see para.4 ) which has been carried forward from last year
14 HazMat/CBRNe standards Which relate specifically to the response to incidents involving Hazardous materials (HAZMAT) and chemical, biological, radiological and nuclear (CBRN) incident. These were introduced in 2014 and have provided the basis of an audit of the Trusts capability and preparedness in responding to such events. A CBRN inventory checklist was included, which is used as part of the in site CBRN assessment visit. The Trust is fully compliant with these standards
This audit was carried out in in November 2015 by Yorkshire Ambulance Service (YAS) and the outcome of this was:
“Following on from the Online Self-Assessment audit and subsequent site visit/meeting Yorkshire Ambulance Service (YAS) have deemed Doncaster Royal Infirmary as “ Prepared” in
4 being able to deal with any Chemical Biological Radiological Nuclear Explosive (CBRN- e)/Hazmat type Incidents. “
Any assessment of Bassetlaw A&E would be undertaken by East Midlands Ambulance Service, and at the time of preparing this report, we have not been advised of a date.
6 Business Continuity ‘deep dive’ (DD) standards
DD1 Organisation has undertaken a Business Impact Assessment
DD2 Organisation has explicitly identified its Critical Functions and set Minimum Tolerable Periods of disruption for these
DD3 There is a plan in place for the organisation to follow to maintain critical functions and restore other functions following a disruptive event.
DD4 Within the plan there are arrangements in place to manage a shortage of road fuel and heating fuel
DD5 The Accountable Emergency Officers has ensured that their organisation, any providers they commission and any sub-contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance which may supersede this
DD6 Review of Critical Services Fuel Requirement Data Collection Programme – NB this does not count towards the self-assessment. It is providing data on estimated fuel requirement to deliver critical services and relates to the revision of the National Emergency Fuel Plan (NeFP)
The Trust is fully compliant with two of the five reportable DD standards; there are elements of the remaining three that need additional work to be able to declare full compliance so these have been declared as AMBER and they have been added to the Improvement Plan with deadlines to complete outstanding elements.
Outcome of self-assessment
Level Compliance Compliance against ‘Deep Dive’ Total against generic HazMat/CBRN standards Business standards Continuity 33 14 2 52 1 0 3 4 0 0 0 0
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6. Trust Declaration of Compliance
All health providers are required to self-assess against the appropriate standards, taking particular note of the ‘deep dive’ business continuity standards. The compliance levels for 2016 have been published, and the Accountable Emergency Officer is required to declare on behalf of the Trust, the overall level of compliance.
In previous years, the Trust has declared full compliance because, of the small number of standards not fully met, there was a work programme and action plan in place to address any changes that needed to be made (see Table 2.)
Table 2. NHS England Definition of Full Compliance up to 2015
Evaluation and Testing Conclusion Compliance Level The plans and work programme in place appropriately Full address all the core standards that the organisation is expected to achieve.
For 2016/17, the definitions for all levels have changed and to enable an organisation to declare full compliance, all standards have to be fully met and require no improvement work. (See Table 3.)
Table 3. NHS England Declaration of Compliance Levels 2016/17
Compliance Level Evaluation and Testing Conclusion Arrangements are in place that appropriately addresses all the core Full standards that the organisation is expected to achieve. The Board or Governing Body has agreed with this position statement.
Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to Substantial achieve. A work plan is in place that the Board or Governing Body has agreed.
Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to Partial achieve. A work plan is in place that the Board or Governing Body has agreed.
Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has Non-compliant been agreed by the Board or Governing Body and will be monitored on a quarterly basis in order to demonstrate future compliance.
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In line with the revised definitions of compliance, the AEO on behalf of the Trust has declared that four standards are AMBER. An improvement plan has been developed to address the outstanding issues. The outcome of this year’s self -assessment against the revised standards means that it is appropriate to make a declaration of SUBSTANTIAL compliance against the 2016/17 Core Standards.
David Purdue, Chief Operating Officer and Accountable Emergency officer
September 2016
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DONCASTER & BASSETLAW HOSPITALS NHS FOUNDATION TRUST
Work Programme following Self-Assessment against National Core Standards for EPRR 2015/16
This table contains the details of the core standards that the Trust has not been able to declare full compliance, and actions to improve this. Of the 51 Core Standards, the Trust has declared AMBER on four standards..
Standard (Generic) Clarifying information Trust Position and Action Plan Rating Revised Rating Demonstrate organisation This is a significant challenge. Individual staff 36 wide (including on-call have attended multi-agency exercises but the personnel) appropriate focus is frequently around partners’ plans so participation in multi- more jointly developed relevant exercises which agency exercises are able to test the health response from acute trust perspective. Needs to be relevant if organisation wide and senior Manager/Exec are required to attend
Action Plan This needs to be a joint venture. Work with partners to set up relevant exercises that also meets the Trusts requirements to exercise the on call team. Trust training does include working with on call staff to set up and run the ICR. Staff have also participated in live situations such as power outage, junior doctors’ industrial action, Tour de Yorkshire.
Work with partners to develop process 2016
Deadline March 2017
Jean Yates, Emergency Planning Lead, 2016/17 Self-Assessment and Assurance of Core Standards 2016 – Improvement Plan
Deep Dive Business Clarifying information Trust Position and Action Plan Rating Revised Continuity Rating DD2 Organisation has explicitly • The organisation has identified their Critical The majority of services have undertaken identified its Critical Functions through the Business Impact business impact assessments to identify their Functions and set Assessment. critical functions and set MTPD. Due to the Minimum Tolerable • Maximum Tolerable Periods of Disruption dynamic nature of BC assessment, further work is Periods of disruption for have been set for all organisational functions - yet required to ensure that all services have fully these including the Critical Functions completed plans; therefore full compliance cannot be declared.
Action Plan Work with Care Group teams to review current BIA and undertake gap analysis – work with CG to develop action plans for full completion of BIA
Deadline March 2017 DD3 Within the Business The plan details arrangements in place to The Trust has a separate Fuel plan which needs to Continuity plan there are maintain critical functions during disruption to be updated. The National Emergency Fuel Plan is arrangements in place to fuel. These arrangements include both road currently being revised, and once this is manage a shortage of road fuel and were applicable heating fuel. published, the Trust plan will be revised fuel and heating fuel accordingly. The Trust does not rely on fuel as a heating source
Action Plan
Commence review of plan ahead of the National Plan. Incorporate any new guidance, required actions once this is released
Deadline March 2017 DD5 The Accountable Refers to NHS Framework for EPRR 2015 New tenders are increasingly asking explicit Emergency Officers has questions regarding Trust BC arrangements. ensured that their Businesses that we seek tenders from are asked
Jean Yates, Emergency Planning Lead, 2016/17 Self-Assessment and Assurance of Core Standards 2016 – Improvement Plan
organisation, any providers about BC arrangements as part of the Trust they commission and any tender documents. Internally Trust Business Case sub-contractors have template includes requirement for staff to have robust business continuity considered the BIA of the new planning arrangements in service/equipment. place which are aligned to The Trust BC plan is currently aligned to NHS BS ISO 22301 or subsequent 25999. At the next revision, it will be aligned to guidance which may the principles of ISO 22301. supersede this . Action Plan Ensure that the next revision of the Trust BC Plan and Strategy is aligned where appropriate to ISO 22301.
Deadline June 2017 (next revision of plan)
Jean Yates, Emergency Planning Lead, 2016/17 Self-Assessment and Assurance of Core Standards 2016 – Improvement Plan
Yorkshire and the Humber Emergency Preparedness, Resilience and Response (EPRR) assurance 2016-2017
STATEMENT OF COMPLIANCE
Doncaster and Bassetlaw Hospitals NHS FT has undertaken a self-assessment against required areas of the NHS England Core Standards for EPRR v4.0.
Following assessment, the organisation has been self-assessed as demonstrating the Substantial compliance level (from the four options in the table below) against the core standards.
Compliance Level Evaluation and Testing Conclusion Arrangements are in place that appropriately addresses all the core Full standards that the organisation is expected to achieve. The Board or Governing Body has agreed with this position statement. Arrangements are in place however they do not appropriately address one to five of the core standards that the organisation is expected to Substantial achieve. A work plan is in place that the Board or Governing Body has agreed. Arrangements are in place, however they do not appropriately address six to ten of the core standards that the organisation is expected to Partial achieve. A work plan is in place that the Board or Governing Body has agreed. Arrangements in place do not appropriately address 11 or more core standards that the organisation is expected to achieve. A work plan has Non-compliant been agreed by the Board or Governing Body and will be monitored on a quarterly basis in order to demonstrate future compliance.
Where areas require further action, this is detailed in the attached core standards improvement plan and will be reviewed in line with the organisation’s EPRR governance arrangements.
I confirm that the organisation has undertaken the following exercises on the dates shown below:
Junior Doctors Industrial A live exercise (required at least every three years) Action April 2016; EMERGO 2013 Denial of Premises June A desktop exercise (required at least annually) 2016 A communications exercise (required at least every six months) April 2016
I confirm that the above level of compliance with the core standards has been confirmed by the organisation’s board / governing body.
______
Signed by the organisation’s Accountable Emergency Officer
______Date of board / governing body meeting Date signed Page 1 of 2
Page 2 of 2 UNAPPROVED DRAFT DONCASTER & BASSETLAW HOSPITALS NHS FOUNDATION TRUST
Minutes of the Financial Oversight Committee Meeting held at 9am on Monday 22 August 2016 DRI Boardroom
PRESENT : Philippe Serna, Non-executive Director (Acting Chair) David Crowe, Non-executive Director
IN ATTENDANCE : Dawn Jarvis, Director of Strategy & Improvement Liela Thorogood, Interim Deputy Director of Finance Mark Pockett, Assistant Director of Finance Andrew Thomas, Finance Programme Director Simon Marsh, Chief Information Office (Agenda Item 14) Andrea Smith, Head of Procurement (Agenda Item 14) Matthew Kane, Trust Board Secretary Angela O’Mara, Exec Team PA
GOVERNOR OBSERVER: Bev Marshall, Public Governor
WORKSTREAM : Karen Barnard, Director of People & OD Anthony Jones, Deputy Director of People & OD
Action Apologies for Absence 16/08/1 Apologies were received from John Parker and Jeremy Cook.
Welcome & Introductions 16/08/2 Introductions were made around the table. Minutes of the previous meeting 16/08/3 The minutes of the meeting held on 11 July 2016 were APPROVED as a true record of the meeting.
Matters arising 16/08/4 16/7/22 – 16/7/44 - Dawn Jarvis suggested a written memo be circulated to DJ brief the committee on post meeting developments relating to the Infrastructure work stream.
Management and Corporate Services Review Workstream
16/08/5 A report summarising progress to date and identified actions for 2017/18 was presented by Karen Barnard.
Page 1 UNAPPROVED DRAFT 16/08/6 The report identified savings of 200K at M4, which was below the year to date target. This was due in part to delays in the timing of planned changes but also anticipated savings from the vacant post of Chief Information Officer not being realised due to an earlier than expected start date. Ongoing discussions across the Care Groups/Directorates were taking place to understand the reason for delays and to identify any additional savings opportunities to bridge the gap.
16/08/7 Predicted year end savings were noted at 921K, which was above the original plan target of 761K but below the stretch target.
16/08/8 In response to a query from the Committee it was confirmed that the steering group referenced in the report had not yet met and would focus on those activities scheduled for 2017/18.
16/08/9 A request was made by David Crowe for more detail to be provided in the next workstream update. This was supported by the Acting Chair of the Committee. KB As an interim measure it was agreed that an update of line by line savings at M4 be shared with the Committee via email.
It was recommended that all workstream leads be prepared to deliver a detailed update by presentation to ensure effective use of the extended meeting time.
The Management and Corporate Services Review workstream report was NOTED.
Turnaround and Cost Improvement Report 16/08/10 The Committee’s attention was drawn to the content of the report, noting savings at M4 of just less than 2.8m, 36K ahead of the stretch target.
16/8/11 The Infrastructure workstream continued to cause concern. Implementation of the Service Assistants Review had been delayed potentially until February 2017 due to a period of consultation with staff around changes to their role; this delay could result in an in year reduction across the whole work stream of 400K, though others areas are being accelerated to seek to compensate for this underperformance. A discussion about the necessity for consultation took place and Dawn Jarvis confirmed she would seek clarification from the Director of People & OD.
A written update provided by the newly appointed workstream lead would be DJ/KEJ shared with the Committee and as previously agreed they would attend September’s meeting, along with the Director of Estates, to provide a progress update.
16/8/12 An update of all workstreams was provided, those of concern were; Management and Corporate Services, Infrastructure and Income.
16/8/13 A wider discussion around the outstanding debtors, Rotherham and Park Hill, took place and clarity was requested on possible next steps for recovery. It was agreed that Jeremy Cook should attend September’s meeting to provide an JC Page 2 UNAPPROVED DRAFT update on the income workstream.
In response to a query it was confirmed there was no provision in the year end accounts for non-payment of the outstanding significant debt; the Committee expressed concern at this and recommended this be reviewed as a matter of urgency.
16/8/14 A request to incorporate month 1 and 6 positions in the efficiencies summary DJ was agreed. Dawn Jarvis also acknowledged the need to provide a more detailed mid-year review to determine future predictions.
16/8/15 It was noted that as the CYE forecast stood below the 12.4m built into the financial plan a review to ensure that this was achieved as a minimum was needed to ensure no negative impact on the overall financial plan.
16/8/16 The two year recovery plan would be presented to the Board of Directors that week. Once finalised it was agreed that this would be shared with Governors at DJ either a timeout or a specially convened meeting.
16/8/17 Progress of the Medical Productivity workstream had been variable across the specialities and despite the job planning policy not yet being formally signed off by the LNC progress will continue.
The Medical Director would provide an update at September’s meeting. SS
The Turnaround and Cost Improvement update was NOTED
Minutes of the Turnaround Programme Board meeting held on 13 June 2016
16/8/18 It was noted the meeting was not quorate, however, due to the small numbers involved and short notice this was not of concern. Since this time the frequency of the meeting had been reviewed and it would now be held on a bi- monthly basis, alternating with the stakeholder group meeting.
The minutes of the Turnaround Programme Board meeting held on 13 June were NOTED.
Escalation Items from work-streams 16/8/19 Concerns with regards to the infrastructure workstream would be raised at Board of Directors.
Finance Report - Month 4 16/8/20 An overview of the Trust’s financial position was presented by Liela Thorogood. In regards to clinical income it was noted that the underperformance in outpatients procedures had been escalated to the workstream lead and the Chief Operating Officer in order to gain an understanding of the cause and possible recovery plans.
16/8/21 A revised forecast based on the position at month 4 predicted a 16m deficit Page 3 UNAPPROVED DRAFT against a planned deficit of 24.7m; this would be reported in the two year recovery plan along with the detailed methodology used to arrive at this.
Whilst the improved position was recognised as a positive a wider discussion took place around confidence in the prediction and NHSI’s view of the revised year end deficit. It was acknowledged that our initial view had proven to be pessimistic as a full picture was not known when control totals were originally agreed, however, this revised prediction was in line with NHSI’s expectation and had no adverse effect on Trust credibility.
16/8/22 Philippe Serna queried why the improved position was not currently reflected in the Trust’s accounts. An explanation of the calculation was offered, the next stage being to show the improved position in the Trust’s account.
16/8/23 Emerging costs pressures were currently being identified and these would be reviewed and reprioritised against existing pressures to ensure the Trust remained within the 9.5m financial limit.
It was suggested that the transition of medical agency provision to HOLT be considered as a potential emerging cost pressure. Leila Thorogood and Dawn Jarvis would discuss this matter outside of the meeting.
16/8/24 In response to a query regarding the anticipated saving on agency spend for nursing it was agreed that Liela Thorogood would seek clarification on how this LT figure had been arrived at and provide feedback to the Committee.
The finance report was NOTED.
Cash Report 16/8/25 The report summarised the position to date and included an update on key debtors.
16/8/26 Following legal advice the Trust had entered into a formal dispute over outstanding debtors. The next stage of the escalation process would be an exec to exec meeting involving the Director of Finance.
The basis of the dispute was identified with a suggestion of the need to either rebase the price or review the level of service included within the contract. Issues and complications arising from a shared theatre and storage area would be considered when agreeing a contract from 2020.
It was confirmed that 100% provision had been made in the Trust’s accounts for this debt.
The Cash Report was NOTED.
Action Tracker: KPMG Report 16/8/28 Of the three recommendations that were overdue one related to budget sign off. In view of the limited number of returns a communication from the
Page 4 UNAPPROVED DRAFT Finance Director had been issued to all budget holders requesting sign off or advising of the appropriate escalation process. A discussion around the reasons for the lack of response took place and it was agreed that this should be escalated to the Board of Directors. LT/JC
16/8/29 A review of departmental practice had identified potential barriers to the completion of reconciliations both from a capacity and capability perspective. Appropriate plans were in place to ensure adequate cover of trained staff to undertake this activity on a ‘business as usual’ basis going forward.
Whilst remaining concerned that the reconciliations had not been completed, the Committee were reassured by the actions described above and it was agreed that a further update would be provided at the next meeting. A number of the more complex control accounts, namely payroll and petty cash required LT further review to ensure a full picture of the challenges were identified.
The Action Tracker: KPMG Report was NOTED.
Month End Checklist
16/8/30 An improved position was reported as compared to last month with a number of further recommendations by KPMG as part of their audit on the month end checklist. These related to the timeliness of tasks, recording and approval practice and the use of clearer descriptors.
16/8/31 In response to a query regarding cash reconciliation it was agreed that clarification would be provided to the Non-Executive Directors and the Governor observer of agreed protocols. AT/MP
The Month End Checklist was NOTED.
Write off of historical control accounts balance 16/8/32 At the time of the financial misreporting a rapid reconciliation of accounts had taken place. A number of accounts could not be reconciled and a member of staff was recruited to specifically address this as a stand-alone exercise.
16/8/33 Work had now been concluded on the payroll account and a favourable 454K had been held as a provision on the balance sheet against future liabilities. This related to the method of accounting rather than payment errors.
16/8/34 Work to understand the reasons for the prudent reporting of drug costs in Pharmacy was ongoing. Once identified a value would be shared which could either be used to bolster provisions or be fed into the I&E position.
The release of historical control accounts balance was NOTED.
Finance Structure Business Case
16/8/35 The business case, recommended for approval by Management Board, would be presented to the Board of Directors that week. Additional recurrent funding Page 5 UNAPPROVED DRAFT has been sought to ensure a fit for purpose structure, through the creation of a number of new posts and the re-grading of some existing posts.
16/8/36 It was suggested that the Board would expect to receive an assurance from Jeremy Cook that the new Director of Finance had been consulted and provided agreement to the revised structure in support of the case.
16/8/37 In response to a question from David Crowe with regards to justification of the re-grading of certain roles it was confirmed this proposal was due to additional responsibilities being incorporated into job plans. Senior finance colleagues were aware of the proposals and understood that this was subject to review.
The new finance structure be RECOMMENDED to the Board of Directors for approval.
iHospital – Review of procurement of scanners
16/8/38 An update presented by Andrea Smith and Simon Marsh provided the committee with the background to the Electronic Document Management project, a summary of actions to date and the proposed next steps. A meeting scheduled for 1st September to include Ideagen (sub-contractor) and Insight would clarify the position regarding project deliverables.
16/8/39 As the Trust’s view on paperlight versus paperless had changed it was agreed that a discussion needed to take place to identify care group and directorate requirements with a final decision to be made by the Executive Team of the way forward. With regards to a timeframe for implementation it was agreed that it was too early at this stage to determine this because of the need to establish requirements.
16/8/40 In response to a question from Philippe Serna it was agreed the main outcome of the 1 September meeting was to ensure that all parties agreed on the current position of the project in terms of what had been delivered. The Trust was also keen to understand what work has been undertaken with other Trusts to move to a paperless situation and if the Trust’s current contract was sufficient to support this.
16/8/41 In answer to a question in respect of the overall cost of the project this would be dependent upon the outcome of the discussions and the Trust’s decision
regarding use of the solution. If the decision was not to utilise the supplied equipment then negotiations around outstanding costs would take place. LT/MP There was a need to identify if provision for this as a cost pressure had been
made.
16/8/42 An update on the outcome of the meeting on 1st September would be provided AS at the next meeting.
The update of the iHospital /EDM project was NOTED. Items for escalation to Board of Directors
Page 6 UNAPPROVED DRAFT 16/8/43 It was agreed that the following items should be escalated; clarification of budget provision for Rotherham debt (16/8/13), Infrastructure workstream (16/8/19) and budget sign off (16/8/28).
Any other business None. Time and date of next meeting: Date: 26 September 2016 Time: 9am Venue: Meeting Room 1 (Directorate of S&I opposite Gate 3 DRI)
Signed:…………………………………………….. …………………………………. Philippe Serna Date
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