Business Meeting of the Board of Directors
Thursday 7 March 2019
Session in public 10am – 1pm
Education Centre Queen Victoria Hospital Holtye Road East Grinstead West Sussex RH19 3DZ
MEETINGS OF THE BOARD OF DIRECTORS: 7 March 2019
Members (voting):
Chair - Beryl Hobson
Senior Independent Director - John Thornton
Non-Executive Directors: - Ginny Colwell - Kevin Gould - Gary Needle
Chief Executive: - Steve Jenkin
Medical Director - Ed Pickles
Director of Nursing - Jo Thomas
Director of Finance and Performance - Michelle Miles
In full attendance (non-voting):
Director of Operations - Abigail Jago
Director of Workforce & OD - Geraldine Opreshko
Director of Communications and Corporate Affairs - Clare Pirie
Deputy Company Secretary (minutes) - Hilary Saunders
Lead Governor - John Belsey
Annual declarations by directors 2018/19
Declarations of interests
As established by section 40 of the Trust’s Constitution, a director of the Queen Victoria Hospital NHS Foundation Trust has a duty:
• to avoid a situation in which the director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the foundation trust. • not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity. • to declare the nature and extent of any relevant and material interest or a direct or indirect interest in a proposed transaction or arrangement with the • foundation trust to the other directors.
To facilitate this duty, directors are asked on appointment to the Trust and thereafter at the beginning of each financial year, to complete a form to declare any interests or to confirm that the director has no interests to declare (a ‘nil return’). Directors must request to update any declaration if circumstances change materially. By completing and signing the declaration form directors confirm their awareness of any facts or circumstances which conflict or may conflict with the interests of QVH NHS Foundation Trust. All declarations of interest and nil returns are kept on file by the Trust and recorded in the following register of interests which is maintained by the Deputy Company Secretary.
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Register of declarations of interests Relevant and material interests Directorships, including Ownership, part ownership Significant or A position of authority Any connection with a voluntary or Any Any "family non-executive or directorship of private controlling share in in a charity or voluntary other organisation contracting for connection interest": an directorships, held in companies, businesses or organisations likely or organisation in the field NHS or QVH services or with an interest of a private companies or consultancies likely or possibly seeking to do of health or social care. commissioning NHS or QVH organisation, close family public limited possibly seeking to do business with the NHS services. entity or member which, companies (with the business with the NHS or or QVH. company if it were the exception of dormant QVH. considering interest of that companies). entering into or director, would having entered be a personal or into a financial pecuniary arrangement interest. with QVH, including but not limited to lenders of banks. Non-executive and executive members of the board (voting) Beryl Hobson Director: Professional Part owner of Nil PGS clients include health Not as far Nil Chair Governance Services Professional Governance charities, including a Royal as I am Ltd Services Ltd College and a health based aware livery company. PGS has also Director of recently undertaken work for a Longmeadow Views charity in East Grinstead Management Company Ginny Colwell Board advisor for Nil Nil Nil Nil Nil Nil Non-Executive Director Hounslow & Richmond Community Healthcare NHS Trust
Kevin Gould Director, Sharpthorne Nil Nil • Trustee and Sharpthorne Services has a Nil Nil Non-Executive Director Services Ltd; Director Deputy Chair for contract to provide consulting CIEH Ltd The Chartered services to Grant Thornton LLP, Institute of although no work has been Environmental performed to date. Health • Independent member of the Board of Governors at Staffordshire University
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Gary Needle 1. Director, Gary Chair of Board of Nil Nil Nil Nil Nil Non-Executive Director Needle Ltd, Trustees at East (management Grinstead Sports Club Ltd consultancy) (registered sport and 2. Director, T& G lifestyle activities charity) Property Ltd (residential property development)
John Thornton 1. Non-Executive Nil Nil Nil Nil Nil Nil Senior Independent Director: Golden Director Charter Ltd 2. Director of Oakwell Consulting Ltd
Steve Jenkin Nil Nil Nil Nil I have known David Cowan (of Nil Nil Chief Executive Cowan Architects, East Grinstead) for 20 years Michelle Miles, Nil Nil Nil Nil Nil Nil Nil Director of Finance
Ed Pickles Nil Nil Nil Nil I am a member of EGAS (East Nil Nil Medical Director Grinstead Anaesthetic Services). A partnership of QVH anaesthetic consultants who, in addition to their NHS work, also provide some private perioperative and anaesthetic care to patients in several local independent hospitals. These patients may be privately insured, self-funded or as part of an NHS contract in the independent sector
Jo Thomas Nil Nil Nil Nil Nil Nil Nil Director of Nursing Other members of the board (non-voting) Abigail Jago Nil Nil Nil Nil Nil Nil Director of operations Geraldine Opreshko Nil Nil Nil Nil Nil Nil Nil Director of HR & OD
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Clare Pirie Nil Nil Nil Nil Nil Nil Nil Director of Communications & Corporate Affairs John Belsey Director of Golfguard Nil Nil Trustee of Age UK None anticipated Nil Nil Lead governor Ltd Ltd, East Grinstead & Director of Mead District Sport & Leisure Ltd Councillor, Mid Sussex District Council
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Fit and proper person declarations
As established by regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the regulations”), QVH has a duty not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director of the trust under given circumstances known as the “fit and proper person test”.
By completing and signing an annual declaration form, QVH directors confirm their awareness of any facts or circumstances which prevent them from holding office as a director of QVH NHS Foundation Trust.
Register of fit and proper person declarations
Categories of person prevented from holding office The person is an The person is the The person is a person The person has made a The person is included The person is The person has been undischarged subject of a bankruptcy to whom a moratorium composition or in the children’s barred prohibited from holding responsible for, been bankrupt or a person restrictions order or an period under a debt arrangement with, or list or the adults’ barred the relevant office or privy to, contributed to, whose estate has interim bankruptcy relief order applies granted a trust deed list maintained under position, or in the case or facilitated any had a sequestration restrictions order or an under Part VIIA (debt for, creditors and not section 2 of the of an individual from serious misconduct or awarded in respect order to like effect relief orders) of the been discharged in Safeguarding carrying on the mismanagement of it and who has not made in Scotland or Insolvency Act respect of it. Vulnerable Groups Act regulated activity, by or (whether unlawful or been discharged. Northern Ireland. 1986(40). 2006, or in any under any enactment. not) in the course of corresponding list carrying on a regulated maintained under an activity, or discharging equivalent enactment in any functions relating to force in Scotland or any office or Northern Ireland. employment with a service provider. Non-executive and executive members of the board (voting) Beryl Hobson NA NA NA NA NA NA NA Chair Ginny Colwell NA NA NA NA NA NA NA Non-Executive Director Kevin Gould NA NA NA NA NA NA NA Non-Executive Director Gary Needle NA NA NA NA NA NA NA Non-Executive Director John Thornton NA NA NA NA NA NA NA Non-Executive Director Steve Jenkin NA NA NA NA NA NA NA Chief Executive
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Michelle Miles NA NA NA NA NA NA NA Director of Finance Ed Pickles NA NA NA NA NA NA NA Medical Director Jo Thomas NA NA NA NA NA NA NA Director of Nursing Other members of the board (non-voting) Abigail Jago NA NA NA NA NA NA NA Director of operations Geraldine Opreshko NA NA NA NA NA NA NA Director of HR & OD Clare Pirie NA NA NA NA NA NA NA Director of Communications & Corporate Affairs John Belsey NA NA NA NA NA NA NA Lead governor
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Business meeting of the Board of Directors Thursday 7 March 2019 10:00 – 13:00 Education Centre, Queen Victoria Hospital RH19 3DZ
Agenda: session held in public
Welcome 39-19 Welcome, apologies and declarations of interest Beryl Hobson, Chair Standing items Purpose Page 40-19 Patient story assurance - Jo Thomas, Director of nursing 41-19 Draft minutes of the meeting held in public on 3 January 2019 approval 1 Beryl Hobson, Chair 42-19 Matters arising and actions pending review 9 Beryl Hobson, Chair 43-19 Chair’s report assurance 10 Beryl Hobson, Chair 44-19 Chief executive’s report assurance 13 Steve Jenkin, Chief executive 45-19 Freedom to speak up assurance 73 Sheila Perkins, FTSU guardian Key strategic objectives 3 and 4: operational excellence and financial sustainability 46-19 Board Assurance Framework Abigail Jago, Director of operations and assurance 76 Michelle Miles, Director of finance 47-19 Financial, operational and workforce performance assurance assurance 78 John Thornton, Committee chair 48-19 Operational performance assurance 81 Abigail Jago, Director of operations 49-19 Financial performance assurance 103 Michelle Miles, Director of finance Key strategic objective 5: organisational excellence 50-19 Board assurance framework assurance 114 Geraldine Opreshko, Director of workforce and OD
51-19 Workforce monthly report assurance 115 Geraldine Opreshko, Director of workforce and OD 52-19 Staff survey results 2018 assurance 129 Geraldine Opreshko, Director of workforce and OD Key strategic objectives 1 and 2: outstanding patient experience and world-class clinical services 53-19 Board Assurance Framework Jo Thomas, Director of nursing, and assurance 139 Ed Pickles, Medical director 54-19 Quality and governance assurance assurance 141 Ginny Colwell, Non-executive director and committee chair 55-19 Corporate risk register (CRR) review 144 Jo Thomas, Director of nursing 56-19 Quality and safety report Jo Thomas, Director of nursing, and assurance 151 Ed Pickles, Medical director Governance 57-19 QVH/WSHT/BSUH Joint executive programme board update and approval of ToRs approval 199 Steve Jenkin, Chief executive 58-19 Nomination and remuneration committee assurance 209 Beryl Hobson, Chair 59-19 Annual review of Board performance assurance 211 Clare Pirie, Director of communications and corporate affairs 60-19 Annual review of Board committee terms of reference approval 231 Clare Pirie, Director of communications and corporate affairs Any other business (by application to the Chair) 61-19 Beryl Hobson, Chair discussion -
Questions from members of the public 62-19 We welcome relevant, written questions on any agenda item from our staff, our members or the public. To ensure that we can give a considered and comprehensive response, written questions must be submitted in advance of the meeting (at least three clear working days). Please forward questions to [email protected] clearly marked "Questions for the discussion - board of directors". Members of the public may not take part in the Board discussion. Where appropriate, the response to written questions will be published with the minutes of the meeting. Beryl Hobson, Chair Date of the next meetings Board of directors: Council of governors Public: 02 May 2019 at 10:00 Public: 08 April 2019 at 16:00
Feedback session to be led by John Thornton (NED)
Document: Minutes (draft and unconfirmed) Meeting: Board of Directors (session in public) Thursday 3 January 2019, 11:00 – 14:00, Education Centre, QVH site Present: Beryl Hobson, (BH) Trust chair (voting) Ginny Colwell (GC) Non-executive director (voting) Kevin Gould (KG) Non-executive director (voting) Abigail Jago (AJ) Director of operations (non-voting) Steve Jenkin (SJ) Chief executive (voting) Michelle Miles (MM) Director of finance (voting) Gary Needle (GN) Non-executive director (voting) Ed Pickles (EP) Medical director (voting) Clare Pirie (CP) Director of communications and corporate affairs (non-voting) Jo Thomas (JMT) Director of nursing (voting) John Thornton (JT) Non-executive director (voting) In attendance: Hilary Saunders (HS) Deputy company secretary (minutes) Nicolle Ferguson (NF) Patient Experience Manager Dave Hurrell (DH) Deputy director of HR Nicolle Ferguson (NF) Patient experience manager [07-19] Apologies: Geraldine Opreshko (GO) Director of workforce and OD (non-voting) Public gallery: Two members of the Care Quality Commission and five members of the QVH Council of Governors.
Welcome
06-19 Welcome, apologies and declarations of interest BH opened the meeting and welcomed DH who was attending on behalf of GO. She went on to welcome as observers Elizabeth Kershaw, inspection manager CQC hospital division, Jacquie Nye CQC Inspector (South East), Acute Hospitals Directorate and five public members of the Council of Governors..
There were no new declarations of interest.
Standing items 07-19 Patient story BH noted the difficulties of identifying a patient who would be prepared to come to Board so early in the New Year. However, NF (the Trust’s Patient experience manager) had agreed instead to provide the Board with an overview of a recent NHS Elect seminar she had attended recently entitled ‘Delivering Great Patient and Customer Care’.
Part of the seminar focus had been on the Friends and Family Test (FFT). Since its inception in 2015, this had become a quantitative rather than qualitative tool which was not the original purpose, and a review was underway by NHS England to improve the way that it works across the country.
NF proposed a number of ways of improving board engagement in the clinical area which included: • inviting a staff member to provide a patient story. • sponsoring a bed and/or chair; board members might then approach the occupant for feedback on their experience, and would gain genuine insight on a random basis.
The Board also asked for suggestions on how to engage with those patients who might be harder to reach. NF described a training video which featured a patient with learning disabilities, and suggested this could be presented at a future seminar. The Board asked that the proposals above be progressed. [Action: CP]
There were no further comments and the Chair thanked NF for her update.
08-19 Draft minutes of the meeting session held in public on 1 November 2018 The minutes of the meeting held in public on 6 September were APPROVED as a correct record, subject to the following amendments: • 171-18: Should read ’52-week breaches’
QVH BoD PUBLIC March 2019 Page 1 of 254 • 173-18: Should read ‘Trust’s quality indicators were being reviewed to include MRSA colonisations….’
09-19 Matters arising and actions pending The board received and approved the current record of matters arising and actions pending.
10-19 Chair’s report As part of her report, BH drew particular attention to feedback from the November Trust induction at which staff had raised concerns at the time taken to offer jobs. However, she stated she was aware that the Workforce team had since been actively working on processes to improve this situation and she invited DH to provide an update.
DH explained that a high turnover of recruitment staff in Q2, coupled with changes in new doctor rotation had exacerbated problems. However, improved recruitment and systems training had now been introduced and an additional post within the recruitment team had been appointed to support the team. Although these changes had accelerated the process, there was still room for improvement.
There were no further comments and the Board NOTED the contents of the latest update.
11-19 Chief executive’s report SJ opened by thanking all staff who had worked over the Christmas and New Year period. He went on to congratulate Marianne Griffiths, (currently leading Western Sussex Hospitals NHS FT and Brighton and Sussex University Hospitals NHS Trust), who had been awarded a damehood for services to the NHS in the New Year Honours List.
He then presented his regular report, comprising: • Board Assurance Framework (BAF) overview: This had been reviewed in December and highlighted that recruitment and retention remained one of the most significant challenges facing the NHS, (although QVH had seen a slight improvement recently, with annual rolling turnover in theatres under 20%). The Trust’s underlying poor financial performance was continuing, and there was now a significant risk to achieving our full year plan. • The main report, including: • A report that the NHS 10-year plan was due for publication shortly. There were clear expectations that the £20bn investment announced in July 2018 should enable trusts to return to financial balance, and achieve those standards required under the NHS Constitution. • Recently received Brexit guidance: ‘No deal’ planning was now moving to operational stage, with required actions to be taken locally to manage the risks of a ‘no-deal’ exit. The Trust’s Senior Responsible Officer (SRO) for EU Exit preparation was MM, who was leading a team comprising leads for Emergency planning, Procurement and Pharmacy. The Board was reminded that the message was not to stockpile goods/medicines etc. The Trust was holding weekly meetings to review implications and the executive management team would consider amending the corporate risk register to reflect the position. The Board was also assured that the Trust was providing support to those EU citizen staff who don’t separately hold settled status in the UK, and had agreed to fund their applications. • Shelia Perkins was now the Trust’s Freedom to Speak up (FTSU) Guardian. There had been three nominations for the role, with the election overseen by the Electoral Commission. • Confirmation that CQC will carry out a provider level inspection of ‘well led’ on 26th and 27th February. In addition, an unannounced inspection of at least one core service would take place at some point prior to the well-led inspection. • Following a generous donation from the League of Friends, the new CT scanner is now installed and operational. • NHS England and NHS Improvement announced its new joint senior leadership team, (the NHS Executive Group). The Executive Regional Managing Director for NHSI & NHSE in the South East is Anne Eden.
The Board commended the new style balanced score care which highlights challenges as well as improvements. It was noted that whilst there continued to be issues with RTT-18 and 52-week targets, the direction of travel was right for both metrics, and the Trust had exceeded those targets agreed by commissioners. The Board again noted the Trust’s long term financial sustainability as a risk.
QVH BoD PUBLIC March 2019 Page 2 of 254 The Board discussed the study commissioned by the Federation of Specialists Hospitals (attached as an appendix to the report). This provided examples of specialist hospitals sharing expertise, adopting standardised pathways and undertaking leadership roles. Whilst welcoming the report, it was noted that more support, including financial, would be required to implement the new care models.
The Board noted the media update and that that given the size of our organisation, QVH generated a strong media and social media presence.
Key strategic objectives 1 and 2: outstanding patient experience and world-class clinical services
12-19 Board assurance framework KSO1: The Board noted that the rationale for the current score included concerns in respect of workforce; however, there was regular triangulation of evidence to provide assurance that a good patient experience was being maintained.
KSO2: The rationale for the current risk rating now included commissioning and reconfiguration of head and neck services. STP and cancer alliance regional meetings for head and neck services in both Kent and Sussex were planned for January and February respectively, and EP welcomed the opportunity to discuss regional networks of care for head and neck cancer, assuring the Board that QVH’s aspiration to lead maxillofacial services across the STPs would be made clear.
13-19 Quality and governance assurance Due to time constraints, GC had been unable to produce a written report for inclusion in the Board pack but asked that this be circulated after today’s meeting. In the meantime, she updated the Board as follows: • A serious incident (subsequently upgraded to a never event) had been declared regarding a retained object. Although the incident had taken place in April, it had not been identified until November. The Board had been notified of this immediately. A root cause analysis had been undertaken and an action plan agreed. • Two dermatome incidents (wrong depth grafts) had been reported. As similar incidents had occurred in the past, the Committee asked for an investigation into the reasons, with a report to be submitted to its next meeting. • The commissioning and STP reconfiguration of head and neck services had been added to KSO2, and also to the corporate risk register. • The Committee had received a report on QVH’s participation in the Getting it Right First Time (GIRFT) national initiative. GC explained that this was an important initiative and subsequent action plans would be monitored through the Q&GC. • The Patient experience report had highlighted how the Trust should manage the lessons learnt from claims. This will be considered more widely at a future Joint Hospital Governance meeting. • The Quality and safety report highlights significant risks to the safe provision of care due to current workforce challenges, but GC was assured that the organisation was doing everything possible to maintain a good patient experience.
There were no further comments and the Board NOTED the contents of the update.
14-19 Corporate risk register The board received the corporate risk register (CRR), noting that key changes in the last two months were that one new Corporate risk had been added, 10 risks had been closed and 11 risk scores reviewed.
The Board sought and received assurance that the new risk relating to Pharmacy was not the same as that which had been closed, and that this reflected different challenges.
The Board also sought clarification with regard to mitigation of risks. JMT assured the meeting that detailed information was available, and she would ensure this was included on future registers. [Action: JMT]
The Board commended the Head of risk for work undertaken to ensure the CRR was now a dynamic, rigorous document. Members sought and received assurance regarding several risks which had been re-scored downwards, noting that this was evidence of effective risk management. However, it was also reminded that new risks, (for example, impact of Brexit and challenges with the Electronic Document Management system) would be added to the CRR before the next board meeting.
QVH BoD PUBLIC March 2019 Page 3 of 254 There were no further questions and the Board NOTED the contents of the latest update.
15-19 Quality and safety report JMT presented the latest Quality and safety update asking the board to note that in particular:
• The Trust had declared a never event in November, the first since October 2017; this related to retention of a trochar-cover, (not subject to a formal count). JMT described circumstances leading up to the incident. The investigation was now complete, with an action plan to share identified learning; this was presented at the December Clinical Governance Group, prior to being reviewed by Quality and Governance Committee. The report was due for submission to the Clinical Commissioning Group Serious Incident Scrutiny Panel at the end of January. JMT noted that this declaration had been made only after some consideration with Commissioners and Regulators as the incident didn't fit the definition of a never event when referencing the NHSI Never Events policy and framework (2018). The Board discussed other potential areas in which an incident like this could occur, for example surgical trollies where it would be difficult to ensure consistency in routine counting and disposal of covers. The position would continue to be monitored and the Board was assured that current practice, supported by policy, was good.
• Whilst focus remained on provision of high quality care and sustained patient experience, there were significant risks to safe provision of care due to workforce recruitment and retention challenges and RTT 52 week breaches, (as highlighted under KSO1 BAF). Quality assurance processes included enhanced scrutiny of key safe care metrics; these were triangulated with workforce and patient experience data on a daily and weekly basis. There had been few patient complaints and all issues resolved without escalation to the Ombudsmen. International and domestic recruitment continued, and there had been an improvement on staffing in theatres and critical care.
• In October, heads of nursing from CCG & Specialist Commissioning undertook a planned review of theatres as part of an ongoing quality assurance cycle. Positive feedback had been received with no new concerns raised, the recommendations from this have been incorporated into the existing theatre action plan.
The Board sought an update on the work underway to provide separate entrances to the burns and critical care units in order to improve compliance with infection control standards. There was a brief discussion as to why this would not be achievable in this financial year. This led on to a wider debate about the Trust’s capital programme which would be monitored carefully by the Finance and performance committee in future.
The Board asked for an update on the overseas recruitment programme. Staff had not arrived as swiftly as hoped due to a number of factors but the executive team were confident that the full cohort should be in post by June 2019. In the meantime, the Trust was continuing with domestic recruitment and currently exploring international recruitment options with another local trust which had over recruited for theatre staff. The Board again asked that regular updates be provided through the Finance and performance committee.
The Board commented that very fine margins on metrics within the Q&GC reports, (ie. no amber rating), provided positive assurance at the level of scrutiny applied.
EP provided an update on the planning of collaborative clinical work between WSHT, BSUH and QVH. It was hoped that business plans for the plastics and burns projects would be presented to Board in March. The business case and indicative costs would also be submitted to commissioners. It was noted that although separate business cases, they were co-dependent. Patient and stakeholder engagement was running in tandem and would inform the final outcome.
There were no further questions and the Board NOTED the contents of the report.
16-19 2018 Emergency preparedness, resilience and response (EPRR) assurance The Board reviewed the results of the external assessment by the Clinical commissioning group and NHS England of our preparedness against the common NHS Emergency, Preparedness, Resilience and Response (EPPR) Core Standards. JMT explained that the Trust is required to carry out a self-assessment and ensure the QVH Board is sighted on the process and results. Assurance and oversight of the EPPR work programme and action plans was managed by the Quality and governance committee.
The Board sought assurance regarding the Trust’s self-assessment against the core standards for emergency
QVH BoD PUBLIC March 2019 Page 4 of 254 planning undertaken by the Deputy director of nursing (DDN). JMT explained this had been reviewed with the lead commissioner and NHS England, with additional assurance provided to the emergency planning officer at the CCG. A joint presentation had then been compiled by the CCG and DDN, and presented for peer review by the Local Health Resilience Partnership (LHRP).
The standard against which QVH is not compliant relates to the Trust’s inability to send representation to both the executive meeting as well as the delivery group. SJ suggested that on-call manager responsibilities should be reviewed in the light of this. JMT confirmed this was being progressed.
JMT reminded the Board that as QVH was not a first line responder our partial compliance would not impact on any major incident. After a short discussion, the Board was assured that compliance was adequate for the level of response required and NOTED the partial compliance rating, together with the contents of report.
Key strategic objectives 3 and 4: operational excellence and financial sustainability
17-19 Board assurance framework KSO3: The Board noted that the rationale for the current score included concerns in respect of managerial capacity.
KSO4: The current risk rating of 20 was as a result of the forecast deficit. A board meeting would be convened on 14 January to approve the financial reforecast.
The Board NOTED the contents of the latest BAFs for KSOs 3 and 4.
18-19 Financial, operational and workforce performance assurance JT presented his report following the most recent Finance and performance committee.
The Board sought and received assurance in respect of the Electronic Document Management (EDM) system. Whilst some progress had been made on some of the operational challenges, a follow-up clinical review had highlighted a number of significant risks. The Board was assured that this had now been added to the CRR in December, with mitigations in place; in addition, EP had been appointed project clinical lead to add further rigour. The current target date for continuing roll out is May; elements of this project would continue to be managed by both Q&GC and F&PC.
19-19 Operational performance AJ presented the latest operational performance report asking the Board to note the following key items: • Trajectories for 2019/20 were now agreed with commissioners. • The Trust continued to work with commissioners on 2018/19 targets, however it would be difficult to sustain capacity in the coming months. • Steady progress had been made on cancer standards with delivery of 2-week and 31-day targets. • Increasing demand coupled, with sickness, had caused an increase in waiting times for Ultrasound; staffing issues continued to create difficulties within Sleep, but no current breaches were identified for January. • Diagnostic imaging: As reported under [11-19], the onsite CT scanner was now live and should gradually support improvement in performance standards. • eRS bookings for GP referrals were above 98% in December, (with less than 10 paper referrals returned weekly). • The Trust was working collaboratively with commissioners to develop new clinical Standard Operating Procedures (SOPs) for dental e-referrals (DeRS). • Project work with FourEyes on theatre productivity was moving increasingly towards business as usual.
The Board commended the high level of eRS bookings for GP referrals which had been due to a fully collaborative system-wide process.
There were no further comments and the Board NOTED the contents of the update.
20-19 Financial performance MM presented the latest finance report advising that: • The Trust would not achieve its control total by the end of the financial year. An exceptional Board meeting
QVH BoD PUBLIC March 2019 Page 5 of 254 had been arranged for 14 January to approve a reforecast which could stand at approximately £6m. NHSI had been made aware of the likely deficit and the Board noted the importance that the reforecast would be achievable by QVH. • The current report did not show the full level of achievement on Cost Improvement Programmes (CIPs), but the changes would not significantly affect the bottom line. • The capital plan was behind, and would also be reforecast this month for submission to NHSI.
The Board sought clarification as to what extent the capital plan would be reforecast; it was advised that whilst there was confidence around medical equipment and IM&T, there had been delays within Estates. However, a substantive capital projects manager was now in post, and significant amount of tendering undertaken in the last couple of months, with several projects due for completion before year-end.
It was noted that the Trust had made limited progress on identification and realisation of CIPs since the beginning of the year; and that the plan had been very ambitious for an organisation the size of QVH. Challenges had been compounded by the RTT-18 wait list issue, and impact of workforce shortages. The Board debated at length its concerns regarding the Cost Improvement Programme. It concluded that there was limited benefit in debating further as to how the Trust had arrived at this position; of greater value would be to focus on developing a culture where everyone took responsibility for achieving cost reduction, whilst maintaining quality, through rigorous process.
The Board noted that commissioners recognised the need to resource the additional waiting list work, and that ongoing work to agree how this will be covered in contracts was significant for QVH. The Board agreed that QVH had done the right thing for patients in prioritising waiting list improvements. SJ stated that he was in discussion with NHSI about what support may be available for a turnaround approach.
There were no further comments and the Board NOTED the contents of the update.
21-19 Network 7 pathology contract MM presented a report for approval by the Board regarding the Network 7 pathology contract. She advised that QVH were asked to join a pathology network in October 2017. The Trust now has an opportunity to become a member in the new STP wide pathology network, (comprising all local acute trusts - apart from East Sussex Healthcare at present).
The Board sought and received assurance that although the business case had yet to be finalised, there would be no current cost or staffing implications. The executive team also clarified that these services related to blood pathology (not histopathology which remained in house).
NHSI required the Trust to provide formal written confirmation that the Chair, CEO and Medical Director agreed the scheme. After a short discussion during which the executive set out the benefits in terms of cost savings and increased resilience, the Board APPROVED the proposal.
22-19 Estates strategy MM provided a verbal update on the report she had commissioned on the potential value of the land proposed for sale. This was now valued at £1.5-2m due to constraints imposed by the planners. This was a significant reduction on the original £8-10m estimate.
MM stated that it was clear that the Trust would not achieve planning permission in this financial year. However, QVH had received an initial offer for purchase of the land without planning permission for £1.8-2m. In addition, a further organisation had also expressed an interest.
To support the decision making process, MM agreed to prepare an options appraisal to consider these approaches, alongside sale of the land with planning permission. This would be presented to the January Finance and performance committee. The Board would be updated at the February Board seminar, prior to a decision being made at the March public Board. [Action: MM]
Key strategic objective5: organisational excellence
23-19 Board assurance framework The Board noted that the current risk rating remained the same. Under ‘controls and assurance’, the Board
QVH BoD PUBLIC March 2019 Page 6 of 254 noted the following: • This had been updated to reflect that QVH had been chosen as a pilot site for the Best Place to Work initiative. • The timeline for overseas recruitment should be amended to reflect that the first influx did not arrive in Q3 2018 [Action: GO]
There were no further comments and the Board NOTED the latest BAF for KSO5.
24-19 Workforce monthly report DH presented the latest Workforce and OD report which provided a breakdown of key workforce indicators and information linked to performance.
He reported that the 2017/18 NHS Public Sector Apprenticeship Target report had been published, and asked the Board to note that the NHS target for all staff to start an apprenticeship in any given year was 2.3%. Whilst the NHS as a whole achieved 1.2%, QVH had achieved 2.2% which was the highest within the Kent, Surrey Sussex region.
Despite the increase in substantive staff numbers, there had not been a corresponding fall in the use of temporary staff. DH assured the Board that stringent appointment processes were now in place, with weekly monitoring undertaken at executive management team meetings.
The Board noted that high volumes of recruitment continued, although registered nursing and theatre practitioner vacancies were still a challenge. There was discussion of what type of roles make up the additional posts and filled vacancies. It was agreed that an additional section (detailing external hires and internal movers based on WTE, by staff group and department, from Aug 2018) would be added to the workforce report for Finance and performance committee. [Action: GO]
There were no further questions, and the Board NOTED the contents of the latest update.
25-19 People and organisational development strategy The Board considered the latest version of the ‘People and organisational development strategy’ following its review at the December seminar. Recognising that not all objectives were quantifiable, the Board queried how it would gain assurance that the strategy was achieving key objectives. It asked that GO provide more detail on how quality would be measured in addition to the examples contained within the introduction, and report back to the May board meeting. [Action: GO]
There were no further comments and the Board APPROVED the strategy.
Governance
26-19 Audit committee The Board noted the report on the meeting which took place on 12 December.
KPMG had provided its update and plan for the 2018/19 audit. KG noted that given the deterioration in the Trust’s financial position, there was now increased risk over the sustainable resource deployment element of the Value for Money criteria.
The Committee had also noted that significant effort would be required from the Finance team to ensure compliance with new accounting standards. MM confirmed that she and SJ were having ongoing discussions regarding resourcing.
The Board queried the reasons for the amount of internal audit work still due for completion. KG explained that this was due to delays on Mazars’ part but also as a result of the Trust postponing audits until later in the year. MM reminded the Board that the internal audit contract would be retendered in March 2019, but in the meantime, she was liaising regularly with Mazars to directly oversee output.
There were no further comments and the Board NOTED the contents of the update. Any other business
QVH BoD PUBLIC March 2019 Page 7 of 254 27-19 There was none.
Questions from members of the public
28-19 There were none.
Chair …………………………………………………. Date ………………………
QVH BoD PUBLIC March 2019 Page 8 of 254 Matters arising and actions pending from previous meetings of the Board of Directors ITEM MEETING REF. TOPIC CATEGORY AGREED ACTION OWNER DUE UPDATE STATUS Month 1 Jan 2019 07-19 Patient story Standing items Proposals from Patient Experience lead CP Jun-19 Pending for improving board engagement to be progressed 2 Jan 2019 14-19 CRR KSO1 More detailed information with regard to JMT Mar-19 Pending mitigation of risks to be included in future CRRs 3 Jan 2019 22-19 Estates strategy KSO4 Options appraisal to be prepared. This MM Mar-19 should be presented to January F&PC, Board will be updated at the February seminar. Formal decision to be made at March public meeting 4 Jan 2019 23-19 BAF KSO5 Timeline for overseas recruitment to be GO Mar-19 Pending amended to reflect that the first influx did not arrive in Q3 2018 5 Jan 2019 24-19 Workforce report KSO5 Additional section detailing external hires GO Mar-19 Pending & internal moves, based on WTE by staff group & department (fro Aug 2018) to be included in workforce reporting to F&PC
6 Nov 2018 171-18 Q&GC assurance KSO1 Review of RTT18 waiting list issue to be CP Feb-19 Scheduled for February 2019 Pending included as part of BoD seminar work programme
QVH BoD PUBLIC March 2019 Page 9 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: Thursday, 07 March, 2019 Agenda reference: 43-19 Report title: Chair’s Report Sponsor: Beryl Hobson, Chair Author: Beryl Hobson, Chair Appendices: NA
Executive summary Purpose of report: To update the Board of Directors on the Chair, NED and governors activities since the last board meeting Summary of key issues Recommendation: For the Board to NOTE the report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework:
Corporate risk register:
Regulation:
Legal:
Resources:
Assurance route Previously considered by: Date: Decision: Previously considered by: Date: Decision: Next steps:
QVH BoD PUBLIC March 2019 Page 10 of 254
Report to: Board of Directors Meeting date: 07 March 2019 Agenda item reference no: 43-19 Report from: Beryl Hobson, Chair Date of report: 25 February 2019
Chair’s Report
Overview
1. As I write this report we are awaiting our CQC well-led inspection over the next two days. The unannounced inspection occurred earlier this month and I would like to thank all our teams who responded so well to the inspection. I would also like to thank the Executive Directors and their teams, particularly Kelly Stevens, who have responded efficiently to the requests for information from CQC.
Chair’s activities
2. Our two longest serving Non-Executive Directors will be leaving the Trust this year at the end of their terms of office. Ginny Colwell (Chair of the Quality and Governance committee) will be leaving in April 2019 and John Thornton (Chair of the Finance and performance committee and Senior Independent Director) will be leaving in September 2019. The Council of Governors has now advertised for two new Non-Executives. Prior to the recruitment exercise we undertook a skills audit of the remaining and departing Non- Executive Directors and recommended to the Governors that we should look for one NED with clinical experience and one with a financial background (preferably to include estates and IT experience). The advertising campaign was led by in-house teams and we have received an amazing total of 86 applications. The Corporate Affairs team, the Director of Workforce and myself have worked with the Governor’s Appointment committee to reduce the 86 applicants down to a manageable shortlist. I am grateful to everyone involved as this has been a time consuming but worthwhile exercise and I am convinced that we will be able to appoint two very high quality candidates. The interviews (over two days) will take place in March and May.
3. Potential applicants for the NED role were offered the opportunity to speak to me about the role and ask any questions – as a result I spoke to 15 people (over 2 days). It became clear from these conversations that there were many high quality applicants coming forward.
4. As this is Ginny’s last public board meeting (she will be here for the board seminar in April and one final Q&G committee) I would like to pay tribute to her service with the Trust since 2013. Ginny’s senior clinical experience has been a great asset to the board as has her wide experience of other healthcare organisations. Ginny has always combined her challenge with care and support for our teams, and I will miss her sense of humour and her constant reminder to ensure that we put the patient at the centre of all our deliberations as a board.
QVH BoD PUBLIC March 2019 Page 11 of 254 5. As a result of the departure of our two committee chairs, we will be reconsidering which NEDs are on which committees – in particular the Chairs of committees. We have decided to consider this once we know who the appointed candidates are, and what experience they will bring. It is however highly likely that the ‘clinical’ NED will Chair the Quality and Governance committee.
6. Since the last board meeting, I have attended a number of meetings and walk rounds including: a. Trust induction – the CEO and I attend the first hour of induction for all new members of staff. In January it was noticeable that a number of the people on the induction course were ‘returners’ to the Trust. It was good to see them again and to hear that they had really wanted to come back to work at QVH and will bring their experience elsewhere with them. b. Walkabouts – since I was appointed I have always undertaken ‘walkabouts’ around the Trust. The purpose of these walkabouts is threefold – to increase board visibility, listen to staff and to enable me to observe what is happening to be able to ‘triangulate’ the information we receive at board. Recent visits include: - C-wing wards - Cashiers - Rowntree Theatre - Estates - Library - Volunteers (front desk) and reception These visits are invaluable in enabling me to understand the work of the Trust and the challenges facing our teams in their day to day work. c. Chair and CEO breakfast and afternoon tea. Steve Jenkin and I make ourselves available in the Spitfire café once a month for staff to come and meet us. These sessions attract a number of staff each time which can vary from one up to eight staff members in a one-hour session. What is particularly encouraging is that staff come with both concerns and also to say thank you for action that has been taken on their behalf (and sometimes just for a chat).
External engagements 7. I attended the annual HFMA Chair conference. As QVH is a corporate member of HFMA we are able to access a high quality level of training and development at no additional cost. This year’s speakers included the Chair of CQC, Peter Wyman (who encouraged Chairs to give him feedback about Well-Led inspections!) and Baroness Dido Harding, Chair of NHSI. My note on the conference was circulated to all board members.
Governor Activity 8. As Chair of the Foundation Trust I am also Chair of the Council of Governors (CoG). The CoG met in January and as always provided a high level of challenge to the Non-Executive Directors as part of their duty of holding the NEDs to account. 9. As can be seen from above, the CoG Appointments committee has been particularly busy in shortlisting the vast number of applicants for the NED role.
QVH BoD PUBLIC March 2019 Page 12 of 254 Board Assurance Framework – Risks to achievement of KSOs
KSO 1 Outstanding Patient KSO 2 World Class Clinical KSO 3 Operational KSO 4 Financial KSO 5 Organisational Experience Services Excellence Sustainability Excellence We put the patient We provide world We provide streamlined We maximize existing We seek to maintain a well at the heart of safe, class services that are services that ensure our resources to offer cost- led organisation delivering compassionate and evidenced by clinical and patients are offered choice effective and efficient care safe, effective and competent care that is patient outcomes and and are treated in a timely whilst looking for compassionate care through provided by well led teams underpinned by our manner opportunities to grow and an engaged and motivated in an environment that reputation for high quality develop our services. workforce meets the needs of the education and training and patient and their families. innovative R&D.
Current Risk Levels The entire BAF was reviewed at executive management team at the Executive Management Team meeting 25 /02/18 alongside the corporate risk register. KSO 1 and 2 were also reviewed at the Quality and Governance Committee, 21 /02/19. KSO 3, 4 and 5 were reviewed 25/02/19 at the Finance and Performance Committee. Changes since the last report are shown in underlined type on the individual KSO sheets. The key risks to outstanding patient experience remains workforce , the key risk to financial sustainability is underperformance against income plan, cost improvement plan and the underlying financial deficit and the key risk to operational excellence remains RTT 18 and the 52 week breach position . The Board is asked to note the rescoring of the KSO4 from 20 to 25 due to the deteriorating financial position and revised forecast. Additional assurance continues to be sought internally and the evidence of this is referenced in the respective director reports to the March trust board .
Q 1 Q2 Q3 Q4 Target risk 2018/19 2018/19 2018/19 2018/ 19 KSO 1 15 15 15 15 9
KSO 2 12 12 12 12 8
KSO 3 20 20 20 20 15
KSO 4 20 20 20 25 16
QVH BoD PUBLIC March 2019 KSO 5 20 20 20 20 15 Page 13 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 07/03/2019 Agenda reference: 44-19 Report title: Chief Executive’s Report Sponsor: Steve Jenkin, Chief Executive Author: Steve Jenkin, Chief Executive Appendices: 1) Integrated Performance Dashboard Summary 2) QVH media update December 2018 and January 2019 3) Sussex and E Surrey Sustainability Transformation Partnership (STP) – ‘Population Health Check’ 4) NHS Long Term Plan Summary
Executive summary Purpose of report: To update the Board on progress and to provide an update on external issues that may have an impact on the Trust’s ability to achieve its internal targets. Summary of key • Integrated Performance Dashboard Summary issues • Paediatric Burns – QVH is developing a business case to reconfigure the paediatric burns service and secure improvements in compliance with national service standards. A further update is expected at the May Board meeting. • QVH priorities for 2019/20
Recommendation: For the Board to NOTE the report and ENDORSE the STP Population Health Check. Action required Approval Information Discussion Assurance Review Y/N Y/N Y/N Y/N Y/N Link to key strategic KSO1: KSO2: KSO3: KSO4: KSO5: objectives (KSOs): Y/N Y/N Y/N Y/N Y/N [Tick which KSO(s) Outstanding World-class Operational Financial Organisational this patient clinical excellence sustainability excellence recommendation experience services aims to support] Implications Board assurance framework:
Corporate risk register: None
Regulation: N/A
Legal: None
Resources: None
Assurance route Previously considered by: EMT Date: 25/02/19 Decision: Review BAF Next steps:
QVH BoD PUBLIC March 2019 Page 14 of 254
CHIEF EXECUTIVE’S REPORT MARCH 2019
TRUST ISSUES Care Quality Commissions (CQC) – Well-led review CQC carried out an unannounced inspection of three of our core services on 29 and 30 January prior to a planned provider level inspection of ‘well led’ on 26 and 27 February 2019.
Paediatric Burns QVH has been developing a business case to reconfigure its paediatric burns service and secure improvements in compliance with national service standards. A number of burns standards cannot currently be met on our East Grinstead site, meaning the paediatric burns service currently operates under a derogation agreed with NHS England. Current gaps in compliance include the 24-hour provision of paediatric cover, pathology and imaging services, and on-site access to paediatric HDU, neonatal critical care and emergency department provision; all of which relate to the provision of emergency inpatient care.
In 2016 a number of options for improving burns standards compliance were considered by QVH and Brighton and Sussex University Hospitals Trust (BSUH) with the provision of emergency inpatient services on the Royal Alexandra Children’s Hospital (RACH) site, agreed to be the preferred option alongside continued provision of outpatient services at both QVH and the RACH. QVH has developed a service specification setting out the requirements for the elements of inpatient and outpatient service that BSUH would provide to support the proposed service development. There are clear financial challenges in the development of this service model due to the low volume of inpatient activity (predicted to be fewer than 40 patients a year) and the staffing required to provide a burns service (paediatric at RACH and adult at QVH) across two sites.
It is anticipated that a detailed report will be considered at our next board meeting.
Finance QVH submitted a re-forecast to NHS Improvement (NHSI) on 16 January as agreed by the board, of £5.9m deficit excluding donated asset adjustments and PSF (Provider Sustainability Fund). A re- forecast of capital was also submitted £550k below budget due to delays in reconfiguration of the critical care and burns units. We are working closely with NHSI and commissioners regarding business planning for 2019/20 and our recovery plan.
Focus on 2019/20 Our three priorities for the new financial year are:
1. Partnership - we will continue to work with Brighton and Sussex University Hospitals Trust (BSUH) and Western Sussex Hospitals Foundation Trust to align further both clinical and support services. Our approach to partnership will be focussed on delivering safe, effective and efficient services, and a secure future for the outstanding care provided by staff at QVH. 2. Productivity - we will continue work to make sure we have full theatre lists and processes that ensure there are no unnecessary delays for patients. We will undertake a focussed programme of work to improve our outpatients productivity, including consideration of virtual clinics to reduce the need for patients to travel for appointments. We will continue to seek efficiencies in how we work both clinically and in support services, making sure our data is accurate and our staffing and systems support us in providing the best patient care.
QVH BoD PUBLIC March 2019 Page 15 of 254 3. People - the knowledge, expertise, hard work and professionalism of our staff is at the heart of QVH. We will ensure staff are well led, well managed and motivated by meaningful work. We will continue to invest in professional and personal development, and to look after our staff health and well-being. We will work innovatively, through recruitment and new ways of working, to address the staff shortages which exist in some professions.
We will be producing an easy-read summary of our operating plan for 2019/20 for staff and stakeholders, which will set our delivery plans in this context.
Integrated Performance Dashboard Summary This month sees a revised version of our Integrated Performance Dashboard summary (Appendix 1) as part of my report highlighting at a glance the key indicators from all areas within the trust including safety and quality, finance and operational performance, and workforce, against each Key Strategic Objective.
Board Assurance Framework (BAF) Attached is the BAF front sheet, the following points are worth noting:
The entire BAF was reviewed by the executive management team on 25 February 2019 alongside the corporate risk register. The key risk to outstanding patient experience remains workforce, the key risks to financial sustainability are underperformance against income plan, cost improvement plan and the underlying financial deficit. Key risks to operational excellence remain our waiting list and the 52 week breach position. The Board is asked to NOTE the rescoring of KSO 4 from 20 to 25 due to the deteriorating financial position and revised forecast.
Media Appendix 2 shows a summary of QVH media activity during December 2018 and January 2019.
SECTOR ISSUES Sussex and E Surrey Sustainability Transformation Partnership (STP) – ‘Population Health Check’ The ‘Population Health Check’ for Sussex and East Surrey has been developed by the Sussex and East Surrey Sustainability Transformation Partnership (STP) Clinical and Professional Cabinet. Membership of the Cabinet includes the Medical Directors and Clinical Chairs of partner organisations including QVH, as well as representation from Chief Nurses, NHS England, Public Health, the Academic Health Science Network and the Clinical Senate. The Population Health Check represents a diagnostic for our local health system and highlights the priority areas that need focus to allow health and care services to better meet the needs of our populations. It builds on local plans and intelligence and aims to provide a unified picture of the key areas for change across the health and care system.
There are five priority areas highlighted in the Health Check:
• Workforce and capacity strategy • Shared decision-making and patient activation • Re-framing our cultural norms to make the right lifestyle choices easy to make • Addressing unwarranted clinical variation • Mental and physical health services and social services closer to home with good communication and co-ordination
The Population Health Check has been endorsed by the STP Executive, which is made up of the Chief Executives from all statutory NHS organisations across Sussex and East Surrey. The STP Clinical and
QVH BoD PUBLIC March 2019 Page 16 of 254 Professional Cabinet will now be using the information outlined in the Population Health Check to develop a clinical strategy for the population. As the strategy is developed, a sustained period of engagement will take place with patients, staff, public, clinicians and other stakeholders. This engagement process will be called ‘Our health and care…Our future’ and will provide the opportunity for the strategy to be co-produced and informed by patient, public and staff feedback. The strategy will be aligned to the delivery of the NHS Long-term Plan. QVH Board is asked to review and endorses the STP Population Health Check (Appendix 3).
NATIONAL ISSUES NHS England – The NHS Long Term Plan
NHS England published the NHS long term plan on 7 January 2019. The plan includes a renewed focus on prevention to stop an estimated 85,000 premature deaths each year. Measures will help prevent 150,000 heart attacks, strokes and dementia cases while more than three million people will benefit from new and improved stroke, respiratory and cardiac services over the next decade. The plan includes a new guarantee that investment in primary, community and mental health care will grow faster than the growing overall NHS budget. The plan includes the biggest ever investment in mental health services rising to at least £2.3bn a year by 2023/24.
The blueprint to make the NHS fit for the future will use the latest technology, such as digital GP consultations for all those who want them, coupled with early detection and a renewed focus on prevention to stop an estimated 85,000 premature deaths each year.
Patients will benefit from services ranging from improved neonatal care for new parents and babies to life-changing stroke therapy and integrated support to keep older people out of hospital, living longer and more independent lives.
The NHS Long Term Plan (Appendix 4 – NHS Long Term Plan Summary) will also:
• Open a digital ‘front door’ to the health service, allowing patients to be able to access health care at the touch of a button • Provide genetic testing for a quarter of people with dangerously high inherited cholesterol, reaching around 30,000 people • Give mental health help to 345,000 more children and young people through the expansion of community based services, including in schools • Use cutting edge scans and technology, including the potential use of artificial intelligence, to help provide the best stroke care in Europe with over 100,000 more people each year accessing new, better services • Invest in earlier detection and better treatment of respiratory conditions to prevent 80,000 hospital admissions and smart inhalers will be piloted so patients can easily monitor their condition, regardless of where they are • Ensure every hospital with a major A&E department has ‘same day emergency care’ in place so that patients can be treated and discharged with the right package of support, without needing an overnight stay.
The Kark Review of the Fit and Proper Person Test In July 2018, the former Minister of State for Health, Stephen Barclay MP, commissioned Tom Kark QC to review the scope, operation and purpose of the Fit and Proper Person Test (FPPT). The review
QVH BoD PUBLIC March 2019 Page 17 of 254 looked in particular at how effective the FPPT is in preventing unsuitable staff from being redeployed or re-employed in the NHS. The review was recommended by Dr Bill Kirkup in his report into Liverpool Community Health NHS Trust, in February 2018.
The review concludes that a system has to be devised to ensure that those who take on the role of senior management at board level in the NHS are equipped with the skills necessary to undertake that important function; that they can be critically assessed to ensure they have those skills; that such assessment is continuous throughout their career; that they can be supported where appropriate to improve their skills; that they are supported and receive further training if things go wrong or if they are found not to have all the skills necessary.
The review makes seven recommendations two of which have been accepted by the Secretary of State for Health and Social Care upon publication of the report.:
1. All directors should meet specified standards of competence to sit on the board of any health providing organisation 2. A central database should be created, holding relevant information about qualifications and history about each director including NEDs
Baroness Dido Harding (Chair, NHSI) has been asked by the Health Secretary to consider the remaining five recommendations and how they can be implemented.
At QVH we include the Fit and Proper Person declaration for each director in every set of Board papers as a regular reminder of the requirements. The Chair signs the declarations on appointment and annually.
Steve Jenkin Chief Executive
QVH BoD PUBLIC March 2019 Page 18 of 254 Integrated Dashboard Summary Key indictators at a glance - January 2019
KSO1 Outstanding Patient Experience & KSO3 Operational Excellence KSO5 Organisational Excellence Activity - M10 Plan Actual 2017/18 KSO2 World Class Clinical Services
C-Diff 0 MIU <4hrs 98.50% Vacancy rate 12.48% MIU attendances 943 1,023 797
MRSA 0 RTT 18 weeks 75.87% Turnover rate 18.73% Elective (day case) 1,387 1,176 1,124
E-coli 0 Cancer 2ww 92.00% Sickness rate 2.97% Elective 421 303 277
Gram-negative BS 0 Cancer 62 day 85.00% Appraisal rate 84.64% Non-elective 497 352 418 Diagnsotics Serious Incidents 0 98.00% MAST 90.68% Critical care 78 52 81 <6weeks Staff FFT (work at Never Events 0 52ww 81 61.59% O/P first attendance 3,840 3,847 3,985 QVH) Staff FFT (care at No of QVH deaths 0 99.00% 91.39% O/P follow up 11,123 11,154 10,600 Referrals via eRS QVH)
No of off-site 1 O/P procedures 2,605 2,697 2,031 deaths
(within 30 days) KSO4 Financial Sustainability Other 3,900 2,373 4,066
Contacts Financial plan (£569k) 20287
Complaints 3 Variance to plan (£1278k)
Patient activity 0 (£374k) Closed <30 days income
FFT CIP delivery YTD (£1912k)
Agency spend % In-patient 99% 4.66% of pay bill
Day surgery 96%
MIU 96%
Trauma 100%
O/Ps 95%
QVH BoD PUBLIC March 2019 Page 19 of 254
QVH media update: December 2018 – January 2019
Life changing surgery meant grandmother could see grandson get married Following on the success of its medical miracles feature last Christmas, the Daily Mail wanted to run a similar piece for the 2018 festive period, this time focusing on some less commonly covered areas including corneal transplants.
We put forward our patient Shirley White and she was featured as the inspiring story from March, the month her grandson got married, a family event she was able to see thanks to our corneoplastics team and the kind donation of a cornea.
Sadly the hospital didn’t get a name check but it’s a positive piece that will hopefully encourage others to consider becoming potential future cornea donors.
The dangers of acrylic nails A public health focused press release we issued warning of the dangers of acrylic nails on children gained much local media interest. It followed a significant rise in the number of children aged 12 and under being seen by our teams over the summer with traumatic injuries resulting from artificial nails. The release was issued in time for the school Christmas holidays and festive party season, with consultant plastic surgeon Nora Nugent advising parents that painted nails are a much safer option.
Nora was also interviewed by local radio station Spirit FM who aired the piece in the days leading up to Christmas. In print media, the East Grinstead Gazette featured the story as a column on the cover of its Christmas edition.
Other media outlets to carry the story included local radio station Heart Sussex; the Surrey Live website; More Radio and its website; The Argus; the Crawley News 24 website; the Crawley Observer website; the Brighton and Hove Independent website (pictured); Oxted District Gazette website; and the Sussex Express website, Families West Kent Magazine Facebook page.
We also shared our advice through our social media channels. On Facebook the story was seen by over 19.2k people and was shared around 150 times making it one of our most popular to date.
QVH BoD PUBLIC March 2019 Page 20 of 254 East Grinstead Mums festive visit On Friday 14 December, to coincide with our Christmas Jumper Day in aid of QVH Charity, we were paid a festive visit by members of the East Grinstead Mums Facebook group who brought mince pies for all of our staff to say thank you for the support QVH gives the local community. This was part of a Christmas campaign by the group to thank staff at local organisations making a difference.
This gained a significant amount of local media interest, particularly involving a film they made of their deliveries to organisations such as ours. It was picked up by the BBC News website in its Sussex news; the Kent Live website; and BBC Radio Sussex.
An edited version of the film has been run across all of the BBC Sussex and south east social media channels, gaining thousands of views.
The story was also picked up by the London Evening Standard who approached us for a quote which they included in their story (pictured).
The story also made it onto the front page of the East Grinstead Courier’s Christmas edition including a picture taken here at QVH with our main reception volunteer Valmai meeting the elves from the East Grinstead Mums (pictured).
We also issued our own press release about Christmas jumper day which was featured in The Mid Sussex Times.
QVH BoD PUBLIC March 2019 Page 21 of 254 Dangers of fireworks Carrying on the momentum of a campaign launched by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) last month calling for changes to the packaging of fireworks, we issued our own press release in time for people considering using fireworks to see in the New Year. It reminded of the dangers of fireworks and why our consultant plastic surgeons are supporting the BAPRAS campaign, calling for changes similar to the health warnings already in place on cigarette packaging.
The story was picked up by the Crawley News 24 website (pictured) and the Mid Sussex Times. Our consultant plastic surgeon Baljit Dheansa was also interviewed by BBC Surrey on the breakfast show on New Year’s Eve, explaining why the campaign is so important.
The fire challenge The Get Surrey website ran a story about the Fire Challenge, a YouTube craze which originated in 2012 with a video of a person setting their chest hair on fire. Since then children have been pouring flammable liquids on themselves and setting it alight, including a recent flurry of incidents in Wales. The website was keen to explore whether there was a local impact resulting from the national coverage the Wales cases had generated. QVH has not received any admissions relating to this.
Nora Nugent our burns lead provided a quote for the piece about the potential life changing injuries such a stunt could cause.
Face reading glasses The Wired UK website ran a piece about Charles Nduka, our consultant plastic surgeon, and the FRAMES project he is working on, which originated from his work here.
This is a combination of face reading glasses and virtual reality technology which we’ve used on our patients with facial palsy.
The piece explores the applications the technology could have for patients with a variety of different conditions.
QVH BoD PUBLIC March 2019 Page 22 of 254 Mum warns of Henna horror The Sun newspaper mentioned us in a story about a three year old girl who has been scarred by a black henna tattoo on holiday.
Freya was brought to our minor injuries unit after her holiday treat cat tattoo caused her skin to itch and burn. The story was initiated by mum Marlana as a warning to other parents.
Festive fun at Standen The December issue of East Grinstead Living magazine featured Jamie Chalmers, AKA Mr. X Stitch and his project to decorate the tree at Standen with hand-made cross stitched baubles.
Our staff are mentioned as ‘hospital workers’ involved in the project.
QVH on social media In addition to our regular posts on social media giving an insight into the life and work of QVH, we featured a post congratulating QVH volunteer, Liz Colenutt, and friend of the hospital, Bob Marchant, who have both been nominated for this year’s national Unsung Hero Awards.
The event is the only national awards for non-medical NHS staff and volunteers who go beyond the call of duty. The post reached more than 1,000 people.
We also continued our promotion to find two new non- executive directors for 2019, with information published on our website and regularly promoted via our social media channels.
Press releases We issued the following information to the public which you can read on the QVH website:
Experts warns of danger of acrylic nails on children
Staff support festive fundraiser for hospital charity
Experts support changes to firework packaging
For more information… Please contact Kathryn Langley, Communications Manager, at [email protected] or call x4508.
QVH BoD PUBLIC March 2019 Page 23 of 254 Sussex & East Surrey Sustainability & Transformation Partnership
Sussex & East Surrey Sustainability & Transformation Partnership
Sussex & East Surrey Sustainability & Transformation Partnership (STP) Sussex & East Surrey OURSustainability POPULATION & Transformation Partnership HEALTH CHECK
A CLINICALLY-LED DIAGNOSIS OF WHAT NEEDS TO CHANGE
QVH BoD PUBLIC March 2019 Page 24 of 254 SUBHEAD STYLE
Contents Introduction
“We have many great services and people, delivering great care. 3 Introduction However, there is an urgency to address the gaps in the quality 4 What is this “population health check”? and responsiveness of some of our services. There has been an 6 Why do we need an STPpopulation health check when we already have local plans? under-investment in prevention and self-care and not enough
6-7 How do we offer best value? emphasis on wellbeing and care. Services are not operationally 7-9 What did we find are the key themes? or financially sustainable in the current set-up, which is based on 10-14 What do we need to change to address these key themes? historic and isolated services, not built around what local people 15-18 Our Population Health Check in context need now. In essence, there is less partnership working than we 19 What we found: our evidence base need between patients and clinicians and between services. Given 19-34 Our evidence: Our Population and Demographics our demography, we need to rely as much on technology-enabled 35-39 Our evidence: Our Public and our Patients care as on state funded clinical and domiciliary workforce. There 40-67 Our evidence: Our Services just won’t be as many employees available in future as would be 68-69 Our evidence: Our Staff needed to provide current services to a larger population with 70-73 Our evidence: Our Infrastructure more retired people and not many more working-age citizens. This 74-75 Our Priorities Population Health Check represents a case for change and provides 76 Next Steps the evidence of the key issues and the priorities we will deliver 76 We need to develop a clinical strategy which delivers “best value” together to ensure we offer sustainable services. Doing nothing is and patient centred care. neither affordable nor sustainable” 76-78 We need to develop a clinical strategy which is future proofed 79-80 We need to develop a clinical strategy which is clear on the optimal Dr Minesh Patel and Mr Peter Larsen-Disney, Co- Chairs, Sussex and population size to lead delivery East Surrey STP Clinical and Professional Cabinet 81 The process of developing the clinical strategy 82-84 Agreement from core members of the STP Clinical and Professional Cabinet 85-87 Contribution list 88-91 References and bibliography 2 3
QVH BoD PUBLIC March 2019 Page 25 of 254 OUR POPULATION HEALTH CHECK OUR POPULATION HEALTH CHECK
l We will be consistent with our messages on increasing population health Population Health Check and well-being and the importance of delivering value for money. l We are able to identify and work together on addressing unwarranted clinical variation to deliver value for money services across the system. This Population Health Check has been developed and agreed by a STP group called the Clinical and Professional Cabinet, which consists of the l We will work together to improve communication and collaboration most senior medical and nursing leaders across our partnership. across the system and between clinicians and the public to enable decision based on objective, best value evidence and conversations.
l We will support each other to manage the impact of the 3Ts WHAT IS THIS “POPULATION HEALTH CHECK”? development at Brighton and Sussex University Hospitals NHS Trust This document is a diagnostic analysis of the key issues we are facing in our (BSUH), which will reduce bed capacity in the short term through We are able to local health systems today. This analysis provides the strong evidence base collaborative redesigning our model of services to enable care closer to identify and we need for the next phase, which will be an STP-wide Clinical Strategy. home (delivering the lowest level of effective care). work together The overall goal of the Population Health Check is to identify the l We will provide STP-wide senior clinical support for local plans which on addressing challenges facing our population’s health and our system’s sustainability in may help the pace of change, with consistent messaging on delivering unwarranted order to develop a strategy, which will see people living with better health value based services. clinical variation that is value focussed and patient centred. l We will develop simpler collaborative commissioning, whilst to deliver value maintaining local engagement and ownership, to make best use of for money services WHY DO WE NEED AN STP POPULATION HEALTH CHECK WHEN WE limited resources and to integrate care for patients, across the system ALREADY HAVE LOCAL PLANS? Our STP is comprised of four ‘places’ responsible for locally driven l We will share best practice and offer support on implementation of community and integrated care with the aim of improving health local transformation plans to deliver better value care at a faster pace, outcomes for our communities and reducing avoidable illness and health and care expenditure. Each place is building a model that best responds l We will further develop the skills of clinical leadership, workforce to both the local health needs and context of the health and care development and resilience through learning from others outside our organisations in the region, however many commonalities exist between neighbouring systems, them. Each place will oversee radical clinical transformation of Long Term Conditions, frailty, mental health, community, social care, general practice l We will support consistent access to supportive mental health services The STP is not one and urgent services to transform outcomes and quality. to reduce costly reactive responses to crisis care. single separate plan. It is a way of The STP is not one single separate plan. It is a way of making sure that l We will develop system-wide digital technology to support the plans of all the partners across the area are joined up and working communication across the system, making sure that together. It aims to ensure that no part of the health and care system the plans of all the operates in isolation. We know that what happens in GP surgeries, for l We will contribute to the strategic planning for the development of partners across example, impacts on social care, which also impacts on hospital wards, estates to ensure we are able to deliver care closer to home across the area are joined and so on. With services feeling the strain, working together will give our the system. nurses, doctors and care staff the best chance of success. up and working l We will provide consistent key message to the public so that A&E is not the together. The “added value” of an STP Population Health Check, which option chosen as the urgent care option but that the public understand 4 complements those Place Based Plans and delivers best value is: the benefits of accessing alternative services in the community. 5
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THE SYSTEM WILL, THEREFORE, COME TOGETHER ON ISSUES WHICH MAKE SENSE TO DO TOGETHER. Some of these initiatives, such as the STP Mental Health Strategy, are OUTCOME already underway and demonstrating significant improvements. However, (health and social) it is crucial that the changes identified throughout are interconnected VALUE with the delivery of the STP Mental Health Case for Change, Mental (of an intervention) = Health Delivery Plan, Mental Health Workforce Plan and the identified RESOURCED REQUIRED (to deliver the coutcome) Mental Health priority work streams and vice versa. This will then emphasise the importance of parity of esteem where mental health is valued equally with mental health. For example – some of the changes will impact and are interdependent with this overall STP Population Health Check e.g. impact of Improving Access to Psychological Therapies (IAPT) Long-term conditions developments on Diabetes, Musculoskeletal (MSK) Forward View. The first principle within the ‘New Care Models’ to and Cardiovascular, the life gap for people with severe mental illness and engage people and communities is that care and support is person- the high proportion of smokers having an severe mental illness. Also the centred: personalised, coordinated, and empowering. Person-centred mental health Crisis & Urgent Care workstream need to work closely with approaches has recently beenpublished by Skills for Health, Skills for the Urgent and Emergency Care workstream. Care and Health Education England as a core skills education and training framework for the health and care workforce. HOW DO WE OFFER BEST VALUE? We need to offer best value care to our patients. In July 2017, the South l We need to begin focusing on assets and “what matters to people” East Clinical Senate produced a briefing entitled ‘Emphasising Quality, rather than “what’s the matter with” people. Delivering Value’ (South East Clinical Senate 2017a), which recognises that: l “The inexorable rise in demand for healthcare and growing We need to improve communication between services. The way pressures and constraints on the workforce and finance threaten the that clinicians work together in providing care to individual patients, sustainability of the NHS. For clinicians across all disciplines, this means and how they communicate with each other, is vital to providing an that we need to focus our combined resources on the care that delivers integrated, coordinated, patient-centred approach, and for delivering the greatest value. the best experience of care and outcomes for patients. Phone calls and conventional letters have been the default means of communication for l Value in healthcare is defined as the achievement of the best outcomes decades, whilst over time technological changes, increasing specialisation, for individual patients and for the public within available resources. It the need for greater efficiency, changing organisational and professional also means doing less of things that add little or no value to patients. boundaries, and changing patient expectations, have ceaselessly evolved. (SE Clinical Senate. 2017b) The inexorable l To achieve best value will require the development and use of rise in demand for standardised outcome measures that are more relevant to patients healthcare and (such as the impact on their functional status and wellbeing), and their WHAT DID WE FIND ARE THE KEY THEMES? more active involvement through the process of shared decision making We found that: growing pressures with well-informed patients. It also involves recognising unwarranted l There are four main unhealthy behaviours of smoking, alcohol misuse, and constraints on local variation in the delivery of high value care and addressing it. poor diet and lack of physical activity, as well as poor emotional and the workforce and mental well-being, which are responsible for at least a third of ill health l Value is not a financial term. It is a term that integrates high quality, and are amenable to cost-effective preventative interventions. Focusing finance threaten safe and cost effective care that improves patient or population on prevention earlier in the life-course will accumulate greater benefits, the sustainability outcomes. It can be represented as follows:” but even in middle and older age groups, preventative approaches are of the NHS. cost-effective. Prevention requires prioritisation and investment across 6 l Better Conversations’ is a fundamental part of delivering the Five Year the system. This includes the need to treat symptoms early in primary 7
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care to stop the development of a long-term condition. To date, across l Bed capacity is expected to increase by 176 beds by 2023/24 at BSUH our STP, there has been an under-investment in prevention and self-care as a result of the 3Ts rebuild. However, in the meantime, there will be a Digital technology and not enough emphasis on wellbeing and care. detrimental impact on capacity which needs to be supported across the needs to better wider system. support l There were 1,314 stillbirths in the South East between 2013-2015, equating to roughly 36 stillbirths per month. A large proportion of l Care is often un-co-ordinated and duplicated leading to poor quality integrated care, stillbirths are attributable to risk factors some of which are fully or partly care with multiple hand-offs. The supportive systems are often difficult population health avoidable, indicating an opportunity for rate reduction. Independent for the public to navigate, resulting in increased attendance to A&E. management and risk factors for stillbirth include: obesity, smoking, acquired medical disorders (diabetes) and disadvantaged populations. l Communication between clinicians across organisations and between empower patients clinicians and patients requires improvement. in managing l The STP covers a wide geographical area and many organisations, with their care. a notable amount of variation in financial performance. For 2017/18, l We have a high level of mental illness and dementia, with the need to the combined net deficit (surpluses and deficits added together) for increase access to supportive services. Clinical Commissioning Groups (CCGs) and Trusts in the footprint was £228.2m. l Digital technology needs to better support integrated care, population health management and empower patients in managing their care. We l There is significant expected growth in the population generally and have not been good at establishing systems for self-support which are an enormous growth in the 65+ and 85+ age groups. Significantly, this cheap, cost effective and improve outcomes – (patient held records, includes an increase in life expectancy for people in poor health. One patient educational materials /fora via online platforms for example) in three over-65s and half of those over 80 will suffer a fall each year. despite 90% of the population owning a smartphone / tablet or PC. In addition to the physical consequences, falls can have a damaging psychological impact, resulting in loss of confidence and independence, l We have unmet need at one end of the spectrum and unnecessary and increased isolation and depression. The Department of Health has and/or non-evidenced treatments at the other with variably informed stated that a falls prevention strategy could reduce the number of falls decision-making in the middle. by 15-30%. l There is variation across the trusts in delivering our constitutional l Pressures on our GP services are critical causing issues with access standards (the standards everyone should expect) including Referral for patients and staff stress. General Practice across the country is to Treatment Times (RTT), emergency admissions, Delayed Transfers of struggling to maintain services, and this situation is mirrored in Sussex Care, bed occupancy, cancer waits and A&E 4-hour performance. The population and East Surrey. The population is getting older, many more people live with multiple chronic diseases, people are seeing their doctor more l Our data shows us we have significant unwarranted variation across is getting older, often and with more complex problems. General Practice has coped the STP that are impacting on quality in many areas but particularly in many more people well so far, but we need to address these issues if we are not to face MSK, Cardiovascular and Falls/Fragility Fractures. There is also evidence live with multiple much bigger problems. that we over treat patients in some specialties. chronic diseases, l We have significant workforce shortages across the system, in particular l Too many people are dying away from their usual place of residence or people are seeing in GP surgeries, mental health and social care, with increasing demand. in a place that is not of their choosing. their doctor more often and with l There have been many years of under-investment in estates, which l Doing nothing is neither affordable nor sustainable. has resulted in non-compliance, high backlog maintenance and an more complex inefficient estate with high running costs. This hampers our ability to 8 problems. shift care closer to home. 9
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WHAT DO WE NEED TO CHANGE TO ADDRESS THESE KEY THEMES? l There are several points of contact for access to services, fragmented We concluded that: pathways and gaps in service availability (geographic and time of We have not focussed enough on promoting the determinants of good day), particularly around admissions avoidance and to support health because: hospital discharges. l There remains considerable, and unacceptable, differences in life expectancy between areas across the STP and within local CCG / local Our patients with mental health needs are not always able to access authority areas. Service access, take up and outcomes need to be support when they need it because: addressed for disadvantaged groups. l There is a lack of a 24/7 crisis support.
l There are four main unhealthy behaviours of smoking, alcohol misuse, l Capacity needs to be built in primary care, closer to home and thereby poor diet and lack of physical activity, as well as poor emotional and reduce presentations and referrals to physical and mental health mental well-being, which are responsible for at least a third of ill health secondary care. and are amenable to cost-effective preventative interventions. l The prevalence of severe mental illness is 5% higher than nationally, l Focusing on prevention earlier in the life-course will accumulate affecting 25,000 individuals greater benefits, but even in middle and older age groups, preventative approaches are cost-effective. Prevention requires prioritisation and l For dementia, prevalence is 25% higher than nationally, will increase investment across the system. Prevention includes the reduction of falls further as the population ages, while the proportion of those with a in the elderly and healthy living to reduce still births. diagnosis is 5% lower. A quarter of those patients with dementia who are fit to leave acute care wait over 50 days for discharge. In order to keep up with increasing demand, we need to collaboratively There is an redesign our service models to bring care closer to home because: l There is an increasing problem of addiction and its impact on the increasing l There is an imbalance of bed/un-bedded capacity and demand in acute, individual and the system. problem of primary, community and social care. addiction and its We do not have the workforce numbers and skills to meet current and l BSUH is undergoing a significant re-build programme through 3Ts, future demands because: impact on the which will have an impact on bed capacity until it is completed. l There is an imbalance in staffing capacity and demand across the whole individual and health and social care system. This includes front line staff providing the system. l We want more people to die in their usual place of residence and place direct patient/client care, back office staff, and key services e.g. of choice. pathology and radiology.
l Bringing care closer to home, cannot be delivered without addressing l The average retirement age is 59 and we have 15 % of staff aged 55 the issue that the sustainability of primary care is significantly years and over. challenged across the system. Dedicated effort to address primary care challenges is crucial. l The turnover rate for all registered nursing, midwifery and health visiting staff ranges from 13% - 20%. Our Urgent and Emergency Care services cannot keep up with demand because: l In social care there is a significant annual turnover of 26% for l Attendances to A&E and handover delays continue to put immense registered nurses. pressure on our services. l There are difficulties recruiting and retaining substantive mental health l Over a quarter of A&E attendances could be treated at another suitable nurses and psychiatrists. location e.g. primary care. 10 l In June 2017, the Sussex and East Surrey STP had a shortfall of GPs 11 (Full-time equivilants) of 193.
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Our digital technology does not meet current and future needs because: THE FOLLOWING CHART SUMMARISES THE KEY THEMES AND We need to l There is a lack of ability and confidence to access shared information to WHAT WE NEED TO CHANGE IN OUR SES STP enable our support for Clinicians, professionals, patients and carers in: (a) Direct Care and Self-Management, 5 BEHAVIOURS workforce to have (b) Population Health Management and Evaluation, 1. Smoking 2. Physical inactivity conversations (c) Research and Innovation. 3. Unhealthy diet which enable 4. Excess alcohol patients to make l Digital systems do not yet integrate effectively enough to support new 5. Social isoloation models of care or meet expectations. LEADS the right decision TO about care l There is a lack of health and care services digital maturity, partnerships 5 RISK FACTORS and agility to take advantage of the opportunities of emerging 1. Hypertension and breathing problems 2. Obesity and High Chloesterol technologies (e.g. Artificial Intelligence (AI), Precision Medicine, Internet 3. Hyperglycaemia of Things) 4. Frailty and falls 5. Anxiety and depression LEADS There is a lack of demand management to create the most efficient TO pathways because: 5 DISEASES l There is a lack of working practice changes required to encourage 1. Cancer ‘channel shift.’ 2. Circulation and respiratory disease 3. Diabetes l There is a lack of standardised communication and engagement 4. Bone and joint conditions 5. Mental Health conditions strategies to reduce demand on the system. LEADS TO l Communication between clinicians across boundaries needs to be 75% OF DEATHS AND DISABILITY addressed as a priority. 5 IMPACTS ON PATIENTS AND SERVICES Unwarranted clinical variation exists across the system leading to inequity 1. There is an increase in life expectancy (increased in access to the good standards of care because demand), which includes an increase of people l There is unwarranted variation in referrals guidelines, treatment, living longer in poor health (higher acuity). medicines and Continuing Healthcare funding when we compare 2. The capacity in the NHS and social care cannot keep up with demand leading to delays and poor ourselves to our demographic peers. quality care. 3. Insufficient numbers of dying patients being cared l There is insufficient shared decision-making between patients and for in their usual place of residence. 4. There is an increase in reactive, urgent care. their healthcare professional. We need to enable our workforce to 5. There is an increase in the cost of delivering have conversations which enable patients to make the right decision services. about care, based on objective evidence and dialogue and containing LEADS TO expectations to value based care. 5 STP PRIORITIES 1. STP workforce and capacity strategy. 2. Shared decision-making and patient activation. 3. Re-framing our cultural norms to make the right lifestyle choices easy to make. 4. Addressing unwarranted clinical variation. 5. Mental and physical health services and social services closer to home with good communication 12 and co-ordination. 13
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OUR POPULATION HEALTH CHECK HAS TRIANGULATED PREVIOUS ANALYSIS INTO A SINGLE CASE
PRIORITY AREA STP EXECUTIVE STP CLINICAL AND STP PLAN AND EXISTING Our Population Health PROFESSIONAL CABNIET REFRESHED SYSTEM PLAN (11 KEY TARGETS/ INTERVENTIONS) MEASURES Older people + 11 Right: bone and joint, MSK Older people, Delayed Check in context disabilities/ Long- interventions unwarranted variation, Falls and dementia end transfers of term conditions MSK Get It Fagility fractures, end of life care, of life care, re- care, dementia Right (GIRFT), over treatment, medicalisation ablement, falls indicators Continuing reduction (improvement There are 24 large organisations in our partnership – NHS Commissioners Healthcare and Assessment Brighton & Hove CCG (CHC), Framework local authorities, providers and clinical commissioning Coastal West Sussex CCG Clinically (IAF), Urgent Effective and Emergency groups. This STP recognises the very critical part Crawley CCG Commissioning, Care GP access, played by so many other smaller but core health, care East Surrey CCG Medicines, Learning Eastbourne Hailsham & Optimisation disabilities and wellbeing organisations across the STP. Seaford CCG Hastings & Rother CCG Circulation and Clinically Rightcare 5:5:5 (prevention, Adults with Quality and Respiratory Effective detection, management / risk physical disability Outcomes High Weald Lewes Havens (cardiovascular Commissioning reduction) – Stable angina, Atrial build knowledge Framework Our footprint is home to 1.7 million people providing health and social CCG disease, coronary (CEC) / Fibrillation (AF) / Hypertension and change (QOF), care at a cost of £4bn. It cannot be under-estimated the importance of Horsham & Mid-Sussex CCG heart disease, Procedures of and breathing problems / High behaviours RightCare, Specialised Commissioning cronic obstructive limites clinical Cholesterol, Hyperglycaemia, diabetes. planning changes to care across the health and social care system so that pulmonary disease effectiveness obesity, diabetic foot Maternal changes are not made in isolation but in partnership, with the impact of (NHS E South) (COPD), diabetes) (POLCE) amputations). Shared decision- smoking, obesity changes being clear and mitigating any negative consequences together. Total = 9 making and social activation (IAF) NHS Providers Cancer 5:5:5 (cancer risk factors; Acute liaison, 2 week wait, screening; early detection and SEMI 31 days, 62 Brighton & Sussex University treatment, survivorship) days Screening, Hospitals stage 1 and 2, East Sussex Healthcare diagnosed in Queen Victoria Hospital A&E South East Coast Ambulance POPULATION SIZE BY LOCATION (M) Mental health Mental health Mental health in relation to 5:5:5 Acute liaison, IAF, IAPT / Service strategy (prevention, wellbeing, early SEMI dementia / acute Surrey & Borders Partnership intervention, social isolation, crisis / CYP East Surrey 0.18 Surrey & Sussex Healthcare mental health and long-term conditions and dementia) Sussex Community Crawley 0.13 Sussex Partnership Urgent and Urgent and Capacity across the health and Rapid response in A&E 4 hour Western Sussex Hospitals Emergency Care emergency care system community and waits GP Providers care including acute services 111, 3Ts Total = 9 (excluding GP Providers) HMS 0.23 Co-ordinated and Digital Strategy Improving communication across Discharge Recruitment well communicated Workforce primary and secondary care. planning Single and retention HWLH 0.17 Non-NHS Providers care strategy Patient activation point of access Agency spend H&R 0.19 Brighton & Hove City Council Specialist advice CWS 0.51 Integrated care East Sussex County Council Surrey County Council Maternity Better Births Supporting a good start in life Still birth West Sussex County Council reduction B&H 0.31 First Community Health and EHS 0.19 Care IC 24 Total = 6
14 STP Total = 24 15
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STPs are a way for the NHS to develop its own, locally appropriate l Sussex Partnership NHS Foundation Trust (SPFT): Developing a single We must also proposals to improve health and care for patients. They are working in access point to ensure that people in crisis can access services 24 hours acknowledge partnership with democratically elected local councils, drawing on the a day and a no ‘wrong front door’ approach with access points for expertise of frontline NHS staff and on conversations about priorities other services. They have set up a front door staffed by peer workers, some of the many with the communities they serve. Partnerships will be forums for shared care navigators, carers, voluntary sector staff and mental health examples we decision making, supplementing the role of individual boards and clinicians. have of great care organisations. Their immediate focus is on refining and implementing across the health their sustainability and transformation plan so that patients can see l South East Coast Ambulance Service NHS Foundation Trust (SECAmb): practical benefits in their local health system. STPs do not replace new 999, Emergency Operations Centre and 111 Rotational Workforce: and social care care models; instead they will allow the ability to build on their success, by Working with HEE and commissioners, SECAmb is developing a services across providing a collaborative system of leadership and governance which will number of rotational workforce positions. These are focussed on our STP. allow new care models to evolve and spread. (NHS England, 2018) rotating staff out (e.g. Paramedic Practitioners in primary care) and rotating staff in from other organisations (e.g. midwives). This is Although this document focusses on what we need to change, we must allowing the Trust to test workforce and governance issues before also acknowledge some of the many examples we have of great care beginning wider work on rotational workforce approaches such as across the health and social care services across our STP. For example: mental health nurses and rotating SECAmb paramedics into hospice and urgent care centre settings. l East Sussex Better Together: Health and Social Care Connect (HSCC) which offers both the public and professionals a single point of access l Sussex Community NHS Foundation Trust: Healthy Child Programme, for adult health and social care enquiries, assessments, services and which provides a range of health interventions and support, beginning referrals. Streamlining access frees GPs to see other patients rather than in pregnancy and continuing through to the end of formal schooling. having to refer to several different services for a patient. It also supports faster access to the services for patients in their home. l IC24: Developing the multi-professional urgent care workforce and strengthening the role of the GP as a clinical leader. l Central Sussex and East Surrey Commissioning Alliance (CSESCA) North: Integrated, patient-centred teams developing in Primary Care l Specialist Palliative Care: The adult and children’s hospices and Homes. East Grinstead is a rapid test site for a Primary Care Home Specialist Palliative Care services serving the STP area are all supported model: Key work-streams are addressing urgent ‘on the day’ primary by their local communities to provide holistic multi-professional care for care capacity with GPs working in the Minor Injury Units (MIUs). those facing death and bereavement. Adults known to hospice services are less likely to die in hospital and have a higher chance of dying in l Central Sussex and East Surrey Commissioning Alliance (CSESCA) their usual place of residence. South: Dementia Golden Ticket in HWLH. The Golden Ticket delivers a holistic mix of services to address health and wellbeing, supporting l Academic Health science Network: The Atrial Fibrillation (AF) project people with dementia and their carers in every aspect of their lives. identified 580 individuals who were eligible for anticoagulation and Adults known to Evaluation of the project shows that it is already reducing GP visits would benefit from a change of treatment to reduce their risk of an hospice services and emergency admissions to hospital. People who said that they had AF-related stroke. By the end of May 2018, 219 individuals had had are less likely to previously felt isolated received support to live more independently. their medicines optimised by their GP practice. This has reduced the die in hospital risk of AF-related strokes to such an extent that the equivalent of six l Coastal Care: Frailty pathway redesign. The Paramedic and AF-related strokes have been avoided, avoiding debilitating effects on and have a higher Occupational Therapy team work together on the Falls Response individuals and their families and avoiding costs to state-funded health chance of dying in vehicle, provided by Sussex Community NHS Foundation Trust, with the and social care of over £160,000. their usual place pilot being funded by Coastal West Sussex CCG. So far the conveyance rate for this vehicle in the first four weeks is 9.18% compared to Some residents living within our STP, are treated in Kent and Medway of residence. 16 20.5% for the previous 5 weeks. and Surrey and are also affected by their STP Cases for Change. Kent and 17
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Medway STP, Surrey Heartlands STP and Frimley STP have all identified the People with same issues in their Cases for Change in that: mental ill health l There is not enough focus on maintaining independence and ill What we found health prevention, have poor
outcomes and l There are challenges in primary care provision, which is extremely may not always fragile in some areas, (our evidence) be able to access l There are gaps in service and poor outcomes for those with long term services health conditions, Our evidence: Our Population and Demographics
l We do not support people with long-term conditions and needs to look OUR APPROACH TO HEALTH AND WELLBEING INEQUALITIES after themselves as effectively as we should,
l Many people are in hospital who could be cared for elsewhere, ltural and ic, cu env l There is a growth in demand from older, more complex patients, m iro no nm co e -e Living and working n l Planned care is not delivered as efficiently and effectively as it could be, io ta c conditions l c so o l n l There are particular challenges in the provision of cancer care, d ra Work it e mu Unemployment i n environment om nity o l People with mental ill health have poor outcomes and may not always d c n e n et n G a w s be able to access services, al l lifestyl o ci ua e f r Water and Education o d a k l There are capacity issues, vi c s sanitation S i to d r s In l There is a lack of Digital integration and innovation, Health care services Agriculture l They have an unsustainable workforce model, and food production Age, sex and Housing l They need to reduce clinical variation, constitutional factors
l Urgent and Emergency care needs to reduce.
In addition they have also identified the following which we have not Ref: Determinants of Health, identified in that some local hospitals find it difficult to deliver services Dahlgren and Whitehead (1991) for seriously ill people: some services are vulnerable and potentially Our approach reflects the responsibilities of the whole system in unsustainable. There is a need to review their specialist acute model addressing health and well-being – NHS, councils, police, education, including mental health. Existing capacity needs to be redesigned to be voluntary sector, communities and individuals. This well-being approach used much more productively. recognises that health is created by wider factors than health services. This approach requires a strategic commitment to building a culture in which individuals, organisations and communities work together to 18 identify and pool their capacity, skills, knowledge, assets and resources 19
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Our Joint Strategic Needs Assessment (JSNA) show our health priorities RELATIVE CONTRIBUTION OF THE DETERMINANTS OF HEALTH are largely the same as elsewhere – good mental health and wellbeing Unhealthy underpins success; poor physical health is linked to lifestyle behaviours, behaviours of SOCIO- HEALTH CLINICAL BUILT health inequalities result from social and income inequality; healthy ECONOMIC smoking, alcohol BEHAVIOURS CARE ENVIRONMENT futures are built on good employment and decent homes. However, FACTORS there are extreme variations in terms of socioeconomic status, health misuse, poor 30% 40% 20% 10% outcomes, environment and economic prosperity. These are often masked diet and lack of by averages, meaning health outcomes can seem on a par with the physical activity, rest of England, when for parts of Sussex and East Surrey the reality is significantly and enduringly worse. as well as poor emotional and Ref: Adapted from to improve health and wellbeing outcomes for all our residents. Such an There remain considerable, and unacceptable, differences in life mental well-being Gonnering RS and Riley WJ expectancy between areas across Sussex and East Surrey and within local approach requires a shift from a demand management approach to a are responsible for (2018) Robert Wood Johnson CCG / local authority areas. Service access, take up and outcomes need to and University of Wisconsin whole system approach to prevention which addresses “the causes of the be addressed for disadvantaged groups. at least a third of Population Health Institute causes” as identified in Dahlgren and Whitehead model (1991) above. The “causes of the causes” recognises that if the causes of poor health ill health are social, economic and environmental then the solutions need to be too Four main unhealthy behaviours of smoking, alcohol misuse, poor diet – from social determinants to those of the built environment, and these and lack of physical activity, as well as poor emotional and mental well- solutions require concerted, sustained, partnership working. being are responsible for at least a third of ill health and are amenable to cost-effective preventative interventions. Substance misuse, in all its forms, continues to present challenges across the STP area, and notably in CAUSES OF THE CAUSES the Hastings and Brighton and Hove areas.
Social Creating opportunities for people to participate in the life of the community: includes education and early childhood MODIFIABLE RISK FACTORS AND LONG TERM CONDITIONS development, providing a sense of place, belonging and safety, information, inclusion, informal social support, health and community services, arts and culture, sport and leisure. MODIFIABLE RISK FACTORS METABOLIC CHANGES LONG- TERM CONDITIONS (these can be reduced or (the biochemical processes Economic Encouraging sustainable economic development and equitable controlled by intervention, involved in the body’s normal access to resources includes regeneration, job creation, training, social protection, benefits, occupational health and and by doing so reduce the functioning) safety and incentives. probability of disease)
Natural Looking after natural surroundings and ecosystems: includes clean water, air, soil, natural, land care, waste recycling, energy consumption and climate change adaption. Tobacco use Raised blood pressure Cardiovascular disease
Physical inactivity Raised total cholesterol Diabetes
Built Altering physical surroundings icludes: urban layout, building Alcohol use Elevated glucose Cancers design and renewal, housing quality, affordability and density, From Health in All Our parks and recreatio facilities, roads, paths and transport and the provision of other amenities, such as seating and toilets. Poor diet (increased fat Overweight and obesity Policies (Local Government and sodium, with low fruit Association 2016) and vegetable intake).
Emotional and mental well-being 20 21
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LIFE COURSE APPROACH A WHOLE SYSTEM APPROACH TO PUBLIC HEALTH As well as individual service interventions, public health interventions to Improving the START WELL LIVE WELL AGE WELL build stronger and more resilient communities and places which support public’s health people to maintain independence and manage their own health and will help secure wellbeing across the course of their lives, are an important components the future of 1 100+ of a whole system approach to prevention across NHS, local authorities, voluntary sector, community groups and wider stakeholders. these services and deliver longer, Starting well in life is important for every child. The first few years of Working together, we can achieve the cultural shift we need to sustain healthier lives for life are critical for readiness to learn, educational achievement, income improvements for people wherever they live and create a focus on health and economic status - strong predictors of future health and wellbeing. rather than the treatment of illness. This is increasingly important if public all our residents. What happens during pregnancy and early years impacts on their risk services are to be sustainable in the future – all parts of the public sector of long term ill health such as obesity, substance misuse, risk of heart face significant budget pressures and the NHS and local government are by disease, dental decay and poor mental health. These differences are no means exempt. Improving the public’s health will help secure the future almost entirely explained by deprivation and inequalities. Public health of these services and deliver longer, healthier lives for all our residents. interventions have an important part to play to stem the tide of long- term conditions and increasing costs. Focusing on prevention earlier in the life-course will accumulate greater benefits, but even in middle and CURRENT RESIDENT POPULATION AND PROJECTED TO 2030 older age, preventative approaches are cost-effective. Prevention requires (DATA ROUNDED TO NEAREST 100) prioritisation and investment across the system. Sources: Aggregated CCG 2016 POPULATION 2030 PROJECTED % CHANGE data provided by ONS. OVERALL RESIDENT POPULATION 2016 Population - ONS Mid-Year Estimate (Resident Self Care Continuum ESBT 375,200 417,900 11.4% Population) 2016. 2030 Environmental Coastal 498,900 558,800 12.0% Place solutions to make the Projected - ONS Population level solutions healthier choice the CSESCA North 528,600 578,900 9.5% Prevent Self care easier choice projections for clinical Social marketing/ CSESCA South 461,800 504,100 9.2% Daily Choices community led commissioning groups and Lifestyle support 0-19 YEARS NHS regions ESBT 79,300 83,00 4.7% Self-managed ailments Community Coastal 104,400 111,200 6.5% level solutions Long terms conditions Digital solutions for CSESCA North 130,100 139,00 6.8% Reduce self-management CSESCA South 99,400 103,900 4.5% Actute conditions 65-84 YEARS Individual/Service level solutions Compulsory psychiatric care ESBT 82,400 109,700 33.1% Major trauma Community - connectivity Coastal 109,200 143,000 31.0% Delay Residential care /changing social norms CSESCA North 79,000 104,900 32.8% Public and patient CSESCA South 66,600 86,900 30.5% support & materials 85 AND OVER Enablers: Asset based needs assessment Systematic workforce development ESBT 16,000 22,200 38.8% Aligned Strategies Embedding prevention into care pathways Coastal 20,200 28,500 41.1% Collaborative partnerships Systematic self care & digital support CSESCA North 14,500 20,600 42.1% CSESCA South 11,700 15,500 32.5%
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QVH BoD PUBLIC March 2019 Page 35 of 254 Disability Free Life Expectancy MEN (2010 - 2012) Source: ONS
72
70
68
66
England = 64.1 years 64
OUR EVIDENCE 62 OUR EVIDENCE
Disability-free life expectancy (DFLE) Years 60
62.5 63.2 64.9 65.7 66.3 67.6 68.0 69.1 58 Hastings & Brighton & Eastbourne, Crawley Coastal W High Weald East Surrey Horsham & Rother Hove Hailsham Sussex Lewes Mid Sussex and Seaford Havens
The resident population across the overall area is projected to increase WOMEN (2010 - 2012) Source: ONS between 2016 and 2030, from a projected 9.2% increase in the CSESCA 71 South area to 12% in Coastal. The greatest increases are projected in the older age groups, notably amongst people aged 85 years or over. 70 Growth in the child population is lower than overall change. The overall 69 population increase, and the rise in the older age groups will impact the 68 demand for health and social care services, with frailty and the number of people with one or more long-term health condition rising. 67 66 England = 65.0 years Disability Free Life Expectancy 65 MEN (2010 - 2012) Source: ONS 64 72 63 62 70 Disability-free life expectancy (DFLE) Years 61 64.1 65.2 65.6 66.2 67.5 68.7 69.0 69.4 68 60 Hastings & Brighton & Eastbourne, Crawley Coastal W High Weald East Surrey Horsham & Rother Hove Hailsham Sussex Lewes Mid Sussex 66 and Seaford Havens
England = 64.1 years 64 Life expectancy varies considerably across the area; this reflects deprivation, with shorter life expectancies in the most deprived local authority areas. 62 In Hastings male disability-free life expectancy is over five years lower than
Disability-free life expectancy (DFLE) Years 60 that in Horsham and Mid Sussex, East Surrey and High Weald, Lewes and the Havens. 62.5 63.2 64.9 65.7 66.3 67.6 68.0 69.1 58 Hastings & Brighton & Eastbourne, Crawley Coastal W High Weald East Surrey Horsham & Rother Hove Hailsham Sussex Lewes Mid Sussex Hastings and Rother also has the lowest female disability-free life and Seaford Havens expectancy at 64.1 years compared with Horsham and Mid Sussex at 69.4 years. WOMEN (2010 - 2012) Source: ONS
71 DEPRIVATION - INDEX OF DEPRIVATION 2015 70 While overall the STP area is relatively affluent, there are some areas, 69 notably along the coastal strip in Hastings, Brighton and Hove and 68 Littlehampton, which rank within the most deprived areas in England; deprivation that has persisted over many years. 67
66 In relation to child poverty, rates at a CCG level (2013) range from 7.3% in England = 65.0 years 65 Horsham and Mid Sussex to 22.7% of children in Hastings and Rother, but again there are neighbourhoods where more than a third of children live in 64 low income households. 63 24 62 25 Disability-free life expectancy (DFLE) Years 61 64.1 65.2 65.6 66.2 67.5 68.7 69.0 69.4 QVH BoD PUBLIC March 2019 60 Hastings & Brighton & Eastbourne, Crawley Coastal W High Weald East Surrey Horsham & Page 36 of 254 Rother Hove Hailsham Sussex Lewes Mid Sussex and Seaford Havens OUR EVIDENCE OUR EVIDENCE
POPULATION – KEY FACTS LONG TERM CONDITIONS - DATA FROM QOF REGISTERS OF PATIENTS IDENTIFIED V MODELLED The pace of The population is increasing, with higher increases in the older age ESTIMATES OF PREVALENCE change in older groups. It is also important to note that the pace of change in older age ASTHMA ATRIAL COPD DEMENTIA DIABETES HYPERTENSION age will increase will increase markedly over the next ten years. In the first five years, the FIBRILLATION annual increase in the 65+ population is projected to be between 6,000 markedly over the to 8,000(across the whole STP area) but this then starts to rise, and peaks next ten years at around 14,000 in the next 10 years. Figures rounded to nearest 50. Register data relate to 2016/17 QOF Register Estimated undianosed QOF Register Estimated undianosed QOF Register Estimated undianosed QOF Register Est diagnosis rate (65+) QOF Register Estimated undianosed QOF Register Estimated undianosed YEAR-ON-YEAR CHANGE IN THE POPULATION AGED 65 OR OVER Brighton & 16,750 4,100 1,850 4,250 1,700 64% 10,500 7,800 28,900 27,950 2017 TO 2041 (COMBINED EIGHT CCGS AREAS) Hove Given the increase in the old age groups, there will be more people Coastal 32,750 13,900 3,650 10,050 5,750 63.2% 30,250 9,250 83,400 54,550 living with a long term health condition. Many people will have multiple West long term conditions. There will be considerable challenges in sustaining Sussex services and maintaining quality. Crawley 7,650 1,950 750 2,050 800 64.3% 7,100 1,150 16,250 11,750 No recent estimate No recent estimate
East- 12,900 6,350 700 4,400 2,500 67.3% 10,750 4,900 34,100 22,100 bourne Year-on-year change in the population aged 65 or over 2017 to 2041 (Combined eight CCGs areas) Hailsham & Seaford 16,000 East Surrey 10,600 3,800 750 2,500 1,500 68.2% 7,800 3,300 22,250 17,050 14,000 12,000 Hastings 10,250 5,000 950 4,250 1,950 65.0% 10,150 5,450 30,700 17,650 10,000 and Rother 8,000 High 10,150 4,300 950 2,900 1,700 66.0% 7,750 4,300 25,750 17,300 Weald 6,000 Lewes 4,000 Havens 2,000 Horsham & 14,750 5,050 1,650 3,250 2,200 67.9% 10,400 4,400 33,650 22,850 0 Mid Sussex 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 % Of Patients Reporting a Long Term Source: ONS Population Projections (combined CCG areas) Musculoskeletal Problem (2017 LA Level)
25%
20%
15%
10%
5%
18.7% 15.7% 14.5% 14.2% 15.4% 16.5% 0% East Sussex West Sussex Brighton & Surrey SE England England 26 Hove 27
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MENTAL HEALTH ESTIMATION OF COMMON MH MENTAL START WELL HEALTH PROBLEMS Smoking at the time of delivery In 2017/18,C 1,600 women were known to be smokers at the time of delivery (9.1% of MENTAL HEALTH B those withA recorded status). The percentage in Hastings and Rother was over 15%. Estimation of Common Mental Health Problems MH 5 2014/15 % of 16-74 years Breastfeeding initiation£ is high C Over 82% of mothers breastfed£ their babies in the first 48hrs after delivery in 2016/17. High Weald Lewes Havens 12.0% B A The rate was highest in Brighton & Hove (88.2%), lowest in Hastings and Rother (73.3%) Eastbourne, Hailsham & Sfd 12.4% 5 Crawley 12.7% Readiness£ for School C In 2017, the£ percentage of children achieving a good level of development in Brighton & Horsham & Mid Sussex 12.8% B A Hove (69.7%) and West Sussex (70.6%) lags behind East Sussex and Surrey, and is lower ? ? Coastal West Sussex 12.9% ? FOR SALE than England. ? ? 5 East Surrey 13.3% £ Social£ mobility rated very good in ...Tendridge (Surrey) Hastings & Rother 13.8% C B But rated very poor in Arun,? Crawley and Hastings A ? ? Brighton & Hove 17.3% FOR SALE ? ? 5 £ Obesity Serious Mental Illness C £ 7.8 % fo reception pupils and 15% of year 6 pupils were measured as obese in the STP B ? ? SERIOUS MENTAL ILLNESS A ? FOR SALE area (2014/15? ? to 2016/17). Higher percentages of excess and obese children in more 1.4 deprived areas. 5 £ £ 7 hours + of sedentary behaviour 1.2 C ? B ? In the 2014/15C “What about Youth” Survey over 60% of 15 years olds surveyed in the A ? FOR SALE ? ? B 1.0 STP area reportedA a mean daily sedentary time (in the last week) over 7 hours per day 5 0.8 £ Smoking at age 15 years 5 £ The percentage of 15 £year olds who said they were “current smokers” was high in ? ? ? £ 0.6 FOR SALE ? ? C Brighton & Hove (14.9%), East Sussex (12.8%) and West Sussex (10.6%). Nationally the B A rate was 8.2%. 0.4 Hospital admissions for self-harm5 (10-24 years) £ ? In STP areas compared with England, Brighton & Hove, Hastings and Rother and Coastal 0.2 ? £
Prevalence of mental health conditions, percent ? ? FOR SALE ? ? West Sussex have particularly high? rates? of admission. FOR SALE ? ? 0.0 Horsham & Crawley East Surrey High Weald Coastal W Eastbourne, Hastings & Brighton & Mid Sussex Lewes Sussex Hailsham Rother Hove Havens and Seaford
? ? ? FOR SALE ? ? 28 29
QVH BoD PUBLIC March 2019 Page 38 of 254 C OUR EVIDENCE B A
5 £ C £ B A
C 5 B £ LIVEA WELL AGEC WELL £ B A Low Unemployment 5 Over 110,000 older people live? alone? ? in the overall STP area £ FOR SALE C STP area has, overall, a low unemployment rate, but some areas higher such Of the older people living on their? own? the vast majority are women (over 70%). Over £ 5 B A as Hastings £83% of older people are owner occupiers £ C But low wages in some areas B 70,000 households? estimated? to be in fuel poverty 5 A ? £ FOR SALE C Notably full-time wages (2017) are low in Adur, Hastings and Eastbourne. Not restricted to older? people,? but health effects can be greater on the very young and £ B A very old. 5 ? ? £ ? C FOR SALE £ ? ? B ? Housing5 Pressures A Admissions? after a fall are high £ ? FOR SALE ? Over 40,000C households on council waiting lists, 450-500 households a quarter In old age groups? a fall can trigger a move into residential care. For people aged 80+ £ B accepted Aas homeless and in priority need. Brighton5 & Hove, Surrey and West Sussex rates of emergency admissions are far higher ? ? £ ? C than the England rate FOR SALE £ ? ? B Over 250,000 smokers on GP registers 5 A C £ ? ? C Considerable differences across the patch and between socio-economic groups. High Over? 183,000B Carers C £ FOR SALE A B rates in Brighton and Hove and Hastings . ? ….in? the STP area, including over 37,000 people who area caring for 50 hours a week A B 5 ? ? ? A £ or more, including 15,000 carers aged 65 or overs. FOR SALE ? ? £ 5 5 Falling short of the “5-a-day” £ £ 5 ? Across the £STP area, adults consume only 2.5 to 3 portions of fruit & vegetables a day, and ? ? C 18,000+ on Dementia£ Registers £ C FOR SALE ? ? B estimates of £overweight or obese adults at local authority level range from 48% to 64%. A But we know that many people with dementia are not diagnosed. B A ? ? ? FOR SALE 250,000+ adults estimated to? be ?“binge” drinkers 5 5 ? £ £In 2016/17 there were over 1,600 alcohol-specific hospital admissions ? Social isolation and loneliness ? £ C FOR SALE ? ? £ Frequently reported by older people? ? and has an impact on mental and physical ? B ? ?A FOR SALE ? ? ? wellbeing. Over 60% of carers ?known? to social care say they do not have as much social FOR SALE ? ? ? FOR SALE Over 155,000 adults? with? depression on GP registers contact as they would like. 5 £ This represents over 10% of patients. Again there is variation – with 13% of patients in C £ Eastbourne, Hailsham and Seaford identified with depression. Deaths at home Overall a higher percentage (50.7% in 2016) of people in the STP die B ? A in their usual residence? (including care homes), compared with England, but this is far ? ? ? ? FOR SALE ? ? FOR SALE Physical? activity? rates vary lower in Crawley (37.2%) 5 £ Measured at local authority level, the % of adults undertaking the recommended £ physical activity level vary from 78% in Brighton & Hove to 62.2% in Crawley. Variation in Disability Free Life Expectancy (DFLE) Hastings and Rother has the lowest DFLE for both men and women (62.5 years and ? ? Rates? of physical inactivity vary 64.1 years respectively) and Horsham and Mid Sussex the highest (69.1 years for men FOR SALE ? ? In Eastbourne 27% of adults are estimated to undertake less than 30 minutes of and 69.4 years for women) physical activity per week. ? ? ? FOR SALE ? ?
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CASE STUDY - WELLBEING PRESCRIPTION SERVICE – EAST SURREY CASE STUDY - EAST SUSSEX - EMBEDDING PREVENTION The Wellbeing Prescription service allows GPs and other health and ACROSS THE SYSTEM social care workers to refer people to local Wellbeing Advisors. The The Personal and Community Resilience Programme in East Wellbeing Advisors are trained to identify the clients’ needs, provide Sussex brings together partners across the statutory (CCGs, local them with advice and signpost them to relevant local services and authorities, Healthcare Trusts, Police, Fire and Rescue Service, activities. The service is delivered in partnership by Tandridge District Department for Work and Pensions) and voluntary and community Council, Reigate & Banstead Borough Council and East Surrey GP sectors to take action to grow strong communities which improve practices and is commissioned working closely with NHS East Surrey health; and to co-ordinate activity to embed prevention across the Clinical Commissioning Group and Surrey County Council through system. The programme includes transformation programmes in key the Better Care Fund. ‘settings’ (the places where people spend their lives) such as schools, nurseries, and healthcare settings including GPs, pharmacies, Quarter 1 18/19 monitoring report shows that 77% of people who hospitals and community health care services, to support them to have used the Wellbeing Prescription service made a positive change play a greater role in improving health. As part of this: to their lifestyle and 75% have visited their GP less often since using l 3,169 frontline staff have been trained to ‘Make Every Contact the service. The Wellbeing Advisors can help people with issues such Count’ as weight management, getting more active, smoking cessation, social isolation and support with mental and emotional wellbeing. l 96% of all primary and secondary schools have developed and are In addition there is Wellbeing Prescription Plus service, which is delivering whole school health improvement plans provided in the homes of patients with multiple, complex needs, as part of an integrated care approach. l 81% of all nurseries (private and local authority) have audited and are improving their healthy eating and physical activity offer
l 89% of General Practices are undertaking new health CASE STUDY - WEST SUSSEX - SUGAR REDUCTION PROGRAMME improvement programmes in their practices The West Sussex Sugar Reduction Programme was launched in January 2015 (N.B. primary school meals sugar reduction began at the end of l 96% of pharmacies registered as Healthy Living Pharmacies 2014). Whilst the overall programme has been successful, sugar (HLP) Level 1, and 30 targeted pharmacies are being developed The programme reduction in primary school meals has achieved particularly significant as HLP Level2 includes results, winning a Public Health England (PHE) award in September transformation 2016 in recognition of this. To date, the following achievements have l 88,579 people received their NHS Health Check (over the past programmes in been made: 5 years) l Primary school meals now have over 2 kilos less sugar, per child, per key ‘settings’ average school year. l A whole systems approach to Social Value is being developed such as schools, across the county, linked to local priorities and growing nurseries, and l Daily sugar consumption reduced from 18.5g to 6.6g per child strong communities healthcare l The total amount of sugar reduced equals 5 double decker London settings including buses per school year! GPs, pharmacies, hospitals and l That’s a 65% sugar reduction in just 3 years! community health 32 l 30,000 children per day are benefiting care services 33
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Our evidence: Our public and our patients This programme is CASE STUDY – BRIGHTON AND HOVE ADOLESCENT We always value the views of patients and carers and we have quoted aiming to reduce HEALTH OFFER This programme is aiming to reduce the harm caused by substance a few examples of patient experience throughout. Some show excellent the harm caused misuse and unsafe, early sexual behaviour in young people. The care and some highlight areas for improvement. For example: by substance offer is a single, integrated service including: misuse and l Music workshops and mentoring programme for young people GOOD EXPERIENCES unsafe, early use cannabis but do not see it as a problem sexual behaviour l DASH (Drug, Alcohol and Sexual Health) Prevention team which “Every staff member I have in young people provides a package of resilience building interventions encountered has been l Specialist Substance Misuse Treatment Service brilliant, respectful and knowledgeable.” l School based health drop-ins staffed by school nurses and youth workers and text messaging support via CHATHEALTH
l PSHE (Personal, Social, Health and Economic) direct support to schools to improve the universal curriculum
l Communication plan, including social media campaign which “When my husband had a is aimed at equipping parents to have direct conversations with young people to explain the harms caused by using drugs / TIA, I could not fault the care drink / tobacco. of ambulance crew, A&E at hospital, emergency floor”
EXAMPLE A homeless woman with mental health issues including suicidal thoughts, supported by an outreach team to apply for funding, diary reminders for appointments. The support has dramatically reduced her illicit substance use and she feels more in control.
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EXPERIENCES THAT COULD BE BETTER Whenever we get into a discussion with patients and the general public there are a number of recurring themes which regularly surface, they are: l Good access to primary care, “Not enough people know EXAMPLE about the wide range of 87 year old discharged post-surgery and told l Keeping care local, to expect a visit from social care that day. No services pharmacies can one came. Only allowed one visit to change l Care that is well coordinated, offer.” her dressing. (ESBT) l Having the right information to support self-care and as much focus on wellbeing as on health,
EXAMPLE l In addition, local people recommended expansion of the range of local The importance of continuity of relationships services in local communities so these would be more integrated and (for young people) with professionals came accessible both for patients and also for family and carers. out in her frustration with the variability and short term nature of those encounters. All across the STP, commissioners have been engaging the public to gain (Coastal Cares) their views on current services and/or proposed changes. In the Alliance, CCGs have been conducting a series of discussions called the ‘Big Health and Care Conversation’ and more of these events are planned.
IDEAS FOR IMPROVING CARE Once we have agreement on the content and strategic direction of the Population Health Check we will engage more widely with our staff, wider partners, Health Overview and Scrutiny Committees etc. and “I would like advocates, “People need to be mobilise our communications and engagement resources to widen debate community navigators and more aware of healthy and gain ownership of the plan. health coaches to have a lifestyles and to take more greater role in supporting responsibility for own OUR EVIDENCE: WHAT DO PATIENTS EXPERIENCE? We need to move from how things are now, a fragmented and reactive people to understand their health. So more education.” system, to a future system designed around the individual. health conditions and medicine” How it looks now: l A fragmented system with multiple providers, characterised by a lack of coordination, We need to move from how l A service which is reactive not proactive, things are now, a EXAMPLE l Pathways of care that are unnecessarily complex. fragmented and The daughter of a 95 year old woman with dementia raised concerns over her mother’s reactive system, care in a care home. Even though they were to a future system funding the care, support to raise concerns designed around would have been welcomed. 36 the individual. 37
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OUR EVIDENCE: WHAT SHOULD OUR PUBLIC AND PATIENTS EXPECT collaboratively with your health and care professionals to develop a We need to work (PRINCIPLES OF CARE)? care and support plan describing what’s important to you. with our local We understand the importance of a person centred asset based approach to empowering people to develop the knowledge skills and confidence to l There is likely to be a key worker or co-ordinated assigned to you. communities to self-manage. help people help l You will have a care record which you will be able to see and add to. themselves. This is The focus needs to be on our population rather than organisational silos, what most people with prevention and self-management at its core. This is enabled through l If you need hospital care, there may be changes to how and where strength based social care, shared decision making, making every contact this is offered, with hospitals working as partners to provide more tell us they want. count, collaborative care and support planning and health coaching. specialised services and with more technology-enabled care.
People have the right to a high-quality health and care service when they l If you are frail and elderly and you need to go into hospital, you are really need it. more likely to receive support to go straight home to recuperate, rather than having to go somewhere else first. With rights, however, come responsibilities. We need to work with our local communities to help people help themselves. This is what most l Health and social care services will work with you as a partner to help people tell us they want. We need to work with people to redesign the you to live your life independently system. To do this, we will adopt the following principles of care: l Make Prevention Everybody’s business, l You can make the last stage of your life as good as possible because everyone works together confidently, honestly and consistently to help l Maximise Independent Living and Self-Care, you and those important to you, including your carers. (ref: National Palliative and End of Life Care Partnership,2015) l Target proactive care of people at highest risk of hospitalisation and needing higher intensity care,
l Reduce the time people stay in hospital for and discharge them safely, Health and social care services will l Make patient journeys more joined up, without waste, repetition work with you as or duplication, a partner to help l Make Sussex and East Surrey STP a great place to work in all our you to live your life local organisations, independently
l Prioritise investment areas which bring maximum benefit for patients.
OUR EVIDENCE: WHAT WILL THIS MEAN FOR US ALL? l You will be empowered and supported to develop the knowledge, skills and confidence to self-manage and stay well.
l We will create environments which make it easier to be healthy. You are also more likely to be offered a personal care or health budget.
38 l If you become unwell with a long-term condition, you will work 39
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Our evidence: Our services Whilst some “Due to the people receive DYING complexity of four excellent care, l We want more patients to die in their usual place of residence. parties being involved “I can’t think of anything you can others experience Across the STP we have a high number of care homes and we should in our mother’s care improve on, I am 91 years old and fragmented capitalise on this and support more residents to die in these supported and homely environments. ([hospice], [care my wife passed away in March and poorly co- home], District nurses of this year at the age of 95. She ordinated care. l In the Sussex and East Surrey STP, there were 19,585 deaths in 2015. and the GP) there had Parkinson’s and dementia, The percentage of all deaths with dementia as an underlying or contributory cause of death were higher in 50% of the CCGs. were times when she wanted to die at home so I communication and looked after her at home for 3 l The percentage of all deaths that are aged 85 years and older were responsibility were years or more and the help and higher than the national average for all CCGs. disconnected” care I got from the NHS was l We are poor at identifying people who are at the end of their life. St Catherine’s hospice so good I can’t say a bad word about it.” l There is fragmentation of services and lack of shared records. Coastal Care-Primary and Urgent
l Whilst some people receive excellent care, others experience care survey) fragmented and poorly co-ordinated care.
3.3.1 Dying 3.3.2.1 A&E 4hr waiting time performance STP wide Percentage of death in different locations by CCG A&E 4HR WAITING TIME PERFORMANCE STP WIDE
94.0% 60 Brighton & Hove Coastal West Sussex 92.3% Crawley East Surrey 92.0% 50 Eastbourne, Hailsham & Seaford Hastings & Rother 91.0% 90.1% 90.1% High Weald Lewes Havens Horsham & Mid-Sussex 90.0% 91.0% 89.7% 40 88.5% 89.5% 88.0% 86.9% 30 87.8% 86.0% 20 85.8% 85.9% 84.0% 10 82.0% 0 15 1615 1615 1615 1616 1716 1716 1716 1717 1817 1817 1817 18 40 Hospital Hospice Home Care Home Other Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 41
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A&E BREACHES STP WIDE Although there is no right or wrong formula of what services should be 3.3.2.2 A&E Breaches STP wide provided in a non-acute setting, it is generally viewed that an over-reliance on acute based care is comparatively more expensive due to the prevailing 20000 17787 18199 payment system (Payment by Results).
15876 17475 15000 15873 14936 There is variation across the trusts in delivering on Referral to Treatment 14343 13741 13030 Times (RTT). 10000 11628 10570 3.3.3.1 Admissions CCG Outcomes Indicator Set- domain 3 3.1 Emergency admissions for 5000 acute conditions that should not usually require hospital admission (2016-2017 (Jul-Jun)) East Surrey and Sussex
0 94.7 - 98.3 15 1615 1615 1616 1716 1716 1716 1717 1817 1817 1817 18 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 98.4 - 113.7
113.8 - 125.6
Whilst individual Trusts occasionally meet the 95% 4 hour A&E waiting 125.7 - 129.7 time standard, as a whole, the Sussex and East Surrey STP has not met the standard since it was formed in late 2015.
4/4 acute providers have breached the four hour waiting time target at Q3 16/17. In 2016/17, 2 of the acute trusts were more than 5% below the expected 95% of patients to be seen within 4 hours – for Type 1 A&E attendances. The other 2 trusts were above 90% but below 95% for 3 of the 4 quarters. The NHS Planning Guidance (2018/19) expects 95% to be achieved by month 12.
There are significant hand over delays at our hospitals. Between 24- 12-2017 and 02-01-2018 SECAmb lost in excess of 3,200 operational RTT performance STP wide ambulance hours to turnaround delays greater than 30 minutes. This was a 13% increase over the same period last year. This is equivalent to losing 91.0% 13 ambulances on duty every day of this 10 day period. 89.8% 90.0% 89.6% Coastal West ACCESS 89.0% Sussex and East 88.3% Sussex areas 88.0% ADMISSIONS 87.3% showing levels There is very large variation in patterns of hospital use for conditions that 87.0% 86.9% 87.1% of hospitalisation would not usually require hospitalisation, with Coastal West Sussex and East 86.8% 86.2% Sussex areas showing levels of hospitalisation almost four times as high as 86.0% almost four times in other areas of the STP. as high as in other 85.0% areas of the STP. The reasons for this are multi-fold and span patient behaviours but also the 84.0% 16-17 16-17 16-17 16-17 17-18 17-18 17-18 17-18 42 availability, accessibility and responsiveness of non-hospital based services. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 43
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CANCER3.3.4.1 Cancer MORTALITY Mortality “I was recently diagnosed with breast cancer following my first over 50 CCG Outcomes Indicator Set- domain 1 1.9 Under 75 mortality rates from cancer (2015) East Surrey and Sussex screening. I have had the surgery and I have just started chemotherapy. I just wanted to let you know how amazing the staff at BSUH have been; 94.7 - 98.3 The radiographers and nurses in the breast care unit, pre assessment clinic, 98.4 - 113.7 theatre and Ansty ward at PRH and imaging.” 113.8 - 125.6
125.7 - 129.7
l There is significant variation in mortality rates from cancer, with patients in coastal areas, in particular Brighton and East Sussex being in some instances 20% more likely to die from cancer than patients in Horsham/Mid Sussex.
l In our STP, cancer incidence is high, with low diagnosis at stage 1 and 2. Take up of cervical and breast screening is low.
l We lack of access to modern, high quality and local radiotherapy services.
l There is inadequate introduction and adoption of timed pathways in 3.3.4.2CANCER Cancer SURVIVAL survival Lung, Prostate and Colorectal cancer. CCG Outcomes Indicator Set- domain 1 1.10 One-year survival from all cancers (Diagnosed 2014) East Surrey and Sussex l There is variation across the trusts in delivering on cancer waits.
66.7 - 67.5 l Diagnostic capacity and workforce shortages continue to be an issue. 67.6 - 69.6 (Ref: STP dashboard 69.7 - 71.1 2018) 71.2 - 72.3 LATEST LATEST RANK SPINE CHART PERIOD VALUE WITHIN = selected STP SOUTH = middle 50% of South STPs = England average = STP median
WORST BEST
Cancer incidence (total tumours)^ 2014 11403 13/13
Cancer incidence (rate) 2014 611.8 9/13
Breast cancer screening coverage 2015/15 72.4% 12/13
Cervical cancer screening coverage 2015/16 73.7% 9/13
Bowel cancer screening coverage 2015/16 60.3% 8/13 44 Diagnosis at stage 1 or 2 2015 50.6% 12/13 45
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UNWARRANTED VARIATION UNWARRANTED VARIATION: CARDIOVASCULAR STROKE We know there are areas of healthcare, which demonstrates variation in In stroke care there is: practice and quality across our STP. l Inadequate achievement of NICE (National Institute for Health and Care Excellence) Guidelines standards for non-elective stroke care and Key areas of variation in our STP are: the South East Clinical Network Stroke standards. l Cardio Vascular Disease (including Stroke care, Atrial Fibrillation, stable angina and diabetes) l There continues to be variation across the STP in stroke services, especially in relation to access to allied access to six-month reviews. l Trauma and Injuries (Falls and Fragility Fractures)
Routinely Trust Brighton East Maidstone Maidstone Medway Surrey and Western Western Admitting and Sussex Sussex and and NHS Sussex Sussex Sussex l MSK Teams University Healthcare Tunbridge Tunbridge Foundation Healthcare Hospitals Hospital Hospitals NHS Trust Wells NHS Wells NHS Trust NHS Trust NHS Trust NHS Trust NHS Trust Trust Trust
Team Royal Eastbourne Maidstone Tunbridge Medway East Surrey St Richards Worthing Name Sussex District District Wells Maritime Hospital Hospital Hospital “After my stroke, I felt County General General Hospital Hospital isolated and lost Hospital Hospital Hospital Number of Admit confidence” patients 200 149 110 140 89 191 164 189
Disch 167 175 101 142 84 198 156 186
Patient D1 Centred Scan A A A A C A B A Data “Mum wasn’t admitted to D2 B B C D E D C C the ward for 9 hours” SU D3 Throm B C C D D B B B
D4 SpecAsst A B B C D B C A
D5 OT B C A B E B C A
D6 PT B C A A D C C B “The aftercare failed to D7 SALT C E A B C C B C
meet any expectations” SOUTH ENGLAND - EAST SCN PATIENT CENTRED - APRIL TO JULY 2017 CENTRED - APRIL TO JULY PATIENT D8 MDT D D B C D B C B
D9 Std Disch A A C D A B B A
D10 Disch Proc B B B B B D C D
PC KI Level B C A C D B C B
Six Month Number Assessment Applicable 126 109 73 84 85 124 112 106
% Applicable 98% 100% 100% 100% 98% 99% 99% 100%
Number assessed 8 14 0 0 3 3 0 0
% 46 Assessed 6% 13% 0% 0% 4% 2% 0% 0% 47
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Routinely Trust Brighton East Maidstone Maidstone Surrey and Western Western UNWARRANTED VARIATION: CARDIOVASCULAR: STROKE Admitting and Sussex Sussex and and Sussex Sussex Sussex PREVENTION AND ATRIAL FIBRILLATION (AF) Teams University Healthcare Tunbridge Tunbridge Healthcare Hospitals Hospital Hospitals NHS Trust Wells NHS Wells NHS NHS Trust NHS Trust NHS Trust For every 25 high risk patients treated for AF, one serious/debilitating NHS Trust Trust Trust stroke is avoided. The chart below shows that, compared with our Team Royal Eastbourne Maidstone Tunbridge East Surrey St Richards Worthing demographic peers, we often have a gap between our expected Name Sussex District District Wells Hospital Hospital Hospital County General General Hospital prevalence versus our actual prevalence. Eastbourne, Hailsham and Hospital Hospital Hospital Seaford CCG and Hastings and Rother CCG are identifying more cases Number of Admit than their comparative peers. Where we are finding patients and putting 210 146 122 148 193 148 164 patients them on blood thinners, our spend on non elective stroke is lower than Disch 180 188 111 132 177 145 159 our demographic peers because we are preventing strokes. Within three years we could stop 660 Strokes if we treated all patients with AF with Patient D6 anti coagulation. This equates to £11.2 million. Centred PT A B A A B C B Data D7 B E A B C C C SALT Stroke-Stroke- Non-electiveNon-elective spendspend onon dischargesdischarges -- BestBest 55 Stroke-Stroke- Non-electiveNon-elective spendspend onon dischargesdischarges -- CCGCCG D8 B D B B B C B MDT Direct current cardioversion (Majority PBC=10C) - Direct current cardioversion (Majority PBC=10C) - Total spend on discharge - Best 5 Total spend on discharges - CCG D9 B A D D A A A Std Disch AF & CHADS2 score 1: % currently treated with AF & CHADS2 score 1: % currently treated with anti-coagulation therapy - Best 5 anti-coagulation therapy - CCG D10 SOUTH ENGLAND - EAST SCN
PATIENT CENTRED - APRIL TO JULY 2017 CENTRED - APRIL TO JULY PATIENT Disch Proc B C B C D D C AF observed prevalence compared to AF observed prevalence compared to expected prevalence - Best 5 expected prevalence - CCG PC KI 100% Level A B B C B C A 8,000 100%
Six Month Number 90% Assessment Applicable 104 126 75 88 158 114 124 7,000 80% % 6,000 Stroke- Non-elective spend on discharges - Best 5 Stroke- Non-elective spend on discharges - CCG Applicable 98% 100% 100% 100% 98% 100% 100% 6,000 70% Number Direct current cardioversion (Majority PBC=10C) - Direct current cardioversion (Majority PBC=10C) - 5,000 60% assessed 2 13 0 0 0 0 0 Total spend on discharge - Best 5 Total spend on discharges - CCG 60% AF & CHADS2 score 1: % currently treated with AF & CHADS2 score 1: % currently treated with 50% % 4,000 anti-coagulation therapy - Best 5 anti-coagulation therapy - CCG 50% Assessed 2% 10% 0% 0% 0% 0% 0% AF observed prevalence compared to AF observed prevalence compared to 40% 3,000 expected prevalence - Best 5 expected prevalence - CCG 100% 8,000 30% 2,000 90% 7,000 20% 1,000 80% 1,000 6,000 10% 70% 0% 0 5,000 60% NHS Brighton NHS Coastal NHS Crawley NHS East NHS NHS Hastings NHS High NHS & Hove CCG West Sussex CCG SurreySurrey CCGCCG Eastbourne, and Rother Weald Lewes Horsham and 50% 4,000CCG Hailsham and CCG Havens CCG Mid Sussex SeafordSeaford CCGCCG CCG 40% 3,000 30% EST. AF PREVALENCE2,000 1.97% 3.44% 2.04% 2.51% 3.58% 3.52% 3.11% 2.81% 20%
EST. BEST 5 PREVALENCE1,000 2.06% 3.07% 2.24% 2.42% 3.15% 3.21% 2.97% 2.53% 10%
0 0% NHS Brighton NHS Coastal NHS Crawley NHS East NHS NHS Hastings NHS High NHS & Hove CCG West Sussex CCG Surrey CCG Eastbourne, and Rother Weald Lewes Horsham and 48 CCG Hailsham and CCG Havens CCG Mid Sussex 49 Seaford CCG CCG
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UNWARRANTED VARIATION: CARDIOVASCULAR DISEASE: DIABETES CCG Major amputations per Major amputations per Major amputations per The NHS reports In diabetes care there is wide variation in: 1,000 diabetic patients 1,000 diabetic patients 1,000 diabetic patients that people who l The number of major and minor amputations and length of stay. April 2011 - March 2014 April 2012-2015 2013-14 2015-16 have diabetes are England 0.8 0.8 0.81 l The average number of major amputations in England is 8.1 per 10,000 East Surrey CCG 1.0 (19) 0.8 (17) 0.9 (19) 15 times more (standardised rate). Across our STP the rate ranges from 5.8 High Horsham & Mid Sussex CCG 0.6 (15) 0.8 (21) 0.82 (21) likely to undergo Weald Lewes Havens CCG to 10.2 Eastbourne, Hailsham and Seaford Crawley CCG 0.5 (9) 0.9 (17) 0.93 (16) amputations than CCG. The average number of minor amputations in England is 20.7 per 10,000 (standardised rate). Across our STP the rate ranges from 17.7 Coastal West Sussex CCG 0.9 (71) 1.0 (79) 0.54 (80) other people (Crawley CCG) to 28.9 Eastbourne, Hailsham and Seaford CCG. Brighton & Hove CCG 1.0 (32) 0.9 (29) 0.8 (27) without the High Weald, Lewes & 0.6 (12) 0.6 (14) 0.58 (16) condition. l Our current diabetic foot amputation rate will continue to rise. Havens CCG Currently 52% of our diabetic foot ulcers are rated as severe and at Hastings & Rother CCG 1.0 (27) 0.9 (27) 0.81 (29) least 56% were unhealed at 12 weeks, with 83% of patients waiting Eastbourne, Hailsham & 1.7 (47) 1.1 (33) 1.02 (36) Seaford CCG more than two days for referral and triage and 38% waiting at least 14 South East Coast Total 578 581 0.82 (613) days (NICE recommendation for referral and triage within two days). CCG Minor amputations, annual Minor amputations, annual Minor amputations, annual rate per 1,000 adults with rate per 1,000 adults with rate per 1,000 adults with l There is still a gap in the actual to expected prevalence rate of diabetes. diabetes diabetes 2012-2015 diabetes 2013-2016 There is variation across our STP in terms of Primary Care achievement England 1.7 1.8 2.1 of quality targets such as blood sugar management, blood pressure, cholesterol and the other 8 Care processes. East Surrey CCG 2.6 (51) 2.3 (48) 2.42 (57) Horsham & Mid Sussex CCG 1.5 (39) 2.0 (57) 2.23 (67)
Crawley CCG 1.4 (25) 1.4 (26) 1.77 (30) KEY FACT Coastal West Sussex CCG 1.9 (143) 2.1 (163) 1.84 (184) The NHS reports that people who have diabetes are 15 times Brighton & Hove CCG 2.1 (66) 1.8 (58) 2.07 (71)
more likely to undergo amputations than other people without High Weald, Lewes & 2.3 (49) 1.8 (39) 2.15 (59) the condition. Diabetes is one of the leading causes of amputation Havens CCG of the lower limbs throughout the world. Charity Diabetes UK Hastings & Rother CCG 2.4 (68) 2.4 (69) 2.05 (74) notes that problems of the foot are the most frequent reasons for Eastbourne, Hailsham & 2.7 (76) 2.9 (84) 2.89 (98) hospitalisation amongst patients who have diabetes. Seaford CCG South East Coast Total 2.02 (1334) (SEC average) 2.07 (1274) 2.33 (1739)
“In the first 5 weeks of attending (the National Diabetes Prevention Programme tailored education) I had lost almost a stone in weight and my cholesterol is falling”
50 51
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UNWARRANTED VARIATION: CARDIOVASCULAR DISEASE: UNWARRANTED VARIATION: TRAUMA AND INJURIES (FALLS AND We have a OVER-TREATING PATIENTS WITH STABLE ANGINA FRAGILITY FRACTURES) higher spend The NICE pathway states that patients with stable angina should have The chart below shows that there is wide variation in the number and a computerised temography angiogram first which is non-invasive and treatment of falls compared with our demographic peers: One in three on angiography cheaper than an invasive angiogram. Only about 20% of patients who over-65s and half of those over 80 will suffer a fall each year. The and stents than have had a CT angiogram would need to go on to have an invasive Department of Health and Social Care has stated that a falls prevention our demographic angiogram. 80% should be given medication to manage their angina. strategy could reduce the number of falls by 15-30%. Admissions relating peers but not If the medication does not help the pain, a shared decision-making to fractures where a fall has occurred, notably hip fractures and those conversation should take place which makes it clear that if the patient has people over 65 without significant injury and are not always getting a always resulting in a stent inserted, it will not prolong their life, with the exception of a small multifactorial falls assessment and exercises, which we know reduce better outcomes defined cohort of our population, but it will help with chest pain. The subsequent falls by 24%. We do not always have effective case-finding chart below shows that compared with our demographic peers, we have and appropriate drug treatment for osteoporosis, particularly after the a lower reported prevalence of CHD than our estimated numbers. Also first fracture has occurred. We know if this treatment is taken then there we have a higher spend on angiography and stents than our demographic is a reduction in the risk of the next fracture by 50%. peers but not always resulting in better outcomes. There is variation in the
implementation of these NICE guidelines across our STP, resulting in too Tendency to fall, not elsewhere classified (R296): Tendency to fall, not elsewhere classified (R296): many invasive angiograms and stents. NEL Spend - per 1,000 - Best 5 NEL Spend - per 1,000 - CCG K633, K364, K636: Angiography - Total spend on K633, K364, K636: Angiography - Total spend on discharges - Best 5 discharges - CCG Rate of injuries due to falls in people aged 65+ per 100,000 Rate of injuries due to falls in people aged 65+ per 100,000 K633, K364, K636: Angiography - Total spend on K633, K364, K636: Angiography - Total spend on age-sex weighted population - Best 5 age-sex weighted population - CCG dischargesK751, K752: - BestStents 5 - Total spend on discharges - Best 5 K751,discharges K752: - CCGStents - Total spend on discharges - CCG
K751, K752: Stents - Total spend on discharges - Best 5 K751, K752: Stents - Total spend on discharges - CCG Percentage of GP registered population aged 75+ - Best 5 Percentage of GP registered population aged 75+ - CCG Reported to estimated prevalence of CHD (%) - Best 5 Reported to estimated prevalence of CHD (%) - CCG
Reported to estimated prevalence of CHD (%) - Best 5 Reported to estimated prevalence of CHD (%) - CCG Mortality from CHD: under 75 - Best 5 Mortality from CHD: under 75 (%) - CCG 3,500 100% 90% Mortality from CHD: under 75 - Best 5 Mortality from CHD: under 75 (%) - CCG 3,000 80% 6,000 100% 2,500 70% 90% 100% 6,000 K633, K364, K636: Angiography - Total spend on K633, K364, K636: Angiography - Total spend on 5,000 discharges - Best 5 discharges - CCG 80% 60% 90% 2,000 5,000 K751, K752: Stents - Total spend on discharges - Best 5 K751, K752: Stents - Total spend on discharges - CCG 70% 50% 4,000 80% 60% 1,500 40% 4,000 Reported to estimated prevalence of CHD (%) - Best 5 Reported to estimated prevalence of CHD (%) - CCG 70% 3,000 50% 60% 1,000 30% Mortality from CHD: under 75 - Best 5 Mortality from CHD: under 75 (%) - CCG 40% 3,000 50% 20% 2,000 30% 40% 500 10% 2,000 20% 100% 1,000 6,000 30% 10% 90% 0 0% 20% Brighton & Coastal West Crawley East Surrey Eastbourne, Hastings and High Weald Horsham and 1,000 5,000 80% 0% Hove CCG Sussex CCG CCG CCG Hailsham and Rother CCG Lewes Mid Sussex 0 10% NHS Brighton NHS Coastal NHS Crawley NHS East NHS NHS Hastings NHS High NHS Seaford CCG Havens CCG CCG 4,000 70% & Hove CCG West Sussex CCG Surrey CCG Eastbourne, and Rother Weald Lewes Horsham and 0% 0 60% NHS Brighton NHSCCG Coastal NHS Crawley NHS East HailshamNHS and NHS CCGHastings HavensNHS High CCG MidNHS Sussex & Hove CCG 3,000West Sussex CCG Surrey CCG SeafordEastbourne, CCG and Rother Weald Lewes HorshamCCG and 50% CCG Hailsham and CCG Havens CCG Mid Sussex 40% 2,000 Seaford CCG CCG CCG CHD PREVALENCE 2.19% 4.11% 2.77% 2.77% 4.12% 4.20% 3.11% 2.96% 30% 1,000 20% BEST 5 PREVALENCE 2.86% 3.71% 2.71% 2.69% 3.89% 3.85% 3.33% 2.70% 10% 0 0% NHS Brighton NHS Coastal NHS Crawley NHS East NHS NHS Hastings NHS High NHS & Hove CCG West Sussex CCG Surrey CCG Eastbourne, and Rother Weald Lewes Horsham and 52 CCG Hailsham and CCG Havens CCG Mid Sussex 53 Seaford CCG CCG
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UNWARRANTED VARIATION: MSK Surgical site infection rates per Trust for Total Hip Replacement For example, In musculoskeletal surgery there is wide variation in: 3.5%
l The volume of Total Hip Replacement surgery per surgeon. 34% of 3.0% surgeons do less then 10 procedures a year, 54% do less than 20 2.5% procedures a year and only 30% perform greater or equal to 50 2.0%
l The number of revisions within a year post joint replacement per surgeon 1.5%
1.0% l The rate of infection post joint replacement per hospital 0.5%
0.0% 2014 2015 2016 Number of Total Hip Replacement per surgeon
10 UNWARRANTED VARIATION: MSK - TOTAL KNEE REPLACEMENT 9 The chart below shows that we are doing more procedures, spending more 8 on elective care and delivering poorer outcomes than our demographic 7 peers. The % of patients 60 and over having same side knee replacement 6 within one year of arthroscopy is declining but is still six times higher 5 than the national average. Nice Guidance recommends conservative 4 management (exercise/weight management/patient education) before 3 consideration for surgery as these approaches can reduce pain, improve 2 function and avoid the need for a Joint replacement as osteoarthritis is not 1 always a progressive condition. Good quality Shared decision making is 0 important to give patients the information they need to make a decision 50+ 30-50 20-29 10-19 0-9 that’s right for them. Total Knee Replacement 1 year revision rates Primary Knee Replacement - Age-Sex Standardised Primary Knee Replacement - Age-Sex Standardised 2.5 Spend per 1,000 - Best 5 Spend per 1,000 - CCG % Of people (over 45) who have knee osteoarthritis % Of people (over 45) who have knee osteoarthritis (total) - Best 5 (total) - CCG 2.0 1.92 Knee Replacement (primary), EQ-SD Index, Health Knee Replacement (primary), EQ-SD Index, Health Gain - Best 5 Gain - CCG 1.59 1.5 18,000 40%
1.20 16,000 35% 14,000 1.0 1.00 30% 0.90 12,000 25% Revision rate (%) 0.66 10,000 0.54 0.50 0.50 0.50 20% 0.5 0.41 0.40 8,000 15% 0.30 0.29 6,000 0.10 4,000 10% 0.0 0.00 0.00 0.00 0.00 0.00 0.00 2,000 5%
WSH-8 WSH-6 WSH-9 WSH-1 0%
WSH-4 WSH-5 WSH-2 0 BSUH-9 BSUH-3 BSUH-1 BSUH-2 BSUH-4 BSUH-6 BSUH-5 BSUH-7 BSUH-8 WSH-13 WSH-14 WSH-11 WSH-12 WSH-16 Hastings and High Weald Eastbourne, Coastal West Crawley Horsham and Brighton & East Surrey Rother CCG Lewes Hailsham and Sussex CCG CCG Mid Sussex Hove CCG CCG 54 Surgeon Havens CCG Seaford CCG CCG 55
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UNWARRANTED VARIATION: MSK - TOTAL HIP REPLACEMENT The chart below shows we are spending more than our demographic “Some people only know peers with health gain worse (apart from Eastbourne, Hailsham and to go to A&E for urgent Seaford CCG) and prevalence is identical. “I would like Community care – there is a lack of Primary Knee Replacement - Age-Sex Standardised Primary Knee Replacement - Age-Sex Standardised Navigation to be extended awareness about other Spend per 1,000 - Best 5 Spend per 1,000 - CCG in the city. I would like places people can go. “ % Of people (over 45) who have knee osteoarthritis % Of people (over 45) who have knee osteoarthritis (total) - Best 5 (total) - CCG patients to be able to self-refer and to have Knee Replacement (primary), EQ-SD Index, Health Knee Replacement (primary), EQ-SD Index, Health Gain - Best 5 Gain - CCG navigators in communities, 18,000 40% like a “go to” person. 16,000 35%
14,000 30% 12,000 25% 10,000 20% 8,000 15% “More needs to be done to promote the 6,000 alternative to A&E and opening times.” 4,000 10% 2,000 5% 0 0% Hastings and High Weald Eastbourne, Coastal West Crawley Horsham and Brighton & East Surrey Rother CCG Lewes Hailsham and Sussex CCG CCG Mid Sussex Hove CCG CCG Havens CCG Seaford CCG CCG
Ambulatory care sensitive conditions AMBULATORY CARE SENSITIVE CONDITIONS CCG Outcomes Indicator Set- domain 2 2.6 Unplanned hospitalisation Attendances at our A&E Departments continue to rise with a 4% increase for chronic ambulatory care sensitive conditions (2016-2017 (Jul-Jun)) East Surrey and Sussex reported over the first 3 quarters of 17-18 compared to 16-17. 156.9 - 239.9
Over a quarter of all attendances at A&E could have been treated at 240.0 - 574.2
another suitable location (e.g. primary care provision) however patient 574.3 - 661.6 behaviours and the availability of alternative pathways continue to drive 661.7 - 752.9 this increase in activity.
There are several points of contact for access to services, fragmented pathways and gaps in service availability (geographic and time of day), particularly around admissions avoidance and to support hospital discharges. This results in multiple handoffs and confusion over the correct pathways, building in inefficiencies in how services are being delivered, increasing conveyance and admissions and the length of stay in hospitals. 56 57
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DELAYED TRANSFER OF CARE (DTOCS) FLOW There are many patients in hospital beds who should be cared for at home. A bed audit carried out across the STP identified 22% of patients across 49% of patients Sussex and East Surrey that are “fit to leave” their current setting of care. who were An increasing rate of incomplete to complete pathways has caused classified as fit to a worsening performance against the Referral to Treatment 18 week A total of 49% of patients who were classified as fit to leave their current incomplete standard. At quarter 2 of 2017/18, 5 out of the 6 providers setting of care have remained in hospital for over a week. There were leave their current breached the standard. In 2016/17 bed occupancy was at 92.7% (ranked 97% of acute patients fit to leave who were admitted as non-elective setting of care as 35/44 across the STPS) and the percentage of beds attributable to patients. A total of 75% of acute patients and 92% of community have remained in Delayed Transfers of Care (DTOC) was 8.9% (ranked as 37/44 across the patients fit to leave their current setting of care are over the age of 70. A hospital for over STPs). 1 = best, 44 = worst. majority of delays are attributed to patients awaiting social care, although patient and family choice is a major cause for delay in the community a week. A disproportionate number of those fit to leave their current setting of setting. (CF April 2017). care have dementia, with over a quarter of patients with dementia or a cognitive impairment fit to leave waiting for over 50 days to leave their settings of care. Beds Occupied by Stranded Patients (7+ days) Sussex and East Surrey
KEY FACT 59% 58% 47% of carers in the “Counting the Cost” survey reported that Surrey and Sussex Healthcare being in hospital had a significant detrimental effect on the general 57% NHS Trust 56% physical health of the person with dementia and 54% reported a East Sussex Healthcare NHS Trust negative effect on the symptoms of dementia such as becoming 55% 54% Western Sussex Hospitals NHS more confused and less independent (Alzheimer’s Society 2009) 53% Foundation Trust 52% Brighton and Sussex University 51% Hospitals NHS Trust South East DTOC % (Bed day delays per occupied bed) 50% Sussex & East Surrey 49% 48% 8.0% 47% South East 46% 7.0% Kent, Surrey and Sussex 45% Nov-17Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 6.0% Brighton and Sussex University Hospital NHS Trust 5.0% Western Sussex Hospital NHS Foundation Trust 4.0% Surrey and Sussex Healthcare 3.0% NHS Trust
2.0% East Sussex Healthcare NHS Trust Queen Victoria Hospital NHS 1.0% Foundation Trust
0.0% 58 Nov-17Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 59
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Beds Occupied by Extended lenght of stay Patients (21+) Reduction in beds: Sussex and East Surrey The Royal Sussex County Hospital site in Brighton is delivering a 10-year strategy to improve their estate, which will impact on their ability to 25% deliver care in a timely way. A strategic/system-wide solution is needed to Surrey and Sussex Healthcare 24% NHS Trust support those pathways affected as all Trusts will be affected.
23% East Sussex Healthcare NHS Trust
22% Western Sussex Hospitals NHS BED DAY UTILISATION Foundation Trust 21% There are currently 3,519 acute inpatient beds across the STP. Bed Brighton and Sussex University occupancy across all sites is forecast to increase in 2016/17. 20% Hospitals NHS Trust
19% Today
18% 3Ts by 2023/24 17% 37 Proposed Emergency Floor redevelopment RSCH Bed capacity 16% will increase as a 176 result of 3Ts and a 15% proposed emergency Nov-17Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 oor redevelopment
Inpatient Beds 586 315 44 695 544 465 465 341 69
BED DAY UTILISATION Royal Sussex Princess Royal East Surrey Worthing St Richard s Conquest Eastbourne Queen Across the STP, bed occupancy per provider ranged from 62% (at the County Royal Alexandra Hospital Hospital Hospital Hospital DGH Victoria Hospital Hospital Childrens Hospital specialist provider) to 96% at Quarter 2 2017/18. Hospital Today Compared with our peers, there is statistically significant variation in the BSUH SaSH WSHT 3Ts by ESHT2023/24 QVH number of bed days across all common conditions. There are currently 37 Proposed Emergency Floor redevelopment RSCH Bed capacity 3,519 acute inpatient beds across the STP. will increase as a 176 result of 3Ts and a l Average length of stay (AloS) increased between 2010/11 – 2016/17. proposed emergency BED OCCUPANCY oor redevelopment
l Over the last three years, the general and acute bed base has remained 15/16 93% 72% 85% 94% 89% 85% 88% 101% 62% Inpatient Beds relatively constant but bed occupancy has increased over time. 16/17 96%586 74%315 88%44 96%695 91%544 87%465 90%465 103%341 64%69 Demand must be l Bed capacity is expected to increase by 176 beds by 2023/24 at BSUH Royal Sussex Princess Royal East Surrey Worthing St Richard s Conquest Eastbourne Queen managed to align County Royal Alexandra Hospital Hospital Hospital Hospital DGH Victoria as a result of the 3Ts rebuild. Hospital Hospital Childrens Hospital acute capacity and Hospital BSUH SaSH WSHT ESHT QVH demand and to l Elective referral rates are increasing across the system and longer prevent shortfalls lengths of stays are driving a significant elective backlog at all Trusts.
in available beds l Demand must be managed to align acute capacity and demand to meet the needs and to prevent shortfalls in available beds to meet the needs of the population. 60 of the population. 61
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Average occupancy by quarter CARE QULITY COMMISSION (CQC) RATINGS Q1 2014 - Q3 2016 Brighton and Sussex University Hospitals NHS Trust (BSUH): The Trust Everything was was last inspected in April 2016 and updated in August 2016. CQC found rated as ‘good’ 100% them to be inadequate in the areas of safety, responsiveness and leadership. or ‘outstanding’, SES Weighted Average The culture of the Trust was viewed as exceptionally challenging. Since the England inspection, Western Sussex Hospitals NHS Foundation Trust has taken over apart from the the management of the BSUH and improvements have been seen in a Emergency 95% number of areas. Department at Eastbourne, East Sussex Healthcare NHS Trust: In June 2018, the CQC noted the Trust which was rated 90% has made a marked improvement in the quality of its care, and concludes that the Trust no longer needs to be in special measures for quality. In the areas as ‘requires inspected by the CQC, everything was rated as ‘good’ or ‘outstanding’, apart improvement’, but from the Emergency Department at Eastbourne, which was rated as ‘requires ‘good’ for well led 85% improvement’, but ‘good’ for well led and caring. and caring. SECAmb: Following CQC inspection in 2017 the Trust was rated as Inadequate. This resulted in the Trust remaining in Special Measures and the development of 80% a recovery plan that addresses CQC findings together with work across different Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 areas of the Trust. This includes an overarching Culture and Organisational Development and an extensive programme of work dealing with workforce, recruitment, training and retention. CQC is conducting an inspection of the Trust in July (Core Services and Emergency Operations Centre) and August (Well Total general and acute bed base Q1 2014 - Q3 2016 Led) this year. The results of the inspection will be published in the Autumn. The work across the Trust is also being informed by a jointly commissioned Demand 1,000 and Capacity review to identify resource requirements to fully meet Ambulance Response Programme standards. 900
800 TRUST CQC RATING BSUH Good 700 ESHT Requires improvement 600 WSHT Outstanding BSUH 500 SASH Outstanding SaSH 400 QVH Good WSHT 300 SPFT Good ESHT SCFT Good 200 QVH FCH Outstanding 100 SB Good
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 SECAMB Inadequate 2014 2014 2014 2014 2015 2015 2015 2015 2016 2016 2016 62 IC24 Good 63
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MENTAL HEALTH SERVICES l For dementia, prevalence is 25% higher than nationally, will increase The health and life outcomes for people experiencing mental health issues further as the population ages, while the proportion of those with a “My partners in our STP will continue to fall short of those of the general population diagnosis is 5% lower. mental health unless we act to deliver the opportunities aligned with the five year forward view for mental health. To meet the government target of 21,000 new l A quarter of those patients with dementia who are fit to leave acute and mine wasn’t mental health posts by 2021, the STP projected response is set out below care wait over 50 days for discharge. a priority after my stillborn, The Sussex and East Surrey STP has an agreed Mental Health Strategy l Three quarters of first episodes of mental ill health occur in young following a detailed Case for Change which identified that: people before the age of 25. they took slightly l Sussex and East Surrey STP need to ensure that 25% of people living better care but with common mental health problems are seen by a local Improved no mention of Access to Psychological Therapies service every year. KEY FACT Life expectancy for those with severe mental illness is twenty years’ mental care at any l Capacity needs to be built in primary care, closer to home and thereby worse than the general population appointments” reduce presentations and referrals to physical and mental health secondary care.
l The prevalence of Severe Mental Illness is 5% higher than nationally, GP SERVICES affecting 25,000 individuals. The National Picture Workload: Actual GP appointment numbers are not routinely collected by NHS England but the information we have would suggest significant rises, for instance 15.4% between 2010/11 and 2014/15. The Kings Fund (2016) estimated that there had been a 15 per cent overall increase in Posts People contacts, 13 per cent increase in face-to-face contacts and a 63 per cent 6000 increase in telephone contacts. Clinical posts: 446 169 Workforce numbers: Nearly a quarter (23%) of the GP workforce is over 5000 446 Impact 271 727 55. Less than a quarter (22%) of GP trainees plan to practise full-time Non-Clinical - 163 vacancy one year after qualifying, according to a recent study by the King’s Fund, 564 posts: 271 242 4000 difference 467 falling to 5% who expect to be working full time after 10 years. ‘The 501 501 636 312 intensity of the working day’ was cited as the most common reason. 3000 - 385 Staff in Post difference Morale: A 2017 survey conducted by Exeter University in the South West indicated that over half of the GP workforce reported low or very low 2000 morale, and 40% of all GPs intended to retire within five years.
Assumption Assumption Less than a modelled modelled Practice Closures: Increasing numbers of practices are either closing their
Mental Health Services - Posts and People 1000 on observed on observed Choice Choice trend Choice trend Choice Fixed Choice lists to new patients (a medium term approach) or capping their list (a quarter (22%) of 3,905 4,290 shorter term approach), in order to maintain the quality of the service to GP trainees plan 0 existing patients within the resources they have. 2016 New posts Transfer Leavers - Replace- Leavers - Improved Newly New roles Dynamic V Static inputs to practise full- in growth posts to Non ment Staff Clinical retention Qualified (Nurse areas transfor- Clinical (Local) Staff from Associates, time one year mation & training Physicians Estates Issues: A 2018 BMA Survey revealed that four out of 10 GPs feel growth Associates after qualifying areas Base Staff in Post Vacancies etc) their premises are not adequate for patient care, describing how they are 64 + Change - Change struggling to provide essential services in buildings that are cramped and 65
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outdated. It also reported that six out of 10 GPs in England are forced to closure of a practice of 8,000 patients. The retirement of partners and Pressure through share consulting rooms or ‘hot-desk’ around their surgeries. salaried GPs has been a contribution factor to 16 practice closures and 10 retirement of mergers. STP examples partners and l Increasing elderly: The West Sussex Joint Services Needs Assessment (JSNA) l Utilising the GP international recruitment scheme has not delivered the volume salaried GPs estimates that the local population aged 70+ will grow at the fastest of new GPs anticipated. A target of 25 was set for 2018 but has been a rate of any demographic; and that by 2039 more than 30% of the CCG only five have been recruited. contributing resident population will be aged 65 or over. They also project that this means that the number of adults in this age group admitted to hospital factor to 16 with falls will nearly double over the same period. There are already OUR SERVICES – KEY FACTS practices closing some small areas of West Sussex where more than 50% of the resident l Our pathways are often fragmented and there are frequent breakdowns in and 10 mergers population are aged 65 or above. Between 2018 and 2030 the JSNA handoffs between agencies. predicts that the number of cases of dementia will rise by 45%. since 2013 l There are delays in people accessing services and therefore may be missing l Workforce: According to NHS England figures, in 2015 there were 960 full out on timely treatment. time equivalent (FTE) GPs across East Surrey and Sussex. In order to deliver the growth required to deliver our proportion of the 5,000 extra GPs l There is a lack of timely access to effective primary and community services promised in the GP Forward View we would need to boost that to 1106 driven by insufficient capacity in primary care and community services. FTE GPs (so an increase of 146) . However the GP FTE across the patch as of Sept 2017 number 936 – a fall of 24 FTE, or 170 short of the target l Discharge arrangements from acute care is variable, which means patients 1106. Figures for nurses seem to be broadly stable, GP Nurses FTE as of spend longer than necessary in hospital. There are gaps in Sept 2015 numbering 502, and as of June 2018, 522. Large percentage reaching minimum of both practice nurses and GPs in our area that are over 55 and coming l We are often not meeting our constitutional standards for A&E, Referral – up to retirement. It is anticipated that there will be a loss of a third of GPs to-Treatment. standards of care over next 10 years as they reach 55+. The retirement risk in ESBT is 46% of in such areas as practice nurses in Hastings and Rother and 31% in Eastbourne, Hailsham l There are gaps in reaching minimum standards of care in such areas as stroke, stroke, diabetes and Seaford age 55+ with GPs 55+ at 24% in Hastings and Rother and diabetes and cancer. and cancer. 17% in Eastbourne, Hailsham and Seaford. Currently 210 GPs (18.5% of the workforce) are over 55 years. l General practice is facing significant issues in workforce with a backdrop of increasing demand l The STP has 203 practices. There are 12 single-handed GP practices and 189 partnerships, with the smallest registered list of 1,379 and the largest MAIN CHALLENGES: being 25,054. Pressure through retirement of partners and salaried GPs l Addressing the significant un-warranted variation in MSK, Cardiovascular and has been a contributing factor to 16 practices closing and 10 mergers falls/ fragility fractures. since 2013. The GP workforce across the STP is in decline, of between 3% in the Coastal West Sussex area to 15% in Hastings and Rother CCG. l Making a step change in managing flow, stranded and super stranded In Brighton, nine surgeries (out of an initial total of 44) have closed in patients. the last four years, displacing more than 33,000 patients, and putting extra pressure on already-struggling practices nearby. Brighton has been l Improving shared decision making. described in the press as possibly ‘the hardest hit town in the whole of the UK?’ In Hastings and St Leonards, at one point in the last 12 months 10 THE CONSEQUENCE WE OBSERVE: out of 14 practices had either closed or capped their patient lists, putting l Frequent, unnecessary admissions to hospital when patients could be cared for enormous pressure on the remaining practices. In Arun in Coastal West in a different setting. 66 Sussex, three out of six practices have had to cap their lists due to the 67 l Challenge in meeting and maintaining A&E and elective care targets.
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Our evidence: Our staff l In social care there is a significant annual turnover of 26% for registered nurses, which rises to 32% turnover amongst support Difficulty OUR PEOPLE - OUR CHALLENGES workers providing direct care in East Sussex. recruiting and retaining l Skills for care estimates that in Brighton & Hove, 8.6% of roles in adult CROSS RECRUITMENT LEADERSHIP STAFF substantive CUTTING social care were vacant, this equates to around 700 vacancies at any & RETENTION CAPABILITY HEALTH THEMES one time. This vacancy rate was similar to the region average, at 6.8% mental health and similar to England at 6.6%. nurses and
l Difficulty recruiting and retaining substantive mental health nurses and psychiatrists, has CROSS COLLABORATIVE USE OF STAFF CUTTING WORKING TEMPORARY psychiatrists, has led to a sustained and increasing agency spend (in led to a sustained ENGAGEMENT THEMES ACROSS STP STAFF Sussex agency spend in mental health services was £2.6m in 2012/13 and increasing rising to £9.8m in 2015/16). agency spend
CROSS LACK OF REDUCTION IN SIGNIFICANT l In June 2017, the SES STP had a shortfall of GPs (FTE) of 193. CUTTING SPECIALIST EDUCATION VARIATIONS IN THEMES POSTHOLDERS FUNDING WORKFORCE l The average level of sickness absence across acute trusts for 2014-15 was just over 4%. Just a 1% improvement in sickness absence equates to £280m in staff costs – without accounting for lower dependence on
CROSS MENTAL HEALTH PRIMARY & ACUTE SECAMB SOCIAL CARE agency staff and reduced cancellations. LOCAL CUTTING Recruitment and COMMUNITY Reliance on High attrition Finding & THEMES CARE retention of staff temporary staff Attraction to keeping the right l Spend on temporary staffing continues to increase. Culture of Lack of GPs Mode/hospital skilled roles staff (current & working in variations Culture Terms & mental health future) conditions of Nursing, Leadership KEY ISSUES: Complex Demographic of midwifery, service structures and workforce medical and AHP Job roles l We have significant issues relating to workforce and need to ensure we links to social Cross site recruitment Working have the right people in the right place at the right time to deliver care. care working/ conditions collaboration New roles l required to Given our demography, we need to rely as much on technology- meet increasing enabled care as on state funded clinical and domiciliary workforce. demand There just won’t be as many employees available in future as would be needed to provide current services to a larger population with more KEY FACTS retired people and not many more working-age citizens. l There are 10,926 headcount staff and 9,375.90 FTE Registered Nursing, Midwifery and Health Visiting Staff across Sussex and East Surrey STP. l We have an inadequate number of mental health posts to meet the needs of our population. l The average retirement age is 59, with 15.38% of staff aged 55 years and over. The staff groups with over 20% of staff aged 55 and over l We need to increase the workforce within Primary Care to support that may be approaching retirement ranges from Registered School changes to the way we deliver care across the system. Nurses at 31% to Community Services (excl. Health Visitors and District Nurses) at 20.68%. THE CONSEQUENCES WE OBSERVE: l There is a real risk that we are failing to attract and retain the best talent. l The Turnover Rate for all Registered Nursing, Midwifery and Health Visiting Staff ranges from 12.84% in Maternity Services (excl. l There is a significant risk to the resilience of services and the 68 Registered Midwives) to 20.29% in district nursing. sustainability of a workforce. 69
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Our evidence: Our infastructure DIGITALISATION Significant Individual Digital Maturity of secondary care providers is broadly in line elements of the ESTATES with national average with evidence of improvement over the past year. estate are either There is a diverse legacy of primary, community and acute provider estate However the maturity levels between providers vary significantly. across the STP. functionally There is significant variation in technology usage across the STP with unsuitable or Historically there have been many years of under-investment in estate, limited consolidation of suppliers except for PACS (Picture and compromised which has resulted in non-compliance, high backlog maintenance and Communication System) for Radiology, which represents a significant inefficient estate with high running costs. opportunity. in the current
configuration Significant elements of the estate are either functionally unsuitable or There is a lack of effective information sharing which presents a significant compromised in the current configuration. barrier to implementing new models of care.
There is multiple ownership of the estate, which ranges from NHS acute Population Health Management and Risk Stratification are fragmented and community provider organisations, GP partners, NHS Property and vary in use and sophistication. Services, third party commercial landlords, public/private partnerships to local authority partners. The information governance community is capable and enthusiastic, but capacity is variable and is a limited resource overall. There is a lack of formal lease/licence agreements in place resulting in ambiguity over estates running costs, occupation and utilisation information. Clinicians and professionals lack clarity and confidence to support information sharing. Estates running costs are higher than the national “Carter” benchmark indicators. Key high cost acute sites include the Royal Sussex County Digital Maturity - Secondary Care Sussex and East Surrey 2016 Hospital, St Richards Hospital, Worthing Hospital, East Surrey Hospital and Sussex and East Surrey 2017 Eastbourne District General Hospital. There is also a substantial backlog 100 maintenance requirement across the acute and community estate, with high and significant risk elements exceeding £81million (excluding primary care and NHS Property Services community estate). 75
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Records Strategy Information Orders & Remote & Asset & Business & Leadership Resourcing Governance Assessment Transfer of Medicine Decision Enabling Standards Alignment Governance Results Assistance Resource Clinical & Plans Care Optimisation Support Infrastructure 70 Management Care Optimisation Intelligence 71
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FINANCE OUR INFRASTRUCTURE – KEY FACTS Current situation: The STP covers a wide geographical area and many There is a multiplicity of IT system many of which do not communicate Our community organisations, with a notable amount of variation in financial to each other. and primary care performance. In 2017/18, seven out of nine Trusts ended the year in assets are not surplus. The two trusts in deficit - East Sussex Healthcare NHS Trust and l We have Information Governance issues. Brighton and Sussex University Hospitals NHS Trust - are in Financial optimised or Special Measures. Of eight CCGs in the footprint, one ended the year in l There is a significant mismatch between revenue and expenditure. necessarily fit for surplus. Overall the combined net deficit (surpluses and deficits added purpose. together) for CCGs and trusts was £228.2m. It should also be noted that l We have higher use of acute services that are proportionally this figure includes significant amounts of one-off funding, including more expensive. Sustainability and Transformation Funding, which was released at the end of the year. l Our community and primary care assets are not optimised or necessarily fit for purpose. 2018/19 planning: Control totals (the required surplus/deficit set by regulators) for 2018/19 add up to a total net deficit of £185.8m for CCGs Main challenges: and Trusts, including one-off sustainability funding for providers. An l The provision of a balanced estate portfolio that is fit for purpose additional £111.6m of commissioner sustainability funding is available to in a constrained capital environment and meets the needs of those CCGs that meet their deficit control totals. the population.
Strategic Financial Framework: The STP has a Strategic Financial l Achieving a sizable reduction in the current deficit position of the STP. Framework that sets out the approach to system-wide financial sustainability over a 5-year time horizon. It is comprised of four elements: l Rising to the Digital requirements as a priority. l Improving productivity and efficiency The consequence we observe: l Delivering the right care to improve value l Duplication in processes.
l Transforming and investing for change l Inability to maximise use of technology for patient benefits.
l Improving system contracting/admin
These elements are progressed through 11 STP programme priority areas and supported by four enabling work streams.
The STP five-year financial model brings these aspects together and calculates their combined medium to long-term financial impact, taking account of risk, to allow financial sustainability to be assessed. This is updated iteratively to reflect the progress and evolution of ongoing transformation work, and to allow reassessment of its financial impact.
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l Reduced productivity. Our priorities l We cannot afford to continue to pay for services at the current rate. 5. Reducing A&E attendances through ensuring the resources are available The evidence presented in the Population Health Check naturally leads to to support patients nearer home, including addressing fragmented pathways, gaps in service availability, communication across services, the following priorities. mental health support and digital shortfalls which block shared access to information. Make navigating the system easy for the public and l Addressing capacity and demand encourage the development of advance and anticipatory care plans which are accessible to all who need to see them. l Tackling unwarranted clinical variation
l Focussing on workforce
l Moving to a people centred value based system
l Reducing the financial deficit
We need to deliver value across our STP i.e. the best outcomes for the individual and for our population within the available resources. This includes doing less of things that add little or no value to patients. This includes reducing the over – medicalisation of care.
This requires: 1. The development and implementation of a clear workforce and capacity strategy, which will address the short-term and long term (future-proofing) crisis in relation to the number of staff and skills.
2. Improving shared decision making i.e. more active involvement with well-informed patients and developing and using standardised outcome measures that are more relevant to patients (such as the impact on their functional status and wellbeing).
3. Leading the reframing our cultural norms, so that making the right choice in relation to lifestyle changes, is the easy choice. This includes putting initiatives, such as “Making Every Contact Count” and healthy eating, into relevant contracts to deliver the highest standards of work- based health.
4. Recognising unwarranted clinical variation and addressing it. We can achieve this through the combination of Right Care, Clinically Effective Commissioning and Getting it Right First Time (GIRFT) all of which 74 describe key clinical areas where Quality Improvement is required. 75
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length of stay and bed occupancy (note the Carnell Farrar data and information provided by Rightcare), and the consequent opportunity this An empowered Next steps affords the STP. This provides both the immediate case for change and the and more initial targets. digitally aware and competent We need to develop a clinical strategy which delivers “best value” and Eric Topol is conducting his review with Health Education England for the patient centred care. Secretary of State on how technology will impact care and the training of population carers. This review builds on Facing the Facts, Shaping the future (Health will demand at Education England, December 2017) and starts with acknowledging that the least that PERSON CENTRED APPROACHES FRAMEWORK (SKILLS FOR the pace of development of genomics, digitisation and data analytics, HEALTH/SKILLS FOR CARE/HEALTH EDUCATION ENGLAND) machine learning and AI, biotech, nanotech and robotics is game the medical changing. information
VELOPMEN H DE T OF known about OUG THE HR W An empowered and more digitally aware and competent population will T OR AY LCEoAvers K them is recorded RNaItNio FO W S with Gns t R demand at the least that the medical information known about them IS E peop OoU e C H OM le TnCg E T C Oag , in a way that N T Me O is recorded in a way that promotes their care. We already see both the I U E R K O S G R G A success and acceptability of care records that can be read by paramedics, O IN RS N promotes their U D RELA I W N AN TION S R IO ON SH A primary care and the emergency department. Advanced care decisions O A V TI I T E P I T A A B O care. L H IC U E N that are not paper based and don’t need to be sought and transferred
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e t length of stay has been demonstrated. s o t 3 Beyond this people will increasingly expect a better offering, more tailored 2 to them as an individual, responsive when they need it not batched for le ab en o provider convenience. Again, within this STP, there are models of care that L B s t E EH ion le A AV rsat op R IOU Conve pe are not face to face and are IT-enabled. These have reduced out-patient NI RS port NG and sup OU attendance, crowding in waiting rooms, and cost (e.g. Digital virtual TCOM ES clinics for people living with inflammatory bowel disease and Virtual Fracture Clinics in BSUH). Importantly they have left patients feeling better supported and better able to manage their long term conditions and stay motivated in their recovery. They provide a digital relationship and WE NEED TO DEVELOP A CLINICAL STRATEGY WHICH IS FUTURE connection to clinicians and healthcare professionals more suited to the PROOFED always on expectations of our digital selves. On a local level Sussex and East Surrey is facing significant challenges in providing sustainable care for its population. These challenges include The importance of the digital agenda has been underlined by the Prime financial pressures as well as workforce recruitment and retention minister in her Macclesfield speech. The Office for Life sciences (OLS) shortfalls. Much of this Population Health Check describes variation in has issued a variety of challenges and at the present time there are open consumption of healthcare, through variation in referral from primary calls for a second wave of digital and Internet of Things (IOT) test beds, 76 care, through to differences locally to peers in secondary care intervention, industrial strategy challenge funding, ageing grand challenges, an active 77
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call for new Collaborations of Leadership in Applied Health Research and WE NEED TO DEVELOP A CLINICAL STRATEGY WHICH IS CLEAR ON Brighton ranked Care (this time badged as Applied Research Collaborations). All of these THE OPTIMAL POPULATION SIZE TO LEAD DELIVERY particularly calls have tens of millions of pounds available to demonstrate new ways Some of the changes needed will be led and delivered locally, supported by of working, drawing on modern and forward-facing technology, that the STP as the direction of travel. A few will be led by the STP organisations strongly in its deliver improved outcomes with a different kind of workforce. All require together, providing that adds value and does not duplicate local work. innovation for scalability and all require a legacy to be left locally. data, virtual reality, health Our STP contains a medical school, two universities, thoughtful and effective collaborations between health and social care, between E - REGIONAL & and artificial academia and industry and care. It has an abundance of small and EMERGENCY SYSTEM - ≈4.5M intelligence medium enterprises with Brighton & Hove ranked fourth in a new index despite being highlighting the size and success of digital industries around the country D - CLINICAL & and their potential for growth. Brighton ranked particularly strongly in relatively DIAGNOSTIC NETWORKS - ≈2.5M its innovation for data, virtual reality, health and artificial intelligence smaller than its despite being relatively smaller than its competitors. It has a strong record competitors of research and of education. It is bracketed by two STPs with similarly C - STP/SYSTEM WIDE - ≈1.75M strong records of new models of care (Kent vanguard, Surrey wave one Internet of Things test bed). Its hospitals already connect digitally around imaging and diagnostics. B - PLACE BASED CARE COMMUNITY - ≈500K
We also should not miss the link that investment in the local economy improves job prospects, affluence and helps mitigate the impact that A - LOCAL COMMUNITY TEAM - ≈30-50K poverty has on the health and wellbeing of our local population. There are strong digital and IT economic sectors already in our local economies with around 25% of Brighton & Hove’s economy is in the Creative Digital and BUSINESS LANDSCAPE IT sector which has seen 40% growth over the past 5 years, with strong academic relationships through the Digital Catapult and one of the first National Engagement Emergency System Partner Support Regional & Emergency System (E) 5G testbeds in the country. Surrey & Sussex Regional Diagnostics Population Health Clinical & Diagnostic In our quest to drive out waste and address historic financial over spend, Cancer Alliance Alliance Intelligence Networks (D) which is urgent, we will take the opportunity to work on models of care Operational Delivery Population Health Integrated Care/ wider STP/Urgent Care that put our people at the heart of new pathways. We must not lose Networks Management system pathways System (C) sight of this. Expert Opinion Capacity Planning & Integrated Urgent & Place Based Care & Diagnostics Coordination Emergency Care Community (B)
Prevention & Self Patient Identification MDTs Local Community Management & Care Planning Team (A)
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LOCAL COMMUNITY TEAM 30-50K THE PROCESS OF DEVELOPING THE CLINICAL STRATEGY (ADDED POST SIGN OFF. STP EXEC GROUP AGREEMENT) This Clinically- Prevention & Self Management Patient identification & care planning Multi-disciplinary Teams The Population Health Check provides the rationale for addressing certain led Strategy will l Falls prevention l Identifying frail & vunerable patients l Care coordination themes as priorities; it does not attempt to offer solutions. l Social prescribing l Developing and implementing care l Reablement describe how we l Health coaching plans l Bringing integrated Health and Social l Building knowledge & changing Care into the home In order to achieve that, we will now: will be moving behaviours l Develop a public-facing version of the report, which will include l Support for people to manage their forward on long term condition graphics and a visual explanation of the report for the open section of delivery of the Boards and Governing Bodies. priorities at pace. PLACE BASED CARE COMMUNITY ≈500K l Draft an engagement and communication strategy in order to ensure Expert Opinion & Diagnostics Capacity Planning & Coordination Integrated Urgent & Emergency Care we are engaging at the earliest opportunity on how to address the
l Timely diagnostics l Demand & Capacity Planning l A&E coordination themes identified. l Access to expert opinion l Transitions of care & patient flow l See and Treat l Timely assessment l Mental health liaison l Rapid response l Our Medical Directors and Chief Nurses will be discussing the report l Social care coordination l Single Point of Access l Community & capacity development l Telecare/health more widely internally with their clinical colleagues and with their Executive leads.
STP/WIDER SYSTEM ≈1.7M l We will be ensuring that co-dependent strategies, such as workforce, Operational Delivery Networks and Population Health Management Integrated Care/wider system pathways clinical networks digital technology, estates etc. are aligned with the Population Health
l Trauma l Population health planning l 111 Service Check and the developing Clinical Strategy. l Maternity l research and Evaluation l UEC l Vascular l Provider and collaboration l Mental Health l Develop a plan to deliver a Clinical Strategy within six months. This l Burns l Capacity (3Ts) l Clinical networks: specialist l Clinical variation Clinically-led Strategy will describe how we will be moving forward on cardiology, cardiac surgery, renal l Maternity delivery of the priorities at pace. dialysis, and paediatric surgery
l Have had an opportunity to contribute to its development. CLINICAL & DIAGNOSTIC NETWORKS ≈12.5 l Agree with the Population Health Check, including the next steps. Clinical & Diagnostic Networks Population Health analytics
l Surrey & Sussex Cancer Alliance l Sussex & Surrey Integrated Dataset l Are committed to championing the Population Health Check and l Radiology Network l Research and Evaluation l Pathology contributing to the development and delivery of the resulting Clinical l South East Clinical Networks Strategy.
REGIONAL & ≈1.7M
National Engagement Emergency System Partner Support
l NHS England l 999 & Ambulance Service l HEE KSS l NHS Improvement l care Plan Sharing service l KSS AHSN l NHS Digital l NIHR Clinical Research Network KSS l Specialist Commissioning l South East Coast Clinical Senate 80 81
QVH BoD PUBLIC March 2019 Page 64 of 254 AGREEMENT AGREEMENT
David Walker Medical Director East Sussex Healthcare NHS Trust 22/08/2018 Agreement from the Core Ed Pickles Medical Director Queen Victoria Hospital NHS FT 17/09/2018 Karen Eastman Clinical Lead for Unwarranted SES STP 12/09/2018 members of the STP Clinical Clinical Variation Fionna Moore Medical Director South East Coast Ambulance 29/08/2018 Services NHS FT and Professional Cabinet Des Holden Medical Director Surrey and Sussex Healthcare 02/10/2018 NHS Trust
Richard Quirk Medical Director Sussex Community NHS FT 13/09/2018 We would like to formally confirm our support for Rick Fraser Consultant Psychiatrist and Sussex Partnership NHS FT 30/08/2018 this Population Health Check. We confirm that we: Chief Medical Officer
Justin Wilson Chief Medical Officer Surrey and Borders Partnership 09/10/2018 l Have had an opportunity to contribute to its’ development NHS Trust
Sue Marshall Executive Chief Nurse Sussex Community NHS FT 13/09/2018 l Agree with the Population Health Check, including the next steps Jonathon Warren Chief Nurse Surrey and Borders Partnership Trust 22/08/2018 l Are committed to championing the Population Health Check and Liz Mouland Chief Nurse and Director of First Community Health and Care 21/08/2018 contributing to the development and delivery of the resulting Clinical Clinical Standards Strategy Patricia Brayden Medical Director St Catherine’s Hospice, Crawley 31/08/2018
Andrew Catto Medical Director IC24 31/08/2018
Name Title Organisation Date agreed Alison Taylor Deputy Medical Director NHSE 29/08/2018
Minesh Patel Clinical Chair (Co-chairperson) NHS Horsham and Mid Sussex CCG 25/09/2018 Allison Cannon Chief Nurse STP Commissioners 28/08/2018
Peter Larsen-Disney Clinical Director of 3Ts Brighton and Sussex 20/08/2018 Karen Devanny Chief Nurse and Director CSESCA 12/09/2018 (Co-chairperson) University Hospital NHS FT of Quality
Rob Haigh Medical Director Brighton and Sussex University 14/09/2018 Guy Boersma Managing Director KSS AHSN 17/09/2018 Hospitals NHS Trust Michael Bosch RCGP STP Ambassador and Alliance for Better Care 20/08/2018 George Findlay Chief Medical Officer/ Deputy Brighton and Sussex 02/10/2018 Alliance for Better Care GP GP Federation CEO University NHS Trust and Federation Western Sussex Hospitals NHS FT Anna Raleigh Director of Public Health WS CC-Evidence: Our Population 18/09/2018 David Supple Clinical Chair NHS Brighton and Hove CCG 05/09/2018 and Demographics
Gill Galliano Acting Lay Chair NHS Coastal West Sussex CCG 02/10/2018 Richard Brown Medical Director S&SLMCs 20/09/2018 Laura Hill Clinical Chair NHS Crawley CCG 05/09/2018
Elango Vijaykumar Clinical Chair NHS East Surrey CCG 25/09/2018
Martin Writer Clinical Chair NHS Eastbourne, Hailsham and 02/10/2018 Seaford CCG
David Warden Clinical Chair NHS Hastings and Rother CCG 13/09/2018 82 Elizabeth Gill Clinical Chair NHS High Weald Lewes Havens CCG 25/09/2018 83
QVH BoD PUBLIC March 2019 Page 65 of 254 AGREEMENT CONTRIBUTORS
Agreement from the Core Contribution list
members of the STP Clinical List of colleagues who have received and have been given the opportunity to contribute to the Population and Professional Cabinet Health Check so far
We would like to formally confirm our support for Bob Alexander STP Executive Chair SES STP this Population Health Check. We confirm that we: Bruce Allan GP Worthing Medical Group Sam Allan Chief Executive SPFT
l Have had an opportunity to contribute to its development Helen Atkinson Executive Director of Public Health and Head of Surrey County Council Adult services
l Agree with the Population Health Check, including the next steps Michael Bailey STP workforce Project lead SES STP
Gaynor Baker STP Estates Lead SES STP
Paul Bennett Delivery and Improvement Director NHSI (SE) Name Title Organisation Date agreed Sarah Billiard Chief Executive First Community Health and Care Lawrence Goldberg Chair South East Clinical Senate 20/08/2018 Michael Bosch RCGP STP Ambassador and Alliance for Better Alliance for Better Care GP Care GP Federation Federation
Guy Boersma Managing Director KSS AHSN
Patricia Brayden Medical Director St Catherine’s Hospice, Crawley
Karen Breen TP Programme Director SES STP
Richard Brown Medical Director Surrey and Sussex LMC
Jessica Britten Chief Operating Officer ESBT
Adrian Bull Chief Executive ESHT
Allison Cannon Chief Nurse STP Commissioners
Andrew Catto Medical Director IC24
Jacqueline Clay Principal Manager West Sussex Public Health and Social Research Unit
Karen Devanny Chief Nurse and Director of Quality CSESCA
Sarah Doffman Chief of Medicine Brighton and Sussex University Hospital NHS FT
Adam Doyle Accountable Officer CSESA and CWS CCG 84 Karen Eastman Lead for Unwarranted Clinical Variation SES STP 85
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Fiona Edwards Chief Executive Surrey and Borders NHS Trust Ralph McCormack Programme Director – Commissioning Programmes STP
Amanda Fadero Director Coastal Care Liz Mouland Chief Nurse and Director of Clinical Standards First Community Health and Care
George Findlay Chief Medical Officer/ Deputy CEO Brighton and Sussex University Minesh Patel CCG Clinical Chair and Co-chairperson of the SES NHS Horsham and Mid Sussex Hospitals NHS Trust STP Clinical and Professional Cabinet CCG Western Sussex Hospitals NHS FT Maggie Patching Workforce Transformation Lead HEKSS
Pennie Ford Director of Assurance and Delivery NHSE (SE) Amanda Philpott Accountable Officer HR CCG and EHS CCG
Rick Fraser Consultant Psychiatrist and Chief Medical Officer Sussex Partnership NHS FT Ed Pickles Medical Director Queen Victoria Hospital NHS FT
Darrell Gale Director of Public Health East Sussex County Council Mark Preston Director of Organisational Development & People SASH
Elizabeth Gill Clinical Chair NHS High Weald Lewes Havens Richard Quirk Medical Director Sussex Community NHS FT CCG Anna Raleigh Director of Public Health and co-ordinating lead West Sussex CC Rachel Gill Consultant in Public Health Surrey County Council for SES STP DsPH input
Lawrence Goldberg Chair South East Clinical Senate Rosalind Ranson Primary Care Lead IC24
Marianne Griffiths Chief Executive WSHT and BSUH Nicola Rosenberg Public Health Consultant BH CC
Tom Gurney Communications Lead SES STP Paul Simpson Chair SES STP Finance Group
Rob Haigh Medical Director Brighton and Sussex University Ashley Scarff Director of Commissioning & Deputy Chief Officer HWLH CCG Hospitals NHS Trust Sam Stanbridge Director of Commissioning East Surrey CCG (CSESA) Des Holden Medical Director Surrey and Sussex Healthcare NHS Su Stone Clinical chair NHS Coastal West Sussex CCG Trust David Supple Clinical Chair NHS Brighton and Hove CCG Laura Hill Clinical Chair NHS Crawley CCG Alison Taylor Deputy Medical Director NHSE Jackie Huddleston NHS England – South East (Kent, Surrey, Sussex) NHS England – South East (Kent, Surrey, Sussex) Tim Taylor Medical Director Western Sussex Hospitals NHS FT
Caroline Huff Clinical Programme Director SES STP Sarah Valentine Strategic Director of Contracting & Performance Sussex & East Surrey CCGs
Steve Jenkin Chief Executive QVH David Walker Medical Director East Sussex Healthcare NHS Trust
Maggie Keating STP UECN Senior Programme Manager SES STP David Warden Clinical Chair NHS Hastings and Rother CCG
Peter Kottlar Chief Operating Officer East Surrey CCG (CSESA) Jonathan Warren Chief Nurse Surrey and Borders Partnership Trust Peter Larsen-Disney Clinical Director of BSUH 3Ts and Co-chairperson Brighton and Sussex University of the SES STP Clinical and Professional Cabinet Hospital NHS FT Mark Watson Digital Programme Manager SES STP
David Lipscomb Chair Diabetes Oversight Group Sussex and Surrey STP SCFT Justin Wilson Chief Medical Director Surrey and Borders Partnership NHS FT Hugo Luck Associate Director of Operations HWLH CCG and CSESA (S) Michael Wilson Chief Executive SASH Nick Lake Deputy Medical Director SPFT Martin Writer Clinical Chair NHS Eastbourne, Hailsham and Vaughan Lewis Medical Director Specialised Commissioning NHS South NHSE Seaford CCG Susan Marshall Chief Nurse Sussex Community NHS FT Elango Vijaykuma Clinical Chair NHS East Surrey CCG Siobhan Melia Chief Executive SCFT
Alistair Hill Director of Public Health BH City Council 86 Fionna Moore Medical director South East Coast Ambulance Services NHS FT 87
QVH BoD PUBLIC March 2019 Page 67 of 254 REFERENCES REFERENCES
ESBT (East Sussex Better Together) (Nov 2016) The Case for Change in East Sussex (Accountable Care) References/bibliography http://news.eastsussex.gov.uk/east-sussex-better-together/wp-content/uploads/ sites/10/2016/11/The-Case-for-Change-in-East-Sussex-Accountable-Care.pdf Eastman, K (2017) Presentation to the SES STP Clinical Board. Available on request. Gonnering RS and Riley WJ (2018) Robert Wood Johnson and University of Wisconsin Population Health Institute: Health Outcomes and Health Factors. https://link.springer.com/chapter/10.1007/978-3-319-73636-5_13 Alzheimer’s Society (2009) Counting the cost: Caring for people with dementia on hospital wards. Hunt, Jeremy (2015) ‘New Deal for General Practice’. https://www.alzheimers.org.uk/sites/default/files/2018-05/Counting_the_cost_ https://www.gov.uk/government/speeches/new-deal-for-general-practice report.pdf House of Commons Library (2015) BMA (2018) GP premises not fit for patients. https://publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/40807.htm https://www.bma.org.uk/news/2014/july/gp-premises-not-fit-for-patients Kings Fund (2009) General Practice in England. Carnell Farrer (CF) (March 2017) Acute services work stream: demand and https://www.kingsfund.org.uk/sites/default/files/General-practice-in-England-an- capacity review. (On application STP Office) overview-Sarah-Gregory-The-Kings-Fund-September-2009.pdf Carnell Farrer (CF) (April 2017) Sussex and East Surrey STP review and Kings Fund (2015) Place-based systems of care: A way forward for the NHS refresh. Summary report. (On application STP Office) in England. www.kingsfund.org.uk Carnell Farrer (April 2017b) Capped expenditure process information for benchmarking and opportunities. Available on application Kings Fund (2016) Understanding pressures in General Practice. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/ Carter, (2016) (DoH) Operational productivity and performance in English Understanding-GP-pressures-Kings-Fund-May-2016.pdf NHS acute hospitals: Unwarranted variations. An independent report for the Department of Health by Lord Carter of Coles Kings Fund (2018) Through the eyes of GP trainees: workforce of the future https://www.gov.uk/government/uploads/system/uploads/attachment_data/ https://www.kingsfund.org.uk/blog/2018/08/gp-trainees-workforce-future file/499229/Operational_productivity_A.pdf National Palliative and End of Life Care Partnership (20150 Ambitions for Central Sussex and East Surrey Alliance (2016) Place Based Delivery Plan Palliative and End of Life Care. http://www.brightonandhoveccg.nhs.uk/sites/btnccg/files/files/CSESA%20Place%20 http://endoflifecareambitions.org.uk/wp-content/uploads/2015/09/Ambitions-for- Based%20Plan%20FINAL.pdf Palliative-and-End-of-Life-Care.pdf CSESA Primary Care Cornerstone of the PBP, (2016) Available on application Nuffield (2017) Shifting the Balance of Care. https://www.nuffieldtrust.org.uk/files/2017-02/shifting-the-balance-of-care-report- Coastal Care (2016): Inspiring healthy communities together web-final.pdf https://www.coastalwestsussexccg.nhs.uk/building-first-class-health-and-care- system-for-sussex-and-east-surrey NHSE (2018) https://www.england.nhs.uk/integratedcare/stps/faqs/ Coastal Care (2017) Coastal Care Delivery Plan (2017) on application NHS Rightcare (2016) Commissioning for Value Focus pack: cardiovascular Dahlgren and Whitehead (1991) Determinants of Health, Dahlgren, G., & disease. Whitehead, M. (1991). Policies and strategies to promote social equity in https://www.england.nhs.uk/rightcare/intel/cfv/data-packs/south/#21 health. Stockholm: Institute for Future Studies. Google Scholar NHS Rightcare (2016b) Commissioning for Value pack: Long Term Conditions https://www.england.nhs.uk/rightcare/products/ccg-data-packs/long-term- DoH (2016) (Professor Tim Briggs: The Future of Commissioning for Planned conditions-packs/#south Surgery Getting it right for orthopaedics Learning from the first round of ‘Getting it Right First time’ NHS Rightcare (2017) Tools and Techniques. http://www.futurefocusedfinance.nhs.uk/sites/default/files/media-posts/163299_ ESBT (East Sussex Better Together) (2014): Commissioning a sustainable, Tools%20%26%20Techniques.pdf integrated health and social care system that best meets population need http://www.eastbournehailshamandseafordccg.nhs.uk/intranet/resources/east- NHS Rightcare (2017b) Mental Health conditions packs 88 sussex-better-together/ https://www.england.nhs.uk/publication/mental-health-conditions-packs-2017-south/ 89
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NHSE (2016) Better Births: Improving outcomes of maternity services in SE Clinical Senate (2016) Reducing avoidable hospital based care: re-thinking England. A Five Year Forward View for maternity care. out of hospital clinical pathways. https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity- [email protected], www.secsenate.nhs.uk review-report.pdf SE Clinical Senate (2017a) Emphasising Quality, delivering value. PHE-Public Health England (2017a) Public Health outcomes framework. [email protected], www.secsenate.nhs.uk http://fingertipsreports.phe.org.uk/public-health-outcomes-framework/e10000011. SE Clinical Senate (2017b) Improving Clinical Communications Between pdf Primary and Secondary Care Clinicians: A review and recommendations for PHE-Public Health England (2017b) Public Health outcomes framework. the Sussex and East Surrey STP. http://fingertipsreports.phe.org.uk/public-health-outcomes-framework/e10000011. [email protected], www.secsenate.nhs.uk pdf SE Clinical Network (2017) Sussex and East Surrey Local Maternity System PHE-Public Health England (2017c) Public Health outcomes framework. (LMS): 10/05/2017: Laura Ansboro presentation. Available on application. http://fingertipsreports.phe.org.uk/public-health-outcomes-framework/e10000011. Skills for Health/Skills for Care/Health Education England (2017) Person- pdf Centred Approaches. Empowering people in their lives and communities to PHE-Public Health England (2017d) Public Health outcomes framework. enable an upgrade in prevention, wellbeing, health, care and support. http://fingertipsreports.phe.org.uk/public-health-outcomes-framework/e10000011. http://www.skillsforhealth.org.uk/images/pdf/Person-Centred-Approaches- pdf Framework.pdf?s=form Public Health (2017) Local Alcohol profile. SPFT (April 2017) Clinical Strategy: The next steps in our journey 2017-2010. http://www.eastsussexjsna.org.uk/profiles http://www.sussexpartnership.nhs.uk/our-clinical-strategy PHE Public Health England (2016a) Health profile. Stevens, Simon (June 2016) speech to NHS Confederation. http://www.eastsussexjsna.org.uk/profiles https://www.england.nhs.uk/2016/06/simon-stevens-confed-speech/ PHE Public Health England (2016b) Health Profile STN (Sussex Trauma Network) (2017) Operational Policy. Available on http://fingertipsreports.phe.org.uk/health-profiles/2016/e06000043.pdf application. PHE Public Health England (2016c) Health Profilehttp://fingertipsreports.phe. Surrey and Sussex Cancer Alliance (March, 2017) – Delivery Plan: A high- org.uk/health-profiles/2016/e06000043.pdf level Cancer Transformation plan to ensure the sustainable development and delivery of cancer services. Available on request. PHE Public Health England (2016d) Health Profile http://fingertipsreports.phe.org.uk/health-profiles/2016/e06000043.pdf PHE, CQC, NHSE (2017) End of Life Care: STP Support tool. PULSE (2018) Revealed: 450 GP surgeries have closed in the last 5 years. http://www.pulsetoday.co.uk/news/hot-topics/stop-practice-closures/revealed-450- gp-surgeries-have-closed-in-the-last-five-years/20036793.article PULSE (2018) Brighton: the hardest hit town in the whole of the UK. http://www.pulsetoday.co.uk/news/hot-topics/postcards-from-the-edge/brighton- the-hardest-hit-town-in-the-whole-of-the-uk/20036786.article Simpson, P. and Holden, D (Jan 2017) Getting it right first time: orthopaedics – Model Hospital Data (available on application) SES STP (Sussex and East Surrey Sustainability and Transformation Plan). http://www.brightonandhoveccg.nhs.uk/search/site/Central%20Sussex%20 and%20East%20Surrey%20Alliance%20%282016%29%20Place%20Based%20 Delivery%20Plan SES STP Finance Group (2017) Capped Expenditure Process: Sussex & East Surrey STP: response stage #2. Available on application. SES STP (July 2017) Mental health in Sussex and East Surrey: the case for 90 change (v0.5) available on application 91
QVH BoD PUBLIC March 2019 Page 69 of 254 Sussex & East Surrey Sustainability & Transformation Partnership
Sussex & East Surrey Sustainability & Transformation Partnership
Sussex & East Surrey Sustainability & Transformation Partnership (STP) Sussex & East Surrey Copyright © 2019 Sussex and East Surrey Sustainability & Transformation Partnership Sustainability & Transformation Partnership Produced by [email protected] Published February 2019 All information correct at time of printing
QVH BoD PUBLIC March 2019 Page 70 of 254
The NHS Long Term Plan – a summary
Find out more: www.longtermplan.nhs.uk | Join the conversation: #NHSLongTermPlan
Health and care leaders have come together to develop a Long Term Plan to make the NHS fit for the future, and to get the most value for patients out of every pound of taxpayers’ investment. Our plan has been drawn up by those who know the NHS best, including frontline health and care staff, patient groups and other experts. And they have benefited from hearing a wide range of views, whether through the 200 events that have taken place, and or the 2,500 submissions we received from individuals and groups representing the opinions and interests of 3.5 million people. This summary sets out the key things you can expect to see and hear about over the next few months and years, as local NHS organisations work with their partners to turn the ambitions in the plan into improvements in services in every part of England.
What the NHS Long Term Plan will deliver for patients These are just some of the ways that we want to improve care for patients over the next ten years: Making sure • reducing stillbirths and mother and child deaths during birth by 50% • ensuring most women can benefit from continuity of carer through and everyone beyond their pregnancy, targeted towards those who will benefit most gets the • providing extra support for expectant mothers at risk of premature birth • expanding support for perinatal mental health conditions best start in • taking further action on childhood obesity life • increasing funding for children and young people’s mental health • bringing down waiting times for autism assessments • providing the right care for children with a learning disability • delivering the best treatments available for children with cancer, including CAR-T and proton beam therapy. Delivering • preventing 150,000 heart attacks, strokes and dementia cases • providing education and exercise programmes to tens of thousands more world-class patients with heart problems, preventing up to 14,000 premature deaths care for • saving 55,000 more lives a year by diagnosing more cancers early • investing in spotting and treating lung conditions early to prevent 80,000 major health stays in hospital problems • spending at least £2.3bn more a year on mental health care • helping 380,000 more people get therapy for depression and anxiety by 2023/24 • delivering community-based physical and mental care for 370,000 people with severe mental illness a year by 2023/24. Supporting • increasing funding for primary and community care by at least £4.5bn • bringing together different professionals to coordinate care better people to • helping more people to live independently at home for longer age well • developing more rapid community response teams to prevent unnecessary hospital spells, and speed up discharges home. • upgrading NHS staff support to people living in care homes. • improving the recognition of carers and support they receive • making further progress on care for people with dementia • giving more people more say about the care they receive and where they receive it, particularly towards the end of their lives.
QVH BoD PUBLIC March 2019 Page 71 of 254 How we will deliver the ambitions of the NHS Long Term Plan To ensure that the NHS can achieve the ambitious improvements we want to see for patients over the next ten years, the NHS Long Term Plan also sets out how we think we can overcome the challenges that the NHS faces, such as staff shortages and growing demand for services, by:
1. Doing things differently: we will give people more control over their own health and the care they receive, encourage more collaboration between GPs, their teams and community services, as ‘primary care networks’, to increase the services they can provide jointly, and increase the focus on NHS organisations working with their local partners, as ‘Integrated Care Systems’, to plan and deliver services which meet the needs of their communities. 2. Preventing illness and tackling health inequalities: the NHS will increase its contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes, with a particular focus on the communities and groups of people most affected by these problems.
3. Backing our workforce: we will continue to increase the NHS workforce, training and recruiting more professionals – including thousands more clinical placements for undergraduate nurses, hundreds more medical school places, and more routes into the NHS such as apprenticeships. We will also make the NHS a better place to work, so more staff stay in the NHS and feel able to make better use of their skills and experience for patients. 4. Making better use of data and digital technology: we will provide more convenient access to services and health information for patients, with the new NHS App as a digital ‘front door’, better access to digital tools and patient records for staff, and improvements to the planning and delivery of services based on the analysis of patient and population data. 5. Getting the most out of taxpayers’ investment in the NHS: we will continue working with doctors and other health professionals to identify ways to reduce duplication in how clinical services are delivered, make better use of the NHS’ combined buying power to get commonly- used products for cheaper, and reduce spend on administration. What happens next Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs), which are groups of local NHS organisations working together with each other, local councils and other partners, now need to develop and implement their own strategies for the next five years. These strategies will set out how they intend to take the ambitions that the NHS Long Term Plan details, and work together to turn them into local action to improve services and the health and wellbeing of the communities they serve – building on the work they have already been doing. This means that over the next few months, whether you are NHS staff, a patient or a member of the public, you will have the opportunity to help shape what the NHS Long Term Plan means for your area, and how the services you use or work in need to change and improve.
January 2019 By April 2019 By Autumn 2019 Publication of the NHS Publication of local Publication of local Long Term Plan plans for 2019/20 five-year plans
To help with this, we will work with local Healthwatch groups to support NHS teams in ensuring that the views of patients and the public are heard, and Age UK will be leading work with other charities to provide extra opportunities to hear from people with specific needs or concerns.
Find out more More information is available at www.longtermplan.nhs.uk, and your local NHS teams will soon be sharing details of what it may mean in your area, and how you can help shape their plans. QVH BoD PUBLIC March 2019 Page 72 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 45-19 Report title: Freedom to Speak Up Guardian’s report Sponsor: Steve Jenkin, chief executive Author: Sheila Perkins, Freedom to Speak Up Guardian Appendices: None
Executive summary Purpose of report: The purpose of this report is to update the Board on the work of the Freedom to Speak Up Guardian. Summary of key issues Recommendation: The board of directors is asked to NOTE the contents of this report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial (KSOs): Organisational patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework: None
Corporate risk register: None
Regulation: None
Legal: None
Resources: None.
Assurance route Previously considered by: N/A Date: Decision: Next steps:
QVH BoD PUBLIC March 2019 Page 73 of 254
Report to: Board of Directors Meeting date: 7 March 2019 Reference number: 45-19 Report from: Sheila Perkins, FTSU guardian Author: Sheila Perkins, FTSU guardian Appendices: None Report date: 27 February 2019
Freedom to speak up
1. I took over the role of Freedom to Speak Up Guardian at the end of November last year and I am still learning the scope and breadth of the role, appropriate to QVH. The role of a Freedom to Speak Up Guardian is to protect patient safety and the quality of care; to improve the experience of the workforce and to promote learning and improvement by: • Addressing barriers to speaking up • Supporting workers to speak up • To promote a culture of speaking up • To use the issues raised as an opportunity to improve; I also believe that my role includes supporting staff after they have spoken up
2. New posters with my photograph and contact details have been circulated around the hospital and put up in staff-facing areas since I took over the role at the end of November. Business cards have been printed and will be put in all staff areas for discreet pick up by staff.
3. I introduce the Freedom to Speak Up role at the new staff induction every month to ensure that ‘Speaking Up’ becomes embedded in the culture of the hospital.
4. I have been making contact with senior staff inside the Trust to whom I will report cases to be investigated and have felt welcomed and supported. I have monthly meetings with Steve Jenkin and have had contact with Geraldine Opreshko and will approach her regarding HR issues that are raised. I have good support from my managers in the Psychological Therapies team and have the autonomy to plan my day to enable me to meet with staff who have concerns to raise.
QVH BoD PUBLIC March 2019 Page 74 of 254 5. I had a brief handover from Andi, the previous Speak Up Guardian and an update of open cases from Steve Jenkin. I haven’t yet undertaken external training in the role and plan to attend the study day in May and I will join the local network to learn from others who have been in the role longer. I have downloaded the guidance on recording and reporting which I have been studying, and have been using the Freedom to Speak Up self-review toolkit to identify and prioritize my training needs. We have already identified a need for mediation skills and I have enrolled on a certified course which runs in June this year.
6. In December I met with two members of staff who had approached me.
• A member of staff unhappy with her Agenda for Change banding. With her consent this was discussed with Steve Jenkin and Geraldine Opreshko; She declined any follow up with me. • A member of staff who had previously ‘whistle blown’. I facilitated a conversation between the staff member and Steve Jenkin; I am supporting her to enable her to process her involvement in the ‘whistle blowing’ and to help her bring some closure. We have had feedback from her that will help us support other staff members who speak out. I have had a telephone conversation with a member of staff working in the team where the ‘whistleblowing’ occurred – we have identified a need to further support that team and will need to plan some support for them. This person wishes remain anonymous.
7. I will continue to publicize the availability of the different mechanisms whereby staff can speak out about their concerns.
Sheila Perkins, FTSU Guardian
QVH BoD PUBLIC March 2019 Page 75 of 254 KSO3 – Operational Excellence Risk Owner – Director of Operations Date last reviewed 20 February 2018
Strategic Objective Risk Appetite The trust has a low appetite for risks that impact on operational Initial Risk 5 (c) x3 (L) =15, moderate We provide streamlined services delivery of services and is working with a range of stakeholders to redesign and Current Risk Rating 5 (C) x 4 (L) = 20, major that ensure our patients are offered improve effectiveness and efficiency to improve patient experience, safety and Target Risk Rating 3 (C) x 3 (L) = 9, low choice and are treated in a timely quality. manner. Rationale for current score Future risks Risk • Waiting list size and challenge with long wait patients • National Policy changes to access targets Sustained delivery of constitutional • Performance challenges across OMFS, plastics and eyes e.g. Cancer & complexity of pathways, access standards • Spoke site links and pathways QVH is reliant on other trusts timely • Vacancy levels in theatre staffing and theatre capacity referrals onto the pathway; Patients & Commissioners lose • Vacancy levels in sleep • NHS Tariff changes & volatility; confidence in our ability to provide • Specialist nature / complexity of some activity • Future impact of Brexit on workforce timely and effective treatment due • Administrative vacancies including appointments team • Reputation as a consequence of RTT to an increase in waiting times and • Variable trust wide processes including booking and scheduling a fall in productivity. • Late referrals from referring organisations
Future Opportunities • Spoke sites offer the opportunity for further partnerships • Closer working between providers in STP – networked care • Partnership with BSUH/WSHFT
Controls / Assurance Gaps in controls / assurance • Weekly RTT and cancer PTL meetings • Variable trust wide processes for booking and scheduling • Revised PTL in place & ongoing work to developed a non RTT PTL • Not all spoke sites on QVH PAS so access to timely information is • Revised access and cancer policies limited • RTT recovery plan in place and system task and finish group (now monthly) • Shared pathways for cancer cases with late referrals from other • Trajectories developed for delivery of RTT position for 18/19 and 19/20 trusts • Repatriation ongoing of low complexity patients for dental • Late referrals for 18RTT from neighbouring trusts • Waiting list validation complete and signed off by NHSI • High vacancy rate in theatre nursing/OPD • Development of revised operational processes underway to enhance assurance and grip • Capacity challenges for both admitted and non admitted pathways • Monthly business unit performance review meetings & dashboard in place with a focus on • Informatics capacity exceptions, actions and forward planning; • Documentation of all booking and scheduling processes underway to inform process redesign • Theatre improvement programme ingoing and work to date has established revised planning arrangements • Service managers now in place for OMFS and eyes • Demand and capacity modelling complete for plastics, OMFS and eyesQVH complete BoD PUBLIC March 2019 • Pathway redesign work underway with commissioners for dental Page 76 of 254 • Planned outpatient improvement programme KSO 4 – Financial Sustainability Risk Owner: Director of Finance & Performance Committee: Finance & Performance Date last reviewed: 20th February 2019
Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that impact Initial Risk 3 (C) x 5(L) = 15, moderate We maximize existing on the Trusts financial position. A higher level of rigor is being placed to Current Risk Rating 5 (C) x 5(L)= 25, catastrophic resources to offer cost- fully understand the implications of service developments and business Target Risk Rating 4(C) x 3(L) = 12, moderate effective and efficient care cases moving forward to ensure informed decision making can be whilst looking for undertaken. opportunities to grow and Rationale for current score (at Month 10) Future Risks develop our services • Deficit £4.6m deficit/ £0.3m surplus plan (excluding donated adjs) NHS Sector financial landscape Regulatory Intervention • CIP forecast delivery - (current material gap - £1.9m forecast) • Autonomy • Finance & Use of resources – 3 (planned 1) • Capped expenditure process • CIP pipeline schemes to be identified to bridge the gap • Single Oversight Framework • High risk factor –availability of staffing - nursing and non clinical posts • Commissioning intentions – Clinical effective commissioning Risk • Commissioner challenge and scrutiny • Sustainability and transformation footprint plans Loss of confidence in the long- • Potential changes to commissioning agendas • Planning timetables–Trust v STP term financial sustainability of • 2018/19 CIPP Gap and non delivery YTD the Trust due to a failure to • Contracting alignment agreement Future Opportunities create adequate surpluses to • Significant underperformance on activity plan c£4m forecast • New workforce model, strategic partnerships; increased trust fund operational and strategic • Significant overspend on agency staffing, however clinical safety is resilience / support wider health economy investments requiring additional agency costs over and above ceiling c£0.6m • Using IT as a platform to support innovative solutions and premium new ways of working • Reforecast Submitted to NHSI post Board Approval of £5.9m Deficit • Improved vacancy levels and less reliance on agency staffing excluding donated adjs • Increase in efficiency and scheduling through whole of the • Agenda for change increase in costs £0.2m patient pathway • Spoke site activity repatriation • Strategic alliances \ franchise chains and networks Controls / Assurances Gaps in controls / assurances • Performance Management regime in place • Structure, systems and process redesign and enhanced cost • Standing Financial Instructions revised and ratified with amended levels of delegation in line with a control turnaround environment to reduce levels of authorisation (June 18) • Model Hospital Review and implementation • Contract monitoring process • Costing Transformation Programme - Implementation Q4 • P erformance reports to the Trust Board 2017/18 – roll out of management information, development • Finance & Performance Committee in place into service line reporting. • Audit Committee and reports • Enhanced pay and establishment controls including • Internal Audit Plan including main financial systems and budgetary control performance against the agency cap • Budget Setting and Business Planning Processes (including capital programme) • Finance and procurement training to budget holders • CIP Governance processes • Establishment review and reconciliation between the ledger • Income / Activity capture and coding processes embedded and regularlyQVH audited BoD PUBLIC March 2019 and ESR • Weekly activity information per Business unit, specialty and POD Page 77 of 254 • Additional Financial Resources required
Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 47-19 Report title: Financial, operational and workforce performance assurance Sponsor: John Thornton, committee chair Author: John Thornton, committee chair Appendices: NA
Executive summary Purpose of report: To provide assurance to the board with regard to matters discussed at the recent Finance and performance committee Summary of key Progress on theatre utilisation and patient waiting lists. But limited assurance on issues plans to reduce costs in line with 2019/20 plan. Recommendation: For the Board to NOTE the contents of this report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework:
Corporate risk register:
Regulation:
Legal:
Resources:
Assurance route Previously considered by: Date: Decision: Previously considered by: Date: Decision: Next steps:
QVH BoD PUBLIC March 2019 Page 78 of 254
Report to: Board of Directors Meeting date: 7 March 2019 Reference no: 47-19 Report from: John Thornton, Committee Chair Report date: 27 February 2019
Finance, operational and workforce performance report
1. Operational performance Theatre utilisation is steadily improving and over 1000 cases were completed in January. It has taken a lot of effort to achieve this but management consider it can be maintained. Our current plan for 2019/20 requires consistently high levels of utilisation to be maintained.
There was some challenge and discussion about the increasing levels of cancellations and the causes. The task and finish group for cancellation is still in place and committee will continue to monitor progress.
The number of patients who haven't been treated in 52 weeks is decreasing in line with our agreed plan. The reduction required in February is significant but management expect to be very close to the target. Committee was encouraged by the reduction not only in the 52 WW but in the number of patients in the 41-51 week bracket which is critical for continued progress.
It is noted that in the next financial year we will be charged financial penalties for being outside the 18WW targets, even if we are meeting our agreed progress plan.
2. Workforce performance Recruitment was again positive in the month and staff in post increased. Overall vacancies are down but there are still areas of significant pressure such as perioperative with 33 advertised posts, where there is little assurance that this will improve in the short term.
Numbers of agency and bank staff are still higher than at this time last year but lower than at the peak earlier this year and moving in the right direction. Levels of sickness absence are below plan which committee considers a positive indicator given the pressures in the hospital.
3. Financial performance Recent performance continued the trend for the year with patient income flat year on year and well below budget, while pay and non pay costs are both up year on year and well over budget.
Overall performance in month was in line with the centrally agreed reforecast but non pay expenditure was still 10% over the new forecast. After challenge and discussion it
QVH BoD PUBLIC March 2019 Page 79 of 254 was agreed that the most likely scenario based on current activity levels is that the agreed reforecast will be met.
Given the accumulating losses and the plan for next year committee discussed the impact on cash balances and the need to ensure liquidity will be available. Executive explained how lines of credit would be made available to QVH to allow us to continue to pay our bills.
The main discussion was around the challenges in next year’s plan.
4. Business Planning Our current financial plan for 2019/20 shows an increase in patient income of almost £3m, combined with an increase in both pay and non pay costs of c.£2.5 (total c.£5m),increasing our deficit year on year by £2m to a loss of £8.5m.
Even this deteriorating position contains significant risks: the growth in income includes additional work to achieve our improvement in waiting times which isn't all agreed with commissioners; and the costs include c£2m of cost reductions and £1m of cost savings (CIP) that haven't yet been fully identified. Next years proposed CIP target is 1.6% of costs significantly lower than this year’s target.
Given that there is now one month to the start of the next financial year and submission of our final plan there was a lack of assurance that specific plans would be in place for these cost savings. Committee agreed it wasn't inclined to accept a budget including CIP savings which didn't have meaningful plans and clear ownership.
It was agreed that the target for agreeing our financial plan would be the next F&P on 25 March and that all Board members would be invited.
It was also noted that this deteriorating budget won't move us towards our stated objective of breaking even in the financial year 2020/21. To achieve this, our run rate will need to be in a significantly better place by the end of 2019/20. This will need further initiatives beyond those currently under discussion. There is currently no visibility of what these plans might be. NHSI has allocated two people to undertake a review of possible actions but they aren't expected to report back for several weeks.
5. EDM Update Significant progress has been made with the action plan to address the issues identified in the clinical led audit.
Expectation is that roll out of the programme can recommence in a month and that full roll out may be completed in 12 months.
A further clinician led audit will be undertaken in June and the committee will review the findings.
John Thornton Chair
QVH BoD PUBLIC March 2019 Page 80 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 07 March 2019 Agenda reference: 48-19 Report title: Operational Performance Report Sponsor: Abigail Jago, Director of Operations Authors: Operations Team Appendices: None Executive summary Purpose of report: To update the Board with regard to current operational performance Summary of key • Improvements in DM01 standards however ongoing challenges in ultrasound issues • Delivery of RTT52 plan in month • Performance against speciality RTT open pathway performance achieved in plastics, sleep, clinical support. Under plan in OMFS and eyes. • Delivery of 62 day cancer standard. Under target for 2ww and 31 days. • Delivery of MIU 4 hour standard • Ongoing delivery of theatre improvement programme • Planned launch of outpatient improvement programme. Recommendation: The Board is asked to NOTE the contents of this report Action required Approval Information Discussion Assurance Review [ Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Financial Organisational (KSOs): Outstanding World-class Operational patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework:
Corporate risk register:
Regulation: Legal: Resources: Assurance route Previously considered by: Finance and performance committee Date: 25 02 19 Decision Noted Next steps: NA
QVH BoD PUBLIC March 2019 Page 81 of 254
www.qvh.nhs.uk
254 of 82 Page
2019 2019 March PUBLIC BoD QVH
2019 March Directors of Board
Operations of Director Jago, Abigail
Operational Performance Report Performance Operational
Summary
Key items to note in the operational report are: • Improvements in DM01 standards however ongoing challenges in ultrasound • Delivery of RTT52 plan in month • Performance against speciality RTT open pathway performance achieved in plastics, sleep, clinical support. Under plan in OMFS and eyes. • Delivery of 62 day cancer standard. Under target for 2ww and 31 days. • Delivery of MIU 4 hour standard • Ongoing delivery of theatre improvement programme • Planned launch of outpatient improvement programme.
2 QVH BoD PUBLIC March 2019 Page 83 of 254 Diagnostic Waits (DM01)
100.0% (Last reporting period – Dec 18 ) (This reporting period – Jan 19 ) 99.0% 94.72% 97.97% 98.0% Modality / test Breaches Perf. Modality / test Breaches Perf. 97.0% CT 1 99.23% CT 0 100.00% 96.0% ECHOCARDIOGRAPHY 0 100% ECHOCARDIOGRAPHY 0 100% 95.0% MRI 0 100.00% MRI 0 100.00% 94.0% NON-OBSTETRIC NON-OBSTETRIC 93.0% 63 93.28% 21 97.51% ULTRASOUND ULTRASOUND 92.0% SLEEP SLEEP 3 92.11% 3 93.48% Jul-17 Jul-18 Jan-18 Jan-19 Jun-17 Jun-18 Oct-17 Oct-18 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Dec-18 Aug-17 Aug-18 Nov-17 Nov-18
Mar-18 STUDIES STUDIES May-17 May-18
Performance Target
Performance commentary Forward look / performance risks
Diagnostic Imaging Diagnostic imaging • Ultrasound performance has improved with the implementation of • Ultrasound remains a risk area due to staffing capacity and vacancies. waiting list initiative lists however some breaches within the month due to Alternative options for cover are being reviewed. capacity and an admin error in terms of booking • Cardiac CT waits continue to be an issue at BSUH. A solution has been agreed with SPIRE Healthcare at Haywards Heath. All new requests for Sleep Studies CTCA are being sent to the Spire by the Radiology team. • Continuing to map patients against available capacity, bringing forward patients where possible. Sleep Studies • Ongoing recruitment, with additional hours and agency engaged to backfill. Reviewing process timelines to minimise delay and proactive call outs to maximise capacity. No anticipated breaches for February or March.
3 QVH BoD PUBLIC March 2019 Page 84 of 254 Histology
TOTAL SPECIMENS <7 day % (Target RECEIVED <7 days 80%) <10 days <10 day % (Target 90%) Total Cases Reported SEP 1310 503 61% 77 70% 829 OCT 1635 685 57% 160 71% 1196 NOV 1518 680 59% 157 73% 1144 DEC 1433 908 79% 87 87% 1149 Target 80% 90%
Performance commentary Forward look / performance risks
• Higher than average number of specimens ongoing (Average is 1365) • The service is currently working on a new Histopathology reporting strategy which involves the training of a senior (Band 7) biomedical scientist (BMS)to report straightforward cases as part of a conjoint Royal • Large resections with bone are some longer wait patients. These cases College of Pathologists/ Institute of Biomedical Sciences qualification. This required decalcification and take >20days to report will provide some mitigation of workforce/ caseload mismatch but is only for skin
4 QVH BoD PUBLIC March 2019 Page 85 of 254 RTT Performance against plan Trust wide Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT plan 74.1% 74.6% 74.6% 75.3% 76.2% 77.3% RTT Actual 73.98% 75.92% 74.36% 74.48% 74.66% 74.04% 75.58% 75.86% 74.48% 75.87% 52 weeks plan 136 127 125 113 100 91 68 60 52 weeks actual Oct 145 135 127 120 95 92 81
Eyes Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT Plan 76.8% 76.6% 76.6% 77.2% 77.9% 78.5% RTT Actual 88.92% 88.77% 83.54% 80.99% 79.64% 78.40% 78.02% 76.63% 76.01% 76.31% 52 weeks plan 12 12 6 0 0 52 weeks actual Oct 14 8 8 5
OMFS Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT Plan 64.5% 65.3% 65.3% 66.4% 67.7% 69.2% RTT Actual 62.8% 64.1% 63.7% 63.5% 64.6% 64.0% 65.53% 65.49% 63.03% 66.27% 52 weeks plan 56 48 45 34 30 52 weeks actual 61 46 45 42
Plastics Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT Plan 77.3% 77.2% 77.2% 77.3% 77.4% 77.7% RTT Actual 76.0% 79.5% 77.8% 78.0% 77.8% 77.5% 79.36% 79.95% 79.07% 79.16% 52 week plan 45 38 36 32 28 52 weeks actual 45 41 39 34
Sleep Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT Plan 92.7% 91.6% 91.6% 90.3% 89.0% 87.8% RTT Actual 98.1% 97.9% 95.7% 95.3% 94.5% 93.8% 91.8% 92.42% 91.06% 92.44% 52 weeks plan 0 0 0 0 0 0 52 weeks actual 0 0 0 0
Clinical Support Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 RTT Plan 95.9% 95.9% 95.9% 95.9% 95.9% 95.9% RTT Actual 95.38% 97.14% 91.25% 96.27% 95.94% 94.88% 94.74% 95.00% 96.31 % 96.41% 52 weeks 0 0 0 0 0 52 weeks actual 0 0 0 0 • The delivery of the trust wide and speciality level 52 week trajectories were achieved. • Incomplete performance at trust and speciality level was achieved for all areas except OMFS and eyes. • OMFS clock stops continue to be lower than average due to the DeRS triage activity. 5 • Eyes are challenged with an orthoptist vacancy which is being addressedQVH BoD plus PUBLIC additional March 2019capacity in the independent sector. Page 86 of 254 RTT18 – Incomplete pathways Trust level performance
Weeks wait Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Change In month there has been a 0-17 (<18) 10977 10862 10823 11389 11078 10401 10056 ↓ fall in patients waiting and a 18-30 2390 2211 2477 2425 2420 2412 2175 ↓ reduction in both 52 week 31-40 821 896 827 809 697 734 694 ↓ and 18 week breaches at 41-51 405 445 363 325 313 325 248 ↓ trust level. >52 145 135 127 120 95 92 81 ↓ Performance has improved at
Total Pathways 14738 14549 14617 15068 14603 13964 13254 ↓ speciality level. Breaches 3761 3687 3794 3679 3525 3563 3198 ↓ Performance 74.48% 74.66% 74.04% 75.58% 75.86% 74.48% 75.87% ↑
Clock starts 3339 3132 3870 3272 2493 3395 ↑
SUMMARY:RTT INCOMPLETE PATHWAYS (Jan 19)
Perf Last Speciality Perf This Month Month Perf <18 18-30 31-40 41-51 >52 Total Jan19 Dec18 Change
Plastic Surgery ↑ 2945 523 138 81 34 3721 79.15% 79.07% Ophthalmology 1884 405 142 33 5 2469 76.31% 76.01% ↑ Oral Surgery 3379 1148 396 134 42 5099 66.27% 63.03% ↑ Sleep 1088 78 11 1177 92.44% 91.06% ↑ Clinical Support 645 17 7 669 96.41% 96.31% ↑
QVH BoD PUBLIC March 2019 6 Page 87 of 254 RTT18 – Incomplete pathways – patients waiting 40 weeks +
Patients 40wks+ with Open Pathways August September October November December January Reported Speciality Total 40 Total 40 Total 40 Total 40 Total 40 With DTA No DTA With DTA No DTA Total 40 wks+ With DTA No DTA With DTA No DTA With DTA No DTA With DTA No DTA wks+ wks+ wks+ wks+ wks+ Oral Surgery 407 236 171 362 220 142 298 174 124 274 137 137 285 160 125 202 119 83 Plastic Surgery 143 92 51 147 107 40 119 80 39 141 90 51 147 104 43 131 91 40 Opthamology 22 20 2 36 31 5 28 27 1 36 33 3 40 37 3 47 43 4 ENT 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 Cardiology 2 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Trauma & Othopaedic 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rheumatology 1 0 1 1 0 1 0 0 0 1 0 1 0 0 0 0 0 0 Other 4 0 4 1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 Total 580 348 232 548 359 189 445 281 164 452 260 192 473 301 172 380 253 127
% patients over 40 weeks with DTA 60.00% 65.51% 63.15% 57.52% 63.64% 66.58%
August September October November December January Reported Speciality Total 40 With TCI Total 40 With TCI Total 40 With TCI Total 40 With TCI Total 40 With TCI No Date No Date Total 40 wks+ With TCI date No Date No Date No Date No Date wks+ date wks+ date wks+ date wks+ date wks+ date Oral Surgery 407 93 314 362 79 283 298 125 173 274 93 181 285 123 162 202 48 154 Plastic Surgery 143 56 87 147 68 79 119 51 68 141 61 80 147 61 86 131 54 77 Opthamology 22 10 12 36 19 17 28 16 12 36 23 13 40 31 9 47 28 19 ENT 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 Cardiology 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 Trauma & Othopaedic 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rheumatology 1 1 1 1 0 0 0 1 0 1 0 0 0 0 0 0 Other 4 1 3 1 1 0 0 0 0 0 0 1 0 1 0 0 0 Total 580 160 420 548 167 381 445 192 253 452 177 275 473 215 258 380 130 250
% patients over 40 weeks with TCI 27.59% 30.47% 43.15% 39.16% 45.45% 34.21%
Total patients waiting > 40 weeks has reduced at trust level and in OMFS and plastics. There has however been an increase in patients over 40 weeks in eyes. Additional capacity is being identified.
There has been an increase in patients waiting that have a decision to admit but a fall in those with a TCI date. For OMFS this has been due to changes to the booking of outsourced capacity whereby new arrangements are being implemented.
7 QVH BoD PUBLIC March 2019 Page 88 of 254 RTT Clock starts and stops by month
In Month Clock Stops Admitted Reported Specialty Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Plastic Surgery 432 369 519 491 445 565 RTT clock stops have increased in Ophthalmology 240 240 224 213 221 298 month for both admitted and non Oral Surgery 177 179 230 278 181 304 admitted pathways. Other 107 100 111 127 103 127 Ear, Nose & Throat (ENT) 7 20 10 8 11 10 Clock starts have resumed to pre Total 963 908 1094 1117 961 1304 December levels with the exception of OMFS which is anticipated due to DeRS In Month Clock Stops Non Admitted triage implementation. Reported Specialty Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Oral Surgery 726 819 859 805 605 938 Plastic Surgery 477 381 434 485 354 461 Other 194 136 169 137 165 274 Ear, Nose & Throat (ENT) 151 299 262 359 291 365 Ophthalmology 120 111 103 103 91 175 Cardiology 35 17 43 47 39 73 Trauma & Orthopaedics 5 6 5 2 1 3 Rheumatology 5 8 9 20 12 12 Total 1713 1777 1884 1957 1558 2301
In Month RTT Clock Starts Reported Specialty Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Oral Surgery 1176 1072 1306 960 681 1002 Plastic Surgery 1051 917 1066 971 810 1038 Ophthalmology 414 530 581 546 408 567 Other 337 390 420 373 276 473 Ear, Nose & Throat (ENT) 307 181 445 337 267 275 Cardiology 39 33 37 76 42 28 Trauma & Orthopaedics 9 1 4 3 5 3 Rheumatology 6 8 11 6 7 9 Total 3339 3132 3870 3272 2496 3395 QVH BoD PUBLIC March 2019 Page 89 of 254 8 RTT18 – Key actions Reporting, governance and grip • Weekly PTL is ongoing with amended process for 52 week forecast to enable increased management and grip • System task and finish and assurance calls ongoing
Repatriation and outsourcing • Repatriation of patients to iMOS providers has now, in agreement with commissioners, ceased following a clinical validation of waiting lists at East Grinstead and spoke sites.
Capacity • Capacity and demand analysis is now complete for OMFS, plastics and eyes. Business units are in the process of looking at subspeciality capacity and developing plans to enable delivery of the required activity and any opportunities to improve the 52 week plan in light of 52week breaches incurring a fine from April. • Additional capacity ongoing for OMFS at Uckfield and McIndoe. Plans to mobilise additional capacity at Sidcup are still under negotiation in regard to costs. • Additional OMFS outpatient clinics are ongoing at Maidstone, Dartford and Medway. • Plans in place to use the McIndoe for eye lists (16 patients per month). • Plans are being developed to extend the breast locum post and continue with hand outsourcing to the McIndoe.
Pathways • Fortnightly dental task and finish group is ongoing to continue online triage and reduce inappropriate referrals.
Theatre Efficiency • Theatre utilisation programme is continuing post the departure of Fours Eyes and is being led within the operations business management team. This includes continue the project approach for the late start and clinic cancellation task
and finish groups and business as usual elements.QVH BoD PUBLIC March 2019 9 • Trust reporting dashboard continues to be developedPage 90 of 254 Cancer standards
100.0% 98.0%
98.0% 2WW 96.0% 31D Performance 96.0% Performance 94.0% 94.0%
92.0% 92.0% Performance 90.0% Performance 90.0% Target Target 88.0% Linear (Performance) Linear (Performance) 88.0% 86.0%
84.0% 86.0%
82.0% 84.0% 80.0%
100.0%
90.0% 62D Performance The 62 day target was met in the reporting month 80.0% (Dec). December saw an increase in the number of 70.0% treatments, our highest to date. 60.0% The 2WW target was not met in month (Dec), with a 50.0% Performance total of 21 breaches = 19 breaches were due to Target 40.0% patient choice, 1 due to clinic cancellation and 1 due Linear (Performance) 30.0% to admin delay on the REGO referral system. 20.0% The 31D target was not met in month (Dec) due to 10.0% capacity. Work is progressing to improve performance 0.0% through the improvement of scheduling, more robust cancer pathway tracking, specifically designed on the Jul-17 Jul-18 Jan-18 Jun-17 Jun-18 Oct-17 Oct-18 Apr-17 Apr-18 Sep-17 Feb-18 Sep-18 Dec-17 Dec-18 Aug-17 Aug-18 Nov-17 Nov-18 Mar-18 May-17 May-18 31D pathways, and clinical engagement.
10 QVH BoD PUBLIC March 2019 Page 91 of 254 Skin Two Week Wait Performance
160 105.0% 140 100.0% 120
100 95.0% 80 60 90.0% 40 85.0% 20 0 80.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breaches 4 5 1 8 17 2 2 6 1 1 1 8 1 0 3 3 6 3 1 0 6 Total 92 69 90 100 112 82 77 91 78 54 77 92 71 140 112 99 112 125 151 116 114 Performance 95.8% 93.2% 98.9% 92.6% 86.8% 97.6% 97.5% 93.8% 98.7% 98.2% 98.7% 92.0% 98.6% 100.0% 97.3% 97.0% 94.9% 97.6% 99.3% 100.0% 95.0% National Standard 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0%
Head and Neck Two Week Wait Performance
250 100.0%
200 95.0%
150 90.0%
100 85.0%
50 80.0%
0 75.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breaches 19 8 3 8 9 22 24 7 3 26 9 21 19 4 9 5 8 8 22 21 15 Total 133 147 168 109 152 117 147 174 139 129 136 125 170 169 134 153 184 125 169 169 129 Performance 87.5% 94.8% 98.2% 93.2% 94.4% 84.2% 86.0% 96.1% 97.9% 83.2% 93.8% 85.6% 89.9% 97.6% 93.7% 96.8% 95.8% 93.9% 88.4% 88.9% 89.5% National Standard 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% QVH93.0% BoD93.0% PUBLIC93.0% March93.0% 2019 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% Page 92 of 254 Skin 62 Day Referral to Treatment
35 120.0%
30 100.0%
25 80.0% 20 60.0% 15 40.0% 10
5 20.0%
0 0.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breached 1 4 2 1 5.5 4.5 2.5 2 3.5 4 1 2 2 2 0.5 2.5 2 2 2 2.5 3 Compliant 16 12.5 12 15.5 11.5 16.5 16 11.5 9.5 11 10 13.5 3 17 12 17.5 16.5 13.5 19 19.5 26 Performance 94.1% 75.8% 85.7% 93.9% 67.6% 78.6% 86.1% 85.2% 73.1% 73.3% 90.9% 87.0% 60.0% 89.4% 96.0% 87.5% 89.1% 87.0% 90.4% 88.6% 89.6% National Standard 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%
Head and Neck 62 Day Referral to Treatment
10 120.0% 9 100.0% 8 7 80.0% 6 5 60.0% 4 40.0% 3 2 20.0% 1 0 0.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breached 1.5 4.5 3.5 2.5 0 4 3 1.5 2.5 2 1.5 1.5 2 1 1.5 1.5 3 1 2 1.5 1 Compliant 5 3 0.5 3 1.5 2.5 3.5 8 2.5 2.5 1 2.5 2.5 2.5 4.5 5 4 5 3 5 3.5 Performance 76.9% 40.0% 12.5% 54.5% 100.0% 38.5% 53.8% 83.3% 50.0% 55.6% 40.0% 62.5% 55.5% 71.4% 75.0% 76.9% 57.1% 83.3% 60.0% 76.9% 77.7% 12 QVH BoD PUBLIC March 2019 National Standard 85% 85% 85% 85% 85% 85% 85% 85% 85%Page 9385% of 254 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% Skin 31 Day Decision to Treat
100 105.0% 90 100.0% 80 70 95.0% 60 50 90.0% 40 85.0% 30 20 80.0% 10 0 75.0% Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breached 0 7 5 7 5 3 2 5 3 Compliant 26 43 41 48 53 29 62 55 85 Performance 100.0% 86.0% 89.1% 87.2% 91.3% 90.6% 96.8% 91.6% 96.5% National Standard 96% 96% 96% 96% 96% 96% 96% 96% 96%
Head and Neck 31 Day Decision to Treat
12 120.0%
10 100.0%
8 80.0%
6 60.0%
4 40.0%
2 20.0%
0 0.0% Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Breached 0 0 1 0 0 0 0 0 2 Compliant 6 7 8 9 10 7 9 10 6 Performance 100.0% 100.0% 88.8% 100.0% 100.0% 100.0% 100.0% 100.0% 75.0% 13 National Standard 96% 96% 96% QVH BoD96% PUBLIC March96% 2019 96% 96% 96% 96% Page 94 of 254 Cancer Performance 104 days and 38 days allocation
35 7 Over 104 days Breach Allocation 30 6 1 1 25 2 5 Worthing 11 4 Other 20 1 8 1 1 East Surrey 2 2 Breast 4 1 1 1 2 West Kent Derm 15 1 4 5 2 3 3 Maxillo-Facial 1 3 7 7 Eastbourne 4 3 4 Skin 10 1 1 20 2 Brighton 15 16 17 15 3 Head and Neck 2 4 2 14 13 6 Medway 5 10 9 8 1 2 2 2 6 4 0 1 0 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18
Over 104 Days Breach Allocation – 38 days (new rules are being applied as of Apr 19) • Reducing the number of patients waiting over 104 days on a 62 day pathway Head and Neck remains a priority. • Challenges remain in referring patients for oncology treatment by day 38 to • Work underway to address pathways in regard to patients waiting for non the treating trust. So far this year H&N have sent 9 late referrals. Through the clinical reasons project management support from Surrey and Sussex Cancer Alliance a timed pathways are being designed to help become compliant with the 38 day rule. Head and Neck • H&N referrals receiving into the trust, for treatment are consistently being • Challenges remain in capacity for follow-up appointments treated within 24 days. QVH has received 5 late referrals this year, all past 62 • Complex diagnostic pathways days – all 5 were treated within 24 days.
Plastics Plastics • Number of late referrals from other hospital trusts over 62 days • Challenges remain in receiving late referrals and treating within 24 days. In • Seeing an increase in the number of complex patients, number of the month of Dec we treated 6 patients who were referred to QVH past 38 comorbidities days, 4 were past 62 days. • Patient choice remains a challenge • Within this number only 2 were treated within 24 days. Bottlenecks remain in outpatient capacity. Going forward Plastics are looking at having dedicated oncology tertiary referral slots to improve waits to outpatient appointment.
QVH BoD PUBLIC March 2019 14 Page 95 of 254 Cancer Performance 62 Day Performance YTD our performance is 83.5% (passing 6 months of the year, not achieving in 3 months of the year). This time last year our performance was at 74.5% (passing 1 month out of 9 months).
2WW Performance QVH to move towards an internal 7 day target for 2WW referrals. This is to allow for a more sustainable 2WW performance and to help achieve the 62 day target. Booking at 7 days instead of 14 days enables the ability to rebook within 14 days following a patient cancellation. In Dec 11 patients cancelled their appointment. Due to the appointment being booked between days 9-14, to rebook within the 14 days is challenging as there are limited options available . In routinely booking within 7 days, this gives more time to treat the patient and achieve the 62 day standard. Through looking at the H&N breaches this year, 5 patients could have achieved the 62 day standard if they were seen within the first 7 days. Currently H&N are booking, on average at day 11 and Skin are booking on average at day 8. Extra capacity is being identified within H&N to reduce the day to first appointment, so far an extra 9 2WW H&N slots have been added.
Breach Allocation (38 day rule) The new breach allocation rules have been postponed until April 2019.
Surrey and Sussex Cancer Alliance QVH is being supported by the Surrey and Sussex Cancer Alliance through project management support. QVH is hosting a project manager on a weekly basis to work alongside the Access and Performance Manager to help deliver improvements in the 62d H&N performance, support implementation of timed pathways, and ultimately prepare for Diagnosis by Day 28.
Increased communication Improved communication with referring trusts – weekly conference calls in place with Medway, Conquest, Brighton, and Kent and Canterbury and taking affect as of Feb West Kent Dermatology. Regular attendance at both the Kent and Medway Cancer Alliance and the Surrey and Sussex Cancer Alliance.
28 Day Diagnosis Data collection on the new faster to diagnosis standard will start as of April 2019, reporting of the standard will start as of April 2020. Challenges for this standard are diagnostic capacity and follow-up capacity., especially within H&N. Working with clinicians to ensure they are requesting diagnostics under the correct priority to ensure the admin booking teams book timely and appropriately. The draft timed pathways for H&N have been completed and are with the clinically teams for review.
31 day Action plan 31 day action plan is being developed to support compliance.
Cancer Board The draft terms of reference has been agreed at HMT, the next step is to agree the first meeting.
Cancer Recovery Plan A new cancer recovery plan for 2019/20 is being developed to assessQVH what BoD PUBLIChas been March achieved 2019 following the first recovery plan and determine what the next 15steps are. Page 96 of 254
Minor Injuries Unit (MIU)
MIU Performance v Target
MIU attendence and Performance 1400 101% 1200 100% 99% 1000 98% 800 97% Attendances 600 96% Performance( target 95%) 95% 400 94% Target 200 93% 0 92%
Performance commentary Forward look / performance risks
• Increase in patients compared to previous years activity. • No specific risks identified
QVH BoD PUBLIC March 2019 16 Page 97 of 254 Outpatients - Electronic Referrals eRS Hard Paper Switch Off • eRS Bookings for GP referrals continue to average close to 99%. We can now focus on exception reporting. • NHSD optimisation review on 31/1/19 highlighted key areas for attention. • Action Plan for eRS development and KPI reporting to be agreed within OPD Efficiency programme • Advice and guidance option to be piloted with CCG
250 Appointments Booked Outside ERS
200 Urgent Routine 150 2WW
100
50
0 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 DeRS system • E- vetting launched on Monday 19th November for dental referrals. This has included working with commissioner to agree a new clinical Standard Operating Procedure (SOP), revised admin SOP and communications to primary care providers. • To date around 19% of referrals have been deemed as suitable for primary care treatment and the work is ongoing. The project has been shared with the Chief Dental Officer. • A programme of work is ongoing to identify subspecialty level on the PTL going forward to include oral surgery, oral medicine, orthodontics, restorative and OMFS to enable greater transparency.
QVH BoD PUBLIC March 2019 17 Page 98 of 254 Outpatient Improvement Programme
An outpatient improvement programme is planned to launch in Areas of focus of the programme are as follows: March with the following aims: Communication including: • Improve patient experience and quality of care • Letters • Improve access to care • Telecommunication • Improve productivity, utilisation and efficiency • Communication related elements of current processes • Improve RTT management Productivity including: Success will be measured through a suite of agreed KPIs to • Reducing cancellations include: • Reducing DNAs (Did Not Attend) • Patient feedback (FFT responses / focus groups / nursing • Improving utilisation of clinic templates strategy values) • Reduced waiting times, cancellations and DNAs Virtual clinics including: • Delivery of financial benefit (c £1.2 million) • Skype • Process metrics / KPIS (e.g. cashing up, outcome completion • Results review form) • Glaucoma diagnostic review • Telemedicine
eRS /DeRS optimisation including: • On line vetting • KPI reporting functionality
Resourcing for the programme is currently being identified.
QVH BoD PUBLIC March 2019 Page 99 of 254 Theatre Activity
Sum of Sum of Sum of Month Elective Elective Elective Total Year PLASTICS MAX FAX OPHTH Apr-18 422 200 199 821 May-18 453 219 168 840 Jun-18 448 225 187 860 Jul-18 486 180 198 864 Aug-18 445 173 262 880 Sep-18 396 164 248 808 Oct-18 504 191 211 906 Nov-18 500 231 213 944 Dec-18 478 181 239 898 Jan-19 528 241 292 1061
Performance commentary Forward look / performance risks • The weekly 6-4-2 and scheduling meetings continue to optimise the • Rowntree / DTC have highlighted challenges with the increased level of theatre utilisation and case throughput. patient throughput. This may potentially impact eye activity / utilisation • Temporary dedicated theatre lead has been in place since January to and is being reviewed. oversee the scheduling efficiency. • Ongoing focus and oversight of list lock down which impacts utilisation, to • Theatre activity in January has exceeded all months YTD. be reported going forward • Staffing capacity / cross cover in some areas is impacting timely lockdown. Services working to address.
QVH BoD PUBLIC March 2019 Page 100 of 254
Patient Cancellations on the Day
Readmit within 28 days - Last Minute non clinical cancellations 25 100% 90% 20 80% 70% 15 60% 50% 10 40% 30% 5 20% 10% 0 0%
Plastics Head & Neck Eyes % Not Rebooked within 28 days
Performance commentary Forward look / performance risks
Cancellations are now being reviewed and validated on a weekly level. • For February 8 patient cancelled on the day due to a faulty door in DTC. Repaired next day Non Clinical hospital cancellations: • Staff sickness • 21 non clinical cancellations in January: • Ongoing review / validation of all cancellation to identify any themes that need - 14 due to theatre closures because of low temperatures to be addressed and discussed at the task and finish group. - 1 Emergency/Trauma - 2 Insufficient time - 4 administration errors
Action underway to reduce cancellations • Estates – temporary arrangements with heating implemented and issue being addressed • Follow up has taken place re admin errors • Patient call outs in place. The benefits will be fully realised once list lock down increases. • Reducing cancellations Task & Finish group is ongoing • New cancellation form developed • Weekly review of all cancellations
QVH BoD PUBLIC March 2019 Page 101 of 254 Theatre on the day cancellation trends
QVH BoD PUBLIC March 2019 Page 102 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 07 March 2019 Agenda reference: 49-19 Report title: Finance Report M10 January 2019 Sponsor: Michelle Miles, Director of Finance & Performance Author: Jason McIntyre, Deputy Director of Finance Appendices: NA
Executive summary Purpose of report: To provide the Board with an overview of the Trust financial position. Summary of key As the Trust has submitted a revised forecast therefore the financial performance has issues been reported against the forecast and the original 2018/19 control total. Performance against revised forecast • The Trust submitted a revised forecast of a deficit of £5.945m before technical adjustments for donated assets and depreciation to NHSI in January. The Trust delivered a deficit of £570k after technical adjustments in month; £56k ahead of forecast. The YTD deficit has increased to £4,822k; a favourable variance of £55k against forecast. Performance against 2018/19 control total • The Trust delivered a deficit of £570k in month; £1,278k below plan. The YTD deficit has increased to £4,822k; an adverse variance of £4,800k against plan. Recommendation: The Board is asked to note the contents of this report. Action required Review
Link to key KSO3: KSO4: KSO5: strategic objectives
(KSOs): Operational Financial Organisational excellence sustainability excellence
Implications Board assurance framework: The BAF has been updated to reflect the Controls / Assurance set out in this paper
Corporate risk register: The risk register has been updated to reflect the gaps in controls / assurance set out in this paper
Regulation: The Finance Use of Resources rating is 3.
Legal: Resources: Nil above current resources Assurance route Previously considered by: Hospital Management Team, Executive Management Team Date: 18.02.19 Decision: N/A Previously considered by: Finance and Performance committee Date: 25.02.19 Decision: N/A Next steps: N/A
QVH BoD PUBLIC March 2019 Page 103 of 254 Trust Board Finance Report January 2019
Executive Director: Michelle Miles
QVH BoD PUBLIC March 2019 Page 104 of 254 Contents
3. Finance Performance - Forecast 4. 2019/20 Summary Trend Position 5. Activity Performance by POD 6. Financial Position by Business Unit 7. CIP – service line performance 8. Balance Sheet 9. Capital 10. Appendix A – 2018/19 Control Total Performance
QVH BoD PUBLIC March 2019 Page 105 of 254 M10 Financial Performance via Forecast
Forecast Performance Annual In Month £'000 Year to Date £'000 Favourable Favourable Income and Expenditure Forecast Forecast Actual Forecast Actual /(Adverse) /(Adverse) Forecast overview Income Patient Activity Income 63,399 5,304 5,792 489 52,912 53,401 489 Other Income 5,827 414 (5) (418) 4,999 4,581 (418) Total Income 69,226 5,717 5,787 70 57,911 57,981 70 The Trust submitted a revised forecast of a deficit of £5.945m before technical Pay Substantive (43,028) (3,560) (3,596) (36) (35,823) (35,859) (36) adjustments for donated assets and depreciation to NHSI in January - part of Bank (2,379) (211) (161) 51 (1,956) (1,905) 51 the previous month’s submission. The technical adjustments for donated Agency (3,221) (279) (185) 93 (2,631) (2,538) 93 Total Pay (48,627) (4,050) (3,942) 108 (40,410) (40,302) 108 assets income and depreciation increases the deficit to £6.159m Non Pay Clinical Services & Supplies (12,928) (1,127) (1,204) (77) (10,814) (10,891) (77) Drugs (1,588) (130) (122) 8 (1,327) (1,320) 8 The Trust delivered a deficit of £570k after technical adjustments in month; Consultancy (218) (54) 34 88 (177) (89) 88 £56k ahead of forecast. The YTD deficit has increased to £4,822k; a Other non pay (7,193) (558) (765) (207) (6,078) (6,285) (207) Total Non Pay (21,928) (1,869) (2,057) (188) (18,396) (18,584) (188) favourable variance of £55k against forecast. Financing (4,616) (437) (372) 65 (3,742) (3,676) 65 Total Expenditure (75,171) (6,356) (6,371) (15) (62,548) (62,563) (15) Income over recovery of £70k and pays underspends of £105k have been Surplus / (Deficit) (5,945) (639) (584) 55 (4,637) (4,582) 55 Adjust for Donated Income 431 3 3 (0) 425 425 - partially offset by net non pay expenditure overspends of £123k (Non pay Adjust for Donated Depn. (217) (16) (16) 0 (185) (185) - overspend £188k less financing underspend of £65k. Adjust for Land Sale ------NHSI Control Total Excluding STF and sale of land (6,159) (626) (570) 56 (4,877) (4,822) 55 In month and YTD forecast performance
The Trust delivered a deficit of £570k in month; £56k better than forecast.
The income position is £70k above forecast. In addition there was a re categorisation of AFC income to patient activity income in month circa £0.5m as per technical guidance.
The pay position is an £108k improvement on forecast due to a decreases within agency and bank staff due to additional substantive recruitment.
The non pay position is £188k more than forecast largely within Other Non Pay due to additional costs within corporate areas which are a continuation of the increased costs within Estates & Facilities for security, rates and provisions and IM&T budgets. Financing is £55k less than forecast due to delay in capital expenditure.
QVH BoD PUBLIC March 2019 Page 3 Page 106 of 254 Summary Trend position - Income and Expenditure Trend
Actual Actual Actual Forecast Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Actuals 18/19 Board Line M10 M11 M12 18/19 In M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 In Month 17/18 17/18 17/18 Month Patient Activity Income 5,389 4,811 5,051 5,006 5,329 5,620 5,577 5,491 5,114 5,121 5,318 5,031 5,792 5,196 5,393 5,303 5,792 Other Income 429 496 898 361 337 523 453 447 823 476 641 523 (5) 363 363 414 (5) Total Income 5,818 5,307 5,949 5,367 5,666 6,143 6,030 5,938 5,938 5,598 5,960 5,554 5,787 5,559 5,756 5,717 5,787 Substantive (3,468) (3,415) (3,497) (3,553) (3,654) (3,536) (3,660) (3,685) (3,188) (3,570) (3,756) (3,661) (3,596) (3,568) (3,637) (3,560) (3,596) Bank (122) (132) (139) (326) (140) (148) (221) (155) (206) (171) (217) (160) (161) (211) (211) (211) (161) Agency (205) (251) (289) (276) (295) (305) (259) (294) (234) (294) (252) (144) (185) (279) (311) (279) (185) Total Pay (3,794) (3,798) (3,925) (4,155) (4,090) (3,989) (4,140) (4,134) (3,628) (4,035) (4,224) (3,965) (3,942) (4,058) (4,159) (4,050) (3,942) Clinical Services & Supplies (1,054) (1,025) (301) (1,076) (944) (1,193) (1,038) (1,031) (752) (1,103) (1,251) (1,299) (1,204) (1,028) (1,086) (1,127) (1,204) Drugs (118) (105) (126) (116) (137) (143) (150) (128) (103) (135) (163) (122) (122) (130) (130) (130) (122) Consultancy (17) - (83) (8) (37) (22) (28) (8) - (3) (16) (1) 34 (21) (21) (54) 34 Other non pay (562) (595) (484) (607) (592) (605) (650) (724) (330) (618) (759) (636) (765) (558) (557) (557) (765) Total Non Pay (1,750) (1,726) (993) (1,807) (1,709) (1,963) (1,866) (1,891) (1,185) (1,859) (2,188) (2,059) (2,057) (1,737) (1,794) (1,869) (2,057) Financing (345) (345) (421) (373) (374) (381) (343) (345) (358) (380) (374) (377) (372) (438) (438) (438) (372) Total Expenditure (5,890) (5,869) (5,340) (6,336) (6,172) (6,334) (6,349) (6,371) (5,170) (6,274) (6,786) (6,400) (6,371) (6,233) (6,392) (6,357) (6,371) Surplus / (Deficit) (72) (561) 609 (969) (506) (191) (318) (433) 768 (676) (826) (846) (584) (674) (636) (640) (584) Donated Income ----- 414 3 3 3 3 -- 3 3 Donated Depreciation (19) (19) 124 (20) (20) (22) (17) (20) (20) (17) (17) (17) (16) (20) (20) (16) (16) Land Sale NHSI Contol Total Excluding STF (52) (542) 485 (950) (486) (169) (301) (413) 373 (662) (812) (832) (570) (654) (615) (627) (570)
Summary
• The forecast for month M11 & M12 is based on the forecast of £5,945 before technical adjustments.
• Income has improved from previous months activity due to the increase in working days within the month. There has been a reclassification of AFC income to Patient Activity Income from Other Income, which has been back dated for prior periods.
• Pay has remained similar levels as prior period, Substantive has slightly reduced due to recharging of staff costs, Agency has increased due to more working days in the period, however is lower than average run rate by £76k.
• Non pay is similar to previous period and remains higher than trend. Main area of increase over the last few months is within Clinical Services & Supplies, within Theatres and Radiology partially due to non recurrent spends. QVH BoD PUBLIC March 2019 Page 107 of 254 Page 4
Activity Performance by POD – M10 2018/19
Activity Performance In Month In Month Year To Date Year To Date Summary Act Acty Actual Plan Act Acty Actual POD Currency Plan Acty Plan £k Var £k Plan £k Var £k Acty Var £k Acty Acty Var £k Minor injuries attendances are 80 and £6k above plan in Minor injuries Attendances 943 1,023 80 68 74 6 9,311 10,225 914 670 736 66 month. YTD activity is 914 attendances and £66k above Elective (Daycase) Spells 1,387 1,176 (211) 1,513 1,293 (220) 10,982 10,168 (814) 12,010 11,109 (901) plan. Elective Spells 421 303 (118) 973 734 (238) 3,312 3,114 (198) 7,700 7,825 125 Non Elective Spells 497 352 (145) 1,175 877 (298) 4,902 4,261 (641) 11,601 10,154 (1,447) Daycase activity in month is 211 spells and £220k below XS bed days Days 57 23 (34) 16 6 (10) 557 679 122 154 182 28 plan with under-performance in plastics (hands & breast) Critical Care Days 78 52 (26) 80 39 (41) 765 888 123 790 1,035 245 £93k, Maxillofacial £72k, Sleep £24k and Corneo Plastics Outpatients - First Attendance Attendances 3,840 3,847 7 531 509 (23) 37,475 38,188 713 5,195 5,107 (88) £31k. YTD activity is 814 spells and £901k under plan Outpatients - Follow up Attendances 11,123 11,154 31 801 817 15 108,593 102,356 (6,237) 7,845 7,535 (310) within Maxillofacial £370k, Plastics £317k and Corneo Outpatient - procedures Attendances 2,605 2,697 92 344 356 11 25,266 25,410 144 3,337 3,365 28 Plastics £166k. Activity in month is higher than average above the average for the year by 177 and 69 more spells Other Other 3,900 2,373 (1,527) 585 557 (28) 37,568 37,948 380 5,684 5,912 228 than January 2018, with the main increases being within Prior Period Adjustments and WIP 80 531 451 412 440 28 Plastics. 6,166 5,792 (374) 55,399 53,401 (1,998) Elective activity in the month is 118 spells below plan and £238k. The activity is under performing in Sleep studies 79 spells & Table 2 - Performance by Service Line £65k below plan, Oral 25 spells & £138k and Plastics 15 spells & £36k, Corneo Plastics slightly over performing by 2 spells. The Activity Financial Performance In Month Year to Date YTD activity is 198 spells below plan and £125k above plan, the over performance is largely within Plastics 11 spells £214k and Actual Service Line Plan £k Actual £k Var £k Plan £k Var £k Eyes 47 spells and £115k. Oral below plan on activity 93 spells, by £94k, and underperformance in Sleep 163 spells, £110k. In £k month is slightly below trend by 9 spells, however 19 more spells than January 2018. Perioperative Care 2 2 0 18 18 (0) Clinical Support 491 496 4 5,057 5,272 214 Non-elective activity has under performed by 145 spells and under performed by £298k in month which is mainly within Eyes 466 552 86 5,037 5,140 104 Plastics, 126 spells and £262k and Maxillofacial 19 spells and £30k. The YTD position reports an under-performance of 641 Oral 977 971 (6) 10,701 10,196 (506) spells and £1,447k underperformance due to under performance within plastics services lines £1,545k partially offset by Plastics 2,618 2,389 (229) 23,762 22,499 (1,262) overperformance within eyes (corneoplastics) £134k. Trend for Non Elective continues to fall, with January being the lowest Sleep 299 274 (25) 3,574 3,598 23 month in the current year and 66 spells lower than the January 2018. Other incuding WIP/ coding 187 347 160 1,083 886 (198) Grand Total 5,040 5,031 (9) 49,233 47,608 (1,625) Critical care days have under -performed by 26 days in month and under performed by £41k. The YTD position is above plan by 123 days and £245k YTD. NB * Other clinical income has been added to analysis (i.e RTA, Private patients) Outpatient attendances (FA/FUs) are on plan for attendances and £7k below plan in month and 5,524 attendances and £397k to reconcile to total Clinical Income. below plan YTD. Outpatient procedures are £11k above plan in month and £28k above plan YTD. Sleep services are the main area of over performance in month £28k and Clinical Support £23k, with Oral £28k and Plastic services £22k all below plan. ** Further activity trend analysis is included on the next page. YTD Plastics is the main area of underperformance £249k and Oral £170k. There is a timing delay in the completion of coding of outpatient procedures , the anticipated value of the coding gain is accrued into the in month position and reflected within *** Total in month and YTD service line performance does not reconcile to prior period adjustments & WIP category as an estimate. activity income analysis by business unit page 7 as non SLAM activity income has not been disaggregated to business unit. Other has under performed in month by £28k mainly due to Clinical Support £21k, mainly within Prosthetic Lab £16k and QVH BoD PUBLIC March 2019 Radiology £8k.Page YTD 108 over of 254 performance of £228k due to Radiology direct access and unbundled outpatients diagnostics, £201k Page 5 and sleep devices £146k, being offset by Head & Neck specialist commissioning top up of £156k. Financial Position by Business Unit – M10 2018/19
Patient Activity Variance by type: in £ks Other Income Pay Non Pay Position In Month Year to Date Income performance against financial Annual % CMV YTDV CMV YTDV CMV YTDV CMV YTDV Budget Actual Variance Budget Actual Variance Contribution plan Budget Contribution Operations 1.1 Plastics (603) (1,830) 12 (160) (89) (782) (43) (52) 24,638 2,381 1,659 (722) 65% 20,241 17,416 (2,824) 78% 1.2 Oral (296) (756) 13 67 (32) (321) (44) (544) 8,061 831 471 (360) 45% 6,569 5,016 (1,553) 48% 1.3 Eyes (29) 88 39 55 (17) (172) (30) (128) 4,488 473 434 (38) 73% 3,631 3,474 (157) 65% 1.4 Sleep 21 (79) 2 3 14 47 (24) (210) 2,352 242 254 12 105% 1,928 1,689 (240) 48% 1.5 Clinical Support (62) 330 34 (44) 27 351 (29) 4 (2,174) (149) (180) (30) -29% (1,798) (1,157) 641 -19% 1.6 Perioperative Care 0 0 (19) 4 (63) (726) (50) (198) (11,703) (941) (1,073) (132) -4054% (9,821) (10,740) (919) -4971% 1.7 Operational Nursing (48) 196 (3) (22) 50 (370) (22) (171) (6,091) (501) (525) (24) -323% (5,081) (5,447) (367) -357% Operations Total (1,018) (2,051) 78 (96) (111) (1,973) (243) (1,298) 19,572 2,336 1,042 (1,294) 15,669 10,250 (5,419) Nursing & Clinical Infrastructure 2.1 Clinical Infrastructure --- 36 (14) (83) 9 11 (1,134) (94) (99) (5) -1921% (947) (983) (36) -2730% 2.5 Director Of Nursing -- (31) 46 (21) (215) (81) (133) (2,800) (231) (364) (133) -364% (2,338) (2,639) (301) -809% Nursing & Clinical Infrastructure -- (31) 82 (35) (298) (73) (121) (3,935) (325) (464) (139) (3,285) (3,622) (337) Corporate Departments 3.1 Non Clinical Infrastructure (3) (27) 1 41 7 (28) (14) (265) (4,352) (357) (365) (8) -731% (3,637) (3,916) (279) -829% 3.2 Commerce & Finance -- 10 25 7 (50) (104) (451) (2,881) (242) (329) (87) -23784% (2,396) (2,872) (476) -8186% 3.4 Finance Other 647 80 (457) 287 (88) 859 136 282 (713) (495) (256) 239 -172% (3,745) (2,237) 1,508 -135% 4.1 Human Resources -- 25 126 (3) (2) 27 (4) (964) (79) (30) 49 -250% (807) (686) 121 -288% 5.4 Corporate -- 3 28 (36) 46 1 (46) (1,826) (150) (181) (31) -2667% (1,526) (1,500) 27 -2656% Corporate Total 644 52 (417) 507 (112) 825 46 (484) (10,736) (1,323) (1,162) 161 (12,111) (11,210) 901
Surplus / (Deficit) (374) (1,999) (370) 493 (258) (1,447) (269) (1,903) 4,900 688 (584) (1,272) 274 (4,582) (4,855) Summary Patient Activity Income: The main areas of under performance in month are, Plastics (Elective, Daycases & Non Elective), Oral (mainly elective & Daycases), Clinical services (Prosthetics excluded devices) and Critical care. There has been a change in classification for the Agenda For Change additional funding from Other Income to Patient Activity Income, which includes prior periods. YTD underperformance of £1,999k is mainly within Plastics (mainly Non Elective & outpatients), Oral services (Daycases, Outpatients & H&N Top up) and Sleep services (Elective, Daycases & Outpatients). This is being offset by Operational Nursing (critical care bed days which have been much higher in prior periods), Clinical Support (MIU/ direct access activities), Eyes (emergency and PBR exclusion activities).
Other income: In month is above plan by £370k mainly due to the reclassification of A4C income, above plan YTD £493k. Plastics in month is mainly due to additional income from Health Education England. Oral in month is due to additional funding for RTT for workforce support. Eyes is mainly due to deferral income for the eye bank. Director of Nursing income has decreased in month due to income incorrectly invoiced in prior periods.
Pay: In month is over spent by £112k in month; over spent by £1,447k YTD. The main drivers of overspend are within plastics and perioperative care. Plastic service is below plan by £89k in month mainly due to additional medical costs, which is being partially funded by the CCG’s and Unidentified CIP. YTD is adverse by £782k which is mainly due to medical pay due to agency usage at the beginning of the year, additional medical payments and the allocation of unidentified CIPs. Perioperative is above by £63k in month and above plan £726k YTD which is due to high agency and bank usage to cover vacancies and additional payments for weekend work. The Trust is above the NHSI agency cap by £1,179m YTD. Agenda for change back pay has seen an increase of £446k, which is offset within income, however the incremental drift due to the higher increases is a cost pressure to the Trust, further work will be undertaken to understand this.
Non Pay: In month is over spent by £269k; over spent YTD £1,903k. There was unidentified saving of £206k in month and £1,334k YTD shown within the position. Plastics is above plan in month which is due to outsourcing with McIndoe. Oral is mainly due to the contract with East Sussex Hospitals. Depreciation costs within Finance other are less than anticipated in month £12k and YTD £252k which is not expected to continue over the remainder of the year. QVH BoD PUBLIC March 2019 Page 6 Page 109 of 254 Cost Improvement Plan (CIP) – M10 2018/19
Change (+ve Estimated Estimated means Sum of NHSI Financial Sum of NHSI Sum of Financial identification of Sum of YTD Sum of YTD Planned CIPP Target Delivery based Planned Forecast Business Unit Lead Delivery 18/19 Gap further CIPPs Actual Savings Over / (Under) Savings Shortfall £ £ on RAG rating Savings YTD £ Savings Total based on compared to Total £ Achievement £ TOTAL £ by as reported at by BU £ RAG rating reported at BU Month 9 Month 9)
1.1 Plastics Paul Gable (461,621) (118,436) (343,185) (79,936) 38,500 (351,760) (66,035) (285,726) (461,621) (88,000) (373,621) 1.2 Oral Georgina Baidya (365,162) (10,000) (355,162) (10,000) 0 (273,428) (13,616) (259,812) (365,162) (20,151) (345,011) 1.3 Eyes Georgina Baidya (170,687) (76,832) (93,855) (76,832) 0 (127,402) (82,138) (45,264) (170,687) (82,218) (88,469) 1.4 Sleep Sue Aston (48,272) (75,230) 26,958 (75,230) 0 (40,503) (69,454) 28,950 (42,267) (83,196) 40,929 1.5 Clinical Support Services Paul Gable (429,084) (287,680) (141,404) (285,452) 2,228 (333,373) (189,717) (143,657) (429,084) (283,313) (145,771) 1.6 Perioperative Care Sue Aston (646,490) (82,235) (564,255) (82,235) 0 (497,700) (47,626) (450,074) (646,490) (41,126) (605,364) 1.7 Operational Nursing Nicky Reeves (182,391) (1,500) (180,891) (1,500) 0 (136,572) (4,167) (132,406) (182,391) (5,003) (177,388) 2.1 Performance & Access Phil Kennedy (50,977) (23,752) (27,225) (23,752) 0 (38,919) (26,857) (12,062) (50,977) (34,441) (16,536) 2.5 Director of Nursing Nicky Reeves (172,735) (96,003) (76,733) (96,403) (400) (141,323) (76,585) (64,738) (178,740) (99,002) (79,738) 3.1 Non Clinical Infrastructure Steve Davies (240,528) (174,113) (66,415) (174,113) 0 (177,958) (39,727) (138,231) (240,528) (181,100) (59,428) 3.2 Commerce & Finance Jason McIntyre (136,847) (207,320) 70,473 (207,320) 0 (127,486) (150,941) 23,455 (135,847) (161,130) 25,283 4.1 Human Resources Dave Hurrell (55,100) 0 (55,100) 0 0 (45,786) (62,069) 16,283 (55,100) (56,735) 1,635 5.4 Corporate Clare Pirie (89,106) 0 (89,106) 0 0 (70,382) (15,469) (64,194) (89,106) 0 (89,106) Targets in Op Plan 0 0 0 0 0 0 0 0 Grand Total (3,049,000) (1,153,101) (1,895,899) (1,112,772) 40,328 (2,362,592) (844,400) (1,527,473) (3,048,000) (1,135,415) (1,912,585)
Summary
• At M10 the Trust YTD delivered £844k against plan; an under delivery of £1,527k. This included unidentified savings that have been factored into the position. • The Trust is forecasting saving of £1,135k for the year. This includes £125k of non recurrent saving. The above savings includes an additional £225k of savings which will have an impact in 2019/20. • There is still a significant gap of £1.9m to address with no formalised plans in place. The Trust is continuing to discuss CIPs every 2 weeks in Performance Review and Performance Review 2 meetings. • A number of task and finish groups have been identified now for cross cutting schemes, together with named SROs and these will report into the PR2 meetings monthly to update progress. The Trust has made limited progress on the identification and realisation of the savings since the beginning of the year.
QVH BoD PUBLIC March 2019 Page 7 Page 110 of 254 Balance Sheet – M10 2018/19
Balance Sheet 2017/18 Current Previous Summary as at the end of January 2019 Outturn Month Month • The capital asset net value has decreased in month by £000s £000s £000s £152k due to the level of capital spend.
Non-Current Assets • Net current assets have decreased in month by £3.3m Fixed Assets 47,588 47,186 47,339 reflecting the operating loss incurred and the loss of Other Receivables - - - incentive PSF that was expected. Sub Total Non-Current Assets 47,588 47,186 47,339 • Inventories are being monitored on a regular basis.
Current Assets • Trade and other receivables have decreased by £1.9m Inventories 1,178 1,177 1,188 which reflects the reduced PSF incentive accrual. Trade and Other Receivables 8,217 9,400 11,283 Cash and Cash Equivalents 8,914 4,319 5,877 • Cash has decreased by £1.6m this period
Current Liabilities (8,933) (10,078) (10,235) • Current liabilities have remained stable • Non current liabilities – no change. Sub Total Net Current Assets 9,376 4,819 8,113
Total Assets less Current Liabilities 56,965 52,005 55,452
Non-Current Liabilities Issues Provisions for Liabilities and Charges (625) (625) (625) • Sufficient cash balances are not currently being generated Non-Current Liabilities >1 Year (5,823) (5,045) (5,045) by the Trust’s operating activities to provide liquidity,
Total Assets Employed 50,517 46,335 49,782 service the capital plan or to meet future loan principal repayment obligations. Tax Payers' Equity Public Dividend Capital 12,237 12,237 12,237 Retained Earnings 26,100 21,918 25,365 Actions Revaluation Reserve 12,180 12,180 12,180 • Further details of actions taken to ensure robust cash
Total Tax Payers' Equity 50,517 46,335 49,782 management processes are outlined on the debtor and cash slides. NB Analysis is subject to rounding differences
QVH BoD PUBLIC March 2019 Page 111 of 254 Page 8 Capital – M10 2018/19
Annual YTD YTD YTD Full Year Full Year Month 10 - January 2019 Plan Plan Actual Variance Forecast Variance Summary £000s £000s £000s £000s £000s £000s • The original Capital plan for 2018/19 was £3,850k including £400k for the Estates projects donated CT scanner. Earlier in the year £1,000k was added following the Backlog maintenance - Energy Management 216 216 - 216 114 102 decision to invest part of the trust's STF funding in capital projects (see Backlog maintenance - Health & Safety 100 105 - 105 89 11 Backlog maintenance - Fire Safety 145 145 3 142 93 52 below). A successful bid for £355k (exact figure to be confirmed) has been Backlog maintenance - Internal Accommodation 210 234 2 232 145 65 made to the Sussex & East Surrey STP for additional funding for the Backlog maintenance - External Works 180 180 - 180 79 101 STF funding allocated to capital 1,000 400 98 302 359 641 electronic observations project; this is now expected in 2019/20. Other projects 413 372 586 (214) 898 (485) • The capital programme has been developed through the 2018/19 business Estates projects 2,264 1,652 690 963 1,779 485 planning process via the Capital Planning Group and with EMT and Board Medical Equipment 1,033 950 773 177 796 237 approval. Information Management & Technology (IM&T) • The STF funding will be used to improve the estate, mainly in the Ordercomms 120 120 175 (55) 183 (63) Infrastructure strategy - wireless extension 60 60 50 10 98 (38) Burns/Critical Care area but also to provide enhanced facilities for staff. Infrastructure strategy - hardware 170 113 - 113 172 (2) £800k has been allocated to the Burns/Critical Care project, but this will Infrastructure strategy - end user reconfiguration 150 100 16 84 150 - require planning permission and detailed development work which will Infrastructure strategy - desktop/mobile 100 67 105 (39) 106 (6) Health & Social Care Network 150 150 43 107 144 6 cause the timescale to stretch into 2019/20. E-Observations 108 72 36 36 96 12 EDM 108 82 166 (84) 210 (102) • Apart from the additional STF funding, the largest element of the Estates Other projects 474 390 253 137 564 (90) programme is backlog maintenance. The Trust is in year 3 of a 5 year Information Management & Technology (IM&T) 1,440 1,154 845 309 1,723 (283) backlog maintenance programme. Most of the planned work is expected to Contingency 113 - - - - 113 Total 4,850 3,756 2,307 1,449 4,298 552 be completed by the end of the financial year. However, progress has been jeopardised by a significant contractor going into liquidation. New contractors have been appointed but there will inevitably be some delays and cost increases. • The IT programme is largely based on the IM&T Strategy. The implementation of Order comms, the electronic ordering of diagnostic tests and images, is now virtually complete. The EDM project is currently in remediation and a recovery plan has been developed. • YTD expenditure is 38% below plan. Forecast full year expenditure is now £552k below plan as a result of the extended timeframe for spending most for the STF funding, partly offset by increases elsewhere in the programme. Progress is being monitored by the Capital Planning Group.
QVH BoD PUBLIC March 2019 Page 9 Page 112 of 254 Appendix A - Control Total Summary Position – YTD M10 2018/19
Financial Performance In Month £'000 Year to Date £'000
Favourable Favourable Summary - Plan Performance Income and Expenditure Annual Budget Budget Actual Budget Actual /(Adverse) /(Adverse)
Income Patient Activity Income 67,086 6,166 5,792 (374) 55,399 53,401 (1,999) • The Trust delivered a deficit of £569k in month; £1,278k below plan. The YTD deficit has increased to Other Income 8,316 365 (28) (393) 3,587 3,913 325 £4,822k; an adverse variance of £4,800k against plan. There was a presentational issue in M09 report as Total Recurrent Income 75,402 6,531 5,764 (767) 58,987 57,313 (1,674) in month plan was £200k more than reported; this has been rectified in current YTD report. Pay Substantive (45,468) (3,621) (3,596) 25 (38,226) (35,859) 2,367 Bank (483) (40) (161) (121) (402) (1,905) (1,503) • The underlying poor financial performance has continued in month. The actions to date have not improved Agency (273) (23) (185) (162) (227) (2,538) (2,311) the run rate. Run rate on expenditure has slightly decreased from the previous month within pay due to Total Pay (46,223) (3,684) (3,942) (258) (38,856) (40,302) (1,447) reduced usage of temporary staffing. Non Pay Clinical Services & Supplies (12,870) (1,231) (1,204) 27 (10,305) (10,891) (585)
Drugs (1,553) (129) (122) 7 (1,294) (1,320) (26) Consultancy (79) (7) 34 41 (66) (89) (23) • The Trust has submitted a reforecast position to NHS of a deficit of £5.95m before PSF, the impact of the Other non pay (5,562) (400) (694) (294) (4,763) (5,504) (741) land sale and donated depreciation / income. The in month position is in line with expected forecast. Total Non Pay (20,064) (1,767) (1,986) (219) (16,429) (17,803) (1,375) Financing (4,714) (393) (372) 21 (3,929) (3,676) 252 Total Recurrent Expenditure (71,002) (5,843) (6,300) (457) (59,213) (61,782) (2,569) In Month Performance Non recurrent income adjustments 500 23 23 500 668 168 Non recurrent expenditure adjustments (71) (71) (781) (781) • The Trust is £1,278k adverse to plan in month. Income is below plan by £767k recurrently and Surplus / (Deficit) 4,900 688 (584) (1,272) 274 (4,582) (4,855) expenditure is overspent by £457k recurrently with £21k of technical adjustments. Non recurrent income in
Adjust for Donated Income 500 - 3 3 500 425 (75) month relates to RTT income and non recurrent expenditure reflects consultancy costs . Adjust for Donated Depn. (226) (20) (17) 3 (204) (185) 20 Adjust for Land Sale 4,000 ------• There was a reclassification of the income received for (Agenda for Change)AFC, as this is now classified NHSI Control Total Excluding STF and sale of land 626 708 (569) (1,278) (22) (4,822) (4,800) as Patient Activity as advised by NHSI, with £459k relates to prior periods.
• Patient activity income: The Trust generated a similar level of patient treatment income as same time last YTD Performance year. • The Trust is £4,800k adverse to plan YTD. Income is below plan by £1,674k YTD recurrently and expenditure is overspent by £2569k recurrently partially with £252k of technical adjustments. Non recurrent • Day case spell activity is under plan by £220k, Elective activity by £238k, Non elective activity by £298k, income relates mainly to RTT income and donated income for CT scanner. The non recurrent expenditure Critical care bed days by £41k, with Outpatient attendances above plan by £4k and a reduction of prior relates to consultancy expenditure, bank expenditure and R&D expenditure. months coding by £32k for flex and freeze. The main areas of under performance are Plastics £229k below plan and Critical care £70k below plan. Offsetting the under performance is Corneo Plastics by • Income has under recovered by £1,6746k YTD recurrently, which is due to patient activity income under £86k and Sleep services by £25k. recovery of £1,999k partially offset by other income over recovery of £325k. • Patient activity income: Day case is under plan by £901k, non elective by £1,465k and • Other Income is below plan by £393k, due primarily to reclassification of income for AFC as stated above, outpatients by £370k. This is partially offset over performing against plan by Elective £125k, MIU additional income within Research £42k mainly for CRN funding and some additional commercial income. £66k, Critical Care £245k and direct access within Radiology £256k.. Additional non recurrent income from CCG’s to support RTT of c£23k within Plastics & Oral services. • The main areas of under performance are Plastics (adverse £1,786k mainly driven by non Income recognised for staff secondments c£20k elective and outpatients first ,F/up and procedures) and Oral services £806k. Eyes services is favourable YTD by £75k, Operational Nursing (Critical care) by £207k and Clinical Support by • Pay is £258k adverse in month. This is mainly due to unidentified savings of £187k, and over spends £230k. within medical staffing of £19k (Plastics and Eyes services) due to additional sessions. An increase in • Other income has over performed largely due to additional income from CCG’s for RTT £107k, spend from the new pay awards for AFC of c£60k which has been partially offset by additional income. additional income from Research and LDA funding. Run rate has reduced in temporary staffing, however spend has increased from previous period by £43k. The Trust has incurred £185k of agency expenditure in month; £50k above ceiling. • The YTD pay position is £1,447k adverse YTD. This includes the AFC award pay pressure of c£567k (partially offset by income of £524k) and £1,236k due to unidentified savings and slippage on schemes. • Non Pay is £219k adverse in month. The main driver is unidentified CIP £206k and non recurrent theatres Medical staffing (Plastics and Oral) and Nursing overspends (Theatres, ITU and Canadian wing) have been productivity consultancy costs £70k. Clinical Services & Supplies has reduced in spend from previous offset by underspends within Clinical support (Therapies, Histopathology and Radiography). month by £103k, this is mainly within Oral services. This has been partially offset by depreciation charges underspends within financing due to delay in the capital programme of £21k. • Non pay is over spent by £1,375k YTD £575k within clinical supplies partially offset by pass-through income within patient activity £161k (Sleep). Within other non pay £1,522k , mainly due to unidentified CIP £1,334k QVH BoD PUBLIC March 2019 and £255k cost in relation to theatres productivity initiative. This has been partially offset by depreciation Page 113 of 254 charges underspends within financing due to delay in the capital programme of £252k. Page 10
KSO5 – Organisational Excellence Risk Owner: Director of Workforce & OD Date: 26 February 2019
Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that Initial Risk 3(C)x 5(L)=15, moderate We seek to maintain a well led impact on Organisational Excellence . The engagement and Current Risk Rating 4(C)x 5(L)=20, major organisation delivering safe, motivation of the workforce, supported by evidence based Target Risk Rating 3(C)x 5(L) = 15 moderate effective and compassionate care research, will impact on patient experience through an engaged and motivated workforce Rationale for risk current score Future risks Risk • National workforce shortages in key nursing areas particularly • An ageing workforce highlighting a significant risk of theatres, CCU retirement in workforce • Staff lose confidence in the • Generational changes in workforce shows high turnover in • Many services single staff/small teams that lack Trust as place to work due to a newly qualified Band 5 nurses in first year of employment capacity and agility. failure to offer: a good working • 2-3 years to train registered practitioners to join the workforce • Developing new health care roles -will change skill mix environment; fairness and • Around 40,000 nursing vacancies in England • Consultant contract negotiations may resume in 2019 equality; training and • managers skill set in triangulating workforce skills mix against unknown financial impact development opportunities ; activity and financial planning and a failure to act on feedback • Unknown impact of STP case for change/clinical strategy to managers and the findings • Staff survey results and SFFT show staff engagement is lower of the annual staff survey. than previous years • Insufficient focus on • Impact on adequate substantive staffing resource in theatres to recruitment and retention Future Opportunities support productivity/meet RTT across the Trust leading to an • Closer partnership working with STP and through LWAB • Agenda for Change 2018 reform impact as yet untested increase in bank and agency particularly for whole system leadership and talent • Addressing the reasons for retention is challenging as pressures costs and having longer term management initiatives on managers/leaders can lead to a reluctance to adopt new issues for the quality of patient ways of working and support significant change care • Overseas nurses will take some months to arrive and have a positive impact
Controls / assurance Gaps in controls / assurance • Developing more robust workforce controls as part of business planning • Management competency in workforce planning • Leading the Way, leadership development programme funded for a further year 2019/20 • Continuing resources to support the development of • All works streams being captured in one People and OD Strategy 2019 staff – optimal use of apprenticeship levy budget • monthly challenge to Business Units at Performance review • Continuing attraction and retention problems in • Investment made in key workforce e-solutions, TRAC delivered on time, E-job plan ongoing, theatres , critical care and paediatrics and C Wing HealthRoster implemented, Activity Manager underway • Theatre recruitment and retention workstream • Engagement and Retention plan actions ongoing launched (Four Eyes) • Overseas recruitment now continues. Next arrivals expected in Q4 • Capacity of workforce team to support the required • The Trust commissioned an external Well Led review and regularly updates the resulting action plan initiatives to address recruitment and retention • Chosen as a pilot site for the Best Place to Work initiative QVH BoD PUBLIC March 2019 challenges including pay and agency controls • Work underway to finalise ESR hierarchy Page 114 of 254 • Reconciliation required between ledger and ESR to • Some positive gains from the 2018 NHS Staff survey results enable full establishment control
Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 51-19 Report title: Workforce Report – February report, Data Sponsor: Geraldine Opreshko, Director of Workforce and OD Author: David Hurrell, Deputy Director of Workforce Appendices: Update on Terms and Conditions Refresh for Agenda for Change workforce
Executive summary Purpose of report: The Workforce and OD report for February 2019 (January data) provides the Trust Board with a breakdown of key workforce indicators and information linked to performance. This report also provides the Board with a high level overview and update on the ongoing Terms and Conditions changes for staff on Agenda for Change. Summary of key Ongoing challenges related to turnover and use of temporary staffing and pay costs issues Recommendation: The Board is asked to note the report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework: The challenges are reflected in KSO 5 Organisational Excellence
Corporate risk register: A number of risks on the Corporate risk register are specific to workforce challenges and in particular the level of vacancies and
use of temporary staffing
Regulation: Workforce challenges will be implicit in all 5 domains of the CQC and in particular – Are they well Led?
Legal: No implications
Resources: The Workforce and OD team are trying to keep pace with demand and the need to support managers within existing resources
Assurance route Previously considered by: Finance and Performance Committee Date: 15.2.19 Decision: For information Previously considered by: Date: Decision: For information Next steps:
QVH BoD PUBLIC March 2019 Page 115 of 254
Workforce & Organisational Development
Workforce Report – February 2019
Reporting Period - January 2019
QVH BoD PUBLIC March 2019 Page 116 of 254 1.1 Current Month Picture
KPI Narrative ‘Staff in Post’ numbers increased by 3.29wte in month to finish at a position of 867.2wte. January saw 14.66wte new starters, including Vacancies 1.41wte qualified nurses across Theatres, Critical Care and Paediatrics. Vacancy levels decreased across the Trust by 0.33%, to an Section 2 overall vacancy percentage figure of 12.48%, which is ahead of the desired trajectory (13.08%) for the month . This was prompted by reduced vacancies in all areas with the exception of Perioperative Care, Director of Nursing office and Plastics. The monthly turnover position of 1.43% is a continuance of the normal range. The annualised rolling turnover position has reduced Turnover further by 0.5% to a new in-month position of 18.73%. This is still above the planned trajectory of 18.2%, but is a continuation of a reduced gap between trajectory and actual figures (Nov – 1.52% gap, Dec – 0.82% gap, this month 0.53% gap). Section 3 These reductions were prompted by decreases within Oral, Perioperative, Clinical Support, Clinical Infrastructure and Operational Nursing areas. There were a total of 11.09wte leavers in month, which included 1wte qualified nurse within Theatres. There was an increase in temporary staffing in month, up from December by 12.49wte to an in month position of 101.61wte. However December’s position was extremely low due to reduced activity over the Christmas and New Year period, and the total in Temporary month position is the lowest in a year if December’s irregularity is disregarded. Staffing Total agency usage increased marginally by 2.52wte in month. This was driven by an increase in need for Qualified Nursing (+2.22) Section 4 and AHPs/ST&Ts (+1.84wte), partically offset by reductions in other areas. Total bank usage increased by 9.97wte, driven by increases for Qualified Nursing (+4.57wte), HCAs (+1.88wte) and non-clinical workers (+3.22wte). Confirmed sickness levels show an in month absence rate of 2.97%, down from last month’s position of 3.16% and below Trust target levels. Analysis at a departmental level shows reductions in all areas with the exception of Corporate Services (to a new total of 1.9% Sickness and below Trust target), Plastics (new total of 3.69%, above Trust target) and Perioperative Services (totallying 4.7%, above Trust Section 5 target). Review of reasons for absence shows Coughs, Cold and Flu as the primary reason for absence (accounting for 57 episodes and 116 total days lost), but with gastrointestinal problems as having the most days lost (38 episodes and 187 days lost). Appraisal compliance figure decreased from 85.94% to 84.64%, although is still above planned trajectory. Sleep remains above Trust Appraisals target (at 100%), and increases were seen in Corporate Services (from 82.14% to 85.03%) and Perioperative Services (from 81.76% to Section 6 82.66%). Decreases were seen in all other business units, with continued deteroriation in Plastics (from 70.59% to 67.07%) and Oral Services now also flagged as red rated (72% to 69.33%). Mandatory and Statutory Training compliance figures continue to increase, up from 89.87% to 90.68%. Improvements were seen in MAST most areas, with the exception of Corporate Services, Sleep, Clinical Support Services and Plastics, with the later remaining red rated Section 6 (78.97%). Operational Nursing continues to meet the Trust green rated tolerance level for an in month position of 95.52%. All topic areas are above 80%, with Information Governance still lowest and declining to 81.44%, Safeguarding Adults (lvl 1) highest at 96.18%.
QVH BoD PUBLIC March 2019 Page 117 of 254 KPI Summary
Workforce KPIs (RAG Rating) Compared to Trust Workforce KPIs Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Previous 2018-19 Month
Establishment WTE 955.65 955.65 955.65 955.65 955.65 955.65 955.65 990.87 990.87 990.87 990.87 990.87 990.87 *Note 1 ◄►
Staff In Post WTE 841.32 838.58 845.26 831.41 827.24 829.77 835.19 848.43 845.94 860.66 868.62 863.91 867.20 ▲
Vacancies WTE 114.33 117.07 110.39 124.24 128.41 125.88 120.46 142.44 144.93 130.21 122.25 126.96 123.67 ▼
Vacancies % >12% 8%<>12% <8% 11.96% 12.25% 11.55% 13.00% 13.44% 13.17% 12.61% 14.38% 14.63% 13.14% 12.34% 12.81% 12.48% ▼
Agency WTE 33.76 38.28 42.51 45.58 50.61 42.85 46.85 46.11 45.33 47.07 44.12 37.43 39.95 ▲
Bank WTE 58.13 58.16 65.26 52.24 59.82 64.34 63.37 59.28 58.49 61.13 65.64 51.69 61.66 *Note 2 ▲
Trust rolling Annual Turnover % (Excluding Trainee Doctors) >=12% 10%<>12% <10% 18.87% 19.30% 19.57% 20.38% 20.43% 19.20% 18.17% 18.42% 19.88% 20.29% 19.52% 19.23% 18.73% ▼
Monthly Turnover 1.75% 1.47% 1.91% 2.24% 1.00% 0.68% 1.10% 1.58% 2.94% 1.56% 0.75% 1.48% 1.43% ▼
Stability % <70% 70%<>85% >=85% 98.68% 97.17% 98.78% 98.18% 99.18% 99.28% 98.66% 98.48% 97.80% 98.86% 99.56% 98.28% 98.87% ▲
Sickness Absence % >=4% 4%<>3% <3% 3.59% 3.73% 3.73% 2.74% 3.04% 3.52% 3.29% 3.23% 2.42% 3.02% 3.16% 2.97% TBC ▼
% staff appraisal compliant <80% 80%<>95% >=95% 81.22% 78.58% 81.89% 81.64% 82.20% 80.40% 79.55% 78.71% 76.89% 81.18% 83.76% 85.94% 84.64% (Permanent & Fixed Term staff) ▼
Statutory & Mandatory Training (Permanent & Fixed Term staff) <80% 80%<>95% >=95% 89.97% 90.72% 89.59% 90.12% 89.07% 89.56% 89.70% 88.54% 87.70% 87.75% 88.31% 89.79% 90.68% ▲ *Note 3
Friends & Family Test - 2017-18 Treatment Measure 2017-18 2018-19 2018-19 Qtr 1 & Qtr 1 Extremely likely Quarter 2: Quarterly staff survery to indicate Quarter 4: Quarter 1: Quarter 2: ▼Response / likely % : Of 212 likelihood of recommending QVH to Of 306 responses: Of 205 responses: Of 151 responses: s Extremely responses: friends & family to receive care or unlikely / 90% : 5.23% 89.27% : 0.49% 91.39% : 2.64% ▲ Likely 92% : 2.4% unlikely% treatment National Staff Survey 2017 : ▲Unlikely 55% 2017-18 2018-19 2018-19 Friends & Family Test - Work Measure Quarter 2: 2017-18 Quarter 1: Qtr 2 & Qtr 2 Extremely likely Quarter 2: Quarterly staff survery to indicate Of 212 Quarter 4: Of 205 responses: ▼Response / likely % : Of 151 responses: likelihood of recommending QVH to responses: Of 306 responses: 51.22% : 20.48%** s Extremely 61.59% : 24.50% friends & family as a place of work unlikely / 66% : 57.19% : 26.47% (**data inaccuracy up to 8% ▲ Likely unlikely% 19.8% due to survey error) ▲Unlikely
*Note 1 - 2018/19 Establishment updated in Aug 18. Establishment updated in August 2017 with nursing update in October 2017 *Note 2 - Bank WTE does not include extra hours worked by medical staff within establishment or overtime worked by all staff groups. *Note 3 - New RAG ratings for 2017/18 for Appraisals and for Statutory & Mandatory Training plus 2 new Board Reportable competences introduced - Fire Safety and Safeguarding Adults Level 2.
QVH BoD PUBLIC March 2019 Page 118 of 254 2. Vacancies and Recruitment Posts Compared to Recruits in VACANCY PERCENTAGES Nov-18 Dec-18 Jan-19 MEDICAL RECRUITMENT (WTE) advertised Previous Month Pipeline this month Corporate 11.52% 12.01% 10.38% ▼ Clinical Support 1.00 1.00 Eyes 0.24% 0.27% 0.24% ▼ of which are Deanery Trainees, Trust Registrars or Fellows 0.00 1.00 Sleep 23.19% 21.32% 20.67% ▼ of which are SAS doctors 0.00 0.00 Plastics -4.58% -1.45% 0.58% ▲ of which are Consultants (including locums) 1.00 0.00 Oral 4.77% 7.27% 6.54% ▼ Plastics 1.00 2.00 Periop 18.93% 19.66% 20.99% ▲ of which are Deanery Trainees, Trust Registrars or Fellows 1.00 2.00 Clinical Support 6.96% 7.22% 6.37% ▼ of which are SAS doctors 0.00 0.00 Clinical Infrastructure 14.93% 14.45% 7.30% ▼ of which are Consultants (including locums) 0.00 0.00 Director of Nursing 8.91% 4.71% 5.91% ▲ Eyes 0.00 2.00 Operational Nursing 20.80% 20.79% 20.70% ▼ of which are Deanery Trainees, Trust Registrars or Fellows 0.00 0.00 QVH Trust Total 12.34% 12.81% 12.48% ▼ of which are SAS doctors 0.00 2.00 of which are Consultants (including locums) 0.00 0.00 Posts advertised NON-MEDICAL RECRUITMENT(WTE) Recruits in Pipeline Sleep 1.00 0.00 this month Corporate 2.75 8.40 Oral 0.00 # 0.00 Eyes 0.00 0.00 of which are Deanery Trainees, Trust Registrars or Fellows 0.00 0.00 Sleep 4.41 0.00 of which are SAS doctors 0.00 0.00 Plastics 0.00 1.00 of which are Consultants (including locums) 0.00 0.00 Oral 0.00 0.53 Periop 1.00 2.00 Periop 33.00 8.00 of which are Deanery Trainees, Trust Registrars or Fellows 0.00 1.00 Clinical Support 2.00 2.80 of which are SAS doctors 1.00 0.00 Clinical Infrastructure 1.00 1.00 of which are Consultants (including locums) 0.00 1.00 Director of Nursing 0.19 0.00 QVH Trust Total 4.00 7.00 Operational Nursing 11.10 2.80 of which are Deanery Trainees, Trust Registrars or Fellows 1.00 4.00 QVH Trust Total 54.45 24.53 of which are SAS doctors 1.00 2.00 of which Qual Nurses / Theatre Practs (external) 11.53 9.80 of which are Consultants (including locums) 1.00 1.00 of which HCA’s & Student/Asst Practs (external) 3.00 0.00
Trust Vacant WT9s for years 2016-17, 2017-18 and 2018-19 200
150 W T 100 9 50
0 Apr aay Wun Wul Aug Sep hct bov 5ec Wan Ceb aar Vacancy WT9 2016-17 Vacancy WT9 2017-18 Vacancy WT9 2018-19
Expected to start in the Expected to start within 2- Expected to start within 4- Started International Recruitment Offered and Accepted (WTE) next month 3 months 6 months Critical Care 16 0 4 0 Other Nurse 13 0 2 0 Theatres / Recovery 29 0 3 10 1 Total 58 0 3 16 1
*Please note 50% of offered are expected to be unsuccessful during the international recruitment process or withdraw.
QVH BoD PUBLIC March 2019 Page 119 of 254
3. Turnover, New Hires and Leavers Compared to Compared to ANNUAL TURNOVER ROLLING 12 MTHS excl. Trainee Doctors Nov-18 Dec-18 Jan-19 MONTHLY TURNOVER excl. Trainee Doctors Nov-18 Dec-18 Jan-19 Previous Previous Month Month Corporate % 19.65% 17.43% 17.59% ▲ Corporate % 0.65% 1.20% 1.12% ▼ Eye s % 25.95% 26.58% 29.63% ▲ Eye s % 0.00% 0.00% 6.09% ▲ Sleep % 23.79% 23.79% 23.98% ▲ Sleep % 0.00% 0.00% 3.41% ▲ Plastics % 13.07% 15.18% 19.13% ▲ Plastics % 0.00% 2.13% 4.00% ▲ Oral % 29.10% 25.50% 21.26% ▼ Oral % 0.00% 2.19% 0.00% ▼ Peri Op % 18.91% 16.15% 15.60% ▼ Peri Op % 2.04% 0.34% 1.41% ▲ Clinical Support % 15.38% 15.32% 15.12% ▼ Clinical Support % 0.81% 1.30% 1.46% ▲ Clinical Infrastructure % 28.39% 28.03% 24.46% ▼ Clinical Infrastructure % 1.13% 0.00% 0.00% ◄► Director of Nursing % 7.41% 10.89% 12.54% ▲ Director of Nursing % 0.00% 3.27% 3.32% ▲ Operational Nursing % 21.36% 22.45% 21.92% ▼ Operational Nursing % 0.36% 3.25% 0.00% ▼ QVH Trust Total % 19.52% 19.23% 18.73% ▼ QVH Trust Total % 0.75% 1.48% 1.43% ▼
Trust Annual Turnover (Rolling 12 Months) Trust Monthly Turnover Percentage Rate 2016-17, Percentage Rate 2016-17, 2017-18 and 2018-19 2017-18 and 2018-19 (percentage rates in RAG colours) 3.00% 25.00% 2.50% 20.00% 15.00% 2.00% 10.00% 1.50% 5.00% 1.00%
0.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 0.50%
0.00% Rolling 12 Mth Turnover % Rate 2016-17 Rolling 12 Mth Turnover % Rate 2017-18 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Rolling 12 Mth Turnover % Rate 2018-19 Green RAG Rating Upper Threshold Amber RAG Rating Upper Threshold Monthly Turnover % Rate 2016-17 Monthly Turnover % Rate 2017-18 Monthly Turnover % Rate 2018-19
Trust Monthly New Hires and Leavers in 2017-18 and 2018-19 (excluding Trainee Rotational medical staff)
25.00
20.00
W 15.00 T E 10.00
5.00
0.00 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Mar Starters 2017-18 Leavers 2017-18 Starters 2018-2019 Leavers 2018-2019
QVH BoD PUBLIC March 2019 Page 120 of 254 4. Temporary Workforce Agency Bank Compared Compared to BUSINESS UNIT (WTE) Nov-18 Dec-18 Jan-19 to Previous BUSINESS UNIT (WTE) Nov-18 Dec-18 Jan-19 Previous Month Month Corporate 5.02 7.87 8.08 ▲ Corporate 7.32 7.48 8.73 ▲ Eyes 0.00 0.00 0.00 ◄► Eyes 2.03 1.11 1.33 ▲ Sleep 0.79 0.12 0.47 ▲ Sleep 3.67 2.51 2.49 ▼ Plastics 0.00 2.74 1.93 ▼ Plastics 3.93 2.77 3.33 ▲ Oral 0.00 0.00 0.00 ◄► Oral 1.83 1.34 1.62 ▲ Periop 18.36 16.14 18.90 ▲ Periop 14.09 11.27 16.17 ▲ Clinical Support 3.28 1.88 3.38 ▲ Clinical Support 7.26 5.27 6.27 ▲ Clinical Infrastructure 0.00 0.00 0.00 ◄► Clinical Infrastructure 6.86 4.62 4.73 ▲ Director of Nursing 0.00 0.00 0.00 ◄► Director of Nursing 1.59 0.81 0.54 ▼ Operational Nursing 16.68 8.68 7.19 ▼ Operational Nursing 17.07 14.51 16.46 ▲ QVH Trust Total 44.12 37.43 39.95 ▲ QVH Trust Total 65.64 51.69 61.66 ▲
Agency Bank Compared Compared to STAFF GROUP (WTE) Nov-18 Dec-18 Jan-19 to Previous STAFF GROUP (WTE) Nov-18 Dec-18 Jan-19 Previous Month Month Qualified Nursing 32.92 23.88 26.10 ▲ Qualified Nursing 23.92 19.02 23.59 ▲ HCAs 2.40 0.94 0.00 ▼ HCAs 7.29 5.92 7.80 ▲ Medical and Dental 0.00 2.17 1.05 ▼ Medical and Dental 0.31 0.12 0.14 ▲ Other AHP's & ST&T 3.78 2.00 3.84 ▲ Other AHP's & ST&T 2.04 2.05 2.33 ▲ Non-Clinical 5.02 8.44 8.96 ▲ Non-Clinical 32.09 24.58 27.80 ▲ QVH Trust Total 44.12 37.43 39.95 ▲ QVH Trust Total 65.64 51.69 61.66 ▲
Trust Agency Usage in WT9s for years 2016-17, 2017-18 and Trust .ank Usage in WT9s for years 2016-17, 2017-18 and 2018-2019 2018-19 60 50 70 60 40 50 30 40 20 30 20 10 10 0 0 Apr aay Wun Wul Aug Sep hct Nov 5ec Wan Ceb aar Apr aay Wun Wul Aug Sep hct Nov 5ec Wan Ceb aar .ank WT9 2016-17 .ank WT9 2017-18 .ank WT9 2018-19 Agency WT9 2016-17 Agency WT9 2017-18 Agency WT9 2018-19
QVH BoD PUBLIC March 2019 Page 121 of 254 5. Sickness Absence
Compared to Oct-18 Nov-18 Dec-18 SHORT TERM SICKNESS Previous Month Short Term Sickness Absence Reasons Corporate 1.88% 1.32% 1.27% ▼ Number of Occurrences 200 Clinical Support 0.93% 1.55% 1.03% ▼ O c 180 Plastics 1.27% 1.03% 1.01% ▼ c 160 u Eye s 0.90% 0.68% 1.85% ▲ 140 r 120 r Sleep 0.81% 0.14% 0.13% ▼ 100 e Oral 0.18% 0.18% 0.63% ▲ n 80 Periop 2.79% 1.86% 2.32% ▲ c 60 e 40 Clinical Infrastructure 0.65% 0.71% 2.04% ▲ s 20 Director of Nursing 0.27% 0.97% 0.23% ▼ 0 Operational Nursing 1.65% 2.16% 1.82% ▼ ct-17 ct-18 ar-18 ec-17 ec-18 ov-17 ov-18 an-18 un-17 un-18 J ul-17 J ul-18 J J J O O Apr-17 Apr-18 Sep-17 F eb-18 Sep-18 D D Aug-17 Aug-18 N N M M ay-17 M ay-18 QVH Trust Total 1.50% 1.37% 1.43% ▲ Cold, Cough, Flu - Influenza Gastrointestinal problems Headache / migraine Chest and Respiratory Back Problems All Other Reasons Compared to Oct-18 Nov-18 Dec-18 LONG TERM SICKNESS Previous Month Corporate 0.00% 0.06% 0.63% ▲ Long Term Sickness Absence Reasons Clinical Support 1.16% 1.28% 1.69% ▲ Number of Occurrences ▲ 40 Plastics 0.00% 0.76% 2.68% O Eye s 2.76% 3.72% 0.00% ▼ c 35 c 30 Sleep 1.30% 4.15% 3.96% ▼ u Oral 0.00% 1.22% 0.47% ▼ r 25 r 20 Periop 2.94% 2.34% 2.38% ▲ e n 15 Clinical Infrastructure 5.51% 4.24% 1.90% ▼ c 10 Director of Nursing 0.00% 0.00% 0.00% ◄► e s 5 Operational Nursing 2.67% 3.36% 1.49% ▼ 0 QVH Trust Total 1.52% 1.79% 1.54% ▼ ct-17 ct-18 ar-18 ec-18 ec-17 ov-17 ov-18 an-18 un-18 un-17 J ul-17 J ul-18 J J J O O Apr-17 Apr-18 Sep-17 F eb-18 Sep-18 D D Aug-17 Aug-18 N N M
Compared to M ay-17 M ay-18 Oct-18 Nov-18 Dec-18 Anxiety/stress/depression/other psychiatric illnesses Other musculoskeletal problems ALL SICKNESS (with RAG) Previous Month Back Problems Benign and malignant tumours, cancers QVH Trust Total 3.02% 3.16% 2.97% ▼ Injury, fracture All Other Reasons
Trust Sickness AbsenceRates 2015-2019 by month Trust Sickness Absence Rates 2016/17, 2017/18 & 2018/19 by Long term & Short term sickness 4.25% 4.00%
3.50% 3.75% 3.00%
3.25% 2.50%
2.00% 2.75% 1.50%
2.25% 1.00%
0.50% 1.75% April May June July Aug Sept Oct Nov Dec Jan Feb Mar 0.00% 2015/16 3.25% 2.36% 2.32% 2.70% 3.23% 3.10% 3.24% 3.91% 3.70% 3.17% 3.72% 3.58% 2016/17 3.19% 2.14% 2.61% 2.57% 2.47% 2.00% 2.69% 2.69% 2.90% 3.20% 3.01% 2.43% 2017/18 2.06% 2.75% 2.04% 2.06% 2.61% 3.15% 3.59% 3.46% 2.66% 3.59% 3.73% 3.73% 2018/2019 2.74% 3.04% 3.53% 3.29% 3.23% 2.42% 3.02% 3.16% 2.97% 2016-17 Short Term Sickness 2016-17 Long Term Sickness 2017-18 Short Term Sickness 2017-18 Long Term Sickness 2018-19 Short Term Sickness 2018-19 Long Term Sickness
QVH BoD PUBLIC March 2019 Page 122 of 254
6. Training, Education and Development
Compared to APPRAISALS Nov-18 Dec-18 Jan-19 Previous Trust Appraisal Compliance % for years Month 2016-17, 2017-18 and 2018-19 Corporate 81.44% 82.14% 85.03% ▲ 100% Eyes 77.78% 85.71% 82.86% ▼ 95% 90% ◄► Sleep 100.00% 100.00% 100.00% 85% Plastics 73.26% 70.59% 67.07% ▼ 80% 75% 70.13% 72.00% 69.33% ▼ Oral 70% Peri Op 80.84% 81.76% 82.66% ▲ 65% Clinical Support 89.24% 93.51% 90.32% ▼ 60% 55% Performance and Access 85.37% 86.05% 81.40% ▼ 50% Director of Nursing 94.29% 97.30% 91.89% ▼ Apr aay Jun Jul Aug Sep hct Nov 5ec Jan Ceb aar Operational Nursing 91.28% 95.91% 93.06% ▼ Trust Appraisal Compliance % 2016-17 Trust Appraisal Compliance % 2017-18 Trust Appraisal Compliance % 2018-19 QVH Trust Total 83.76% 85.94% 84.64% ▼
Compared to MANDATORY AND STATUTORY TRAINING Nov-18 Dec-18 Jan-19 Previous Month Trust Statutory & aandatory Training Compliance % Corporate 93.53% 93.86% 92.66% ▼ for years 2016-17, 2017-18, and 2018-19 100% Eyes 88.60% 91.20% 94.32% ▲ 95% Sleep 90.20% 92.16% 91.11% ▼ 90% Plastics 79.04% 79.22% 78.97% ▼ 85% 80% Oral 84.56% 86.09% 87.99% ▲ 75% Peri Op 81.98% 82.81% 85.64% ▲ 70% 65% 91.81% 94.91% 94.35% ▼ Clinical Support 60% Performance and Access 89.71% 91.94% 94.96% ▲ 55% 50% Director of Nursing 90.81% 92.86% 94.32% ▲ Apr aay Jun Jul Aug Sep hct Nov 5ec Jan Ceb aar Operational Nursing 93.09% 95.00% 95.52% ▲ Trust Stat & aand Compliance % 2016-17 Trust Stat & aand Compliance % 2017-18 QVH Trust Total 88.31% 89.87% 90.68% ▲ Trust Stat & aand Compliance % 2018-19
QVH BoD PUBLIC March 2019 Page 123 of 254 7. Medical and Dental Workforce
Medical Workforce
• Local Clinical Excellence Awards: The Awards round is now open and application forms and guidance have been sent to all Consultants • Trac/ Induction: February’s Induction went smoothly with all doctors, including HEE trainees, were cleared using the Trac Recruitment System • Locum Agencies: one agency locum consultant in Plastic Surgery this month • Permanent Recruitment: We are currently recruiting for a Consultant in Sleep Medicine and a Consultant in Histopathology • Fixed Term Recruitment: Two Locum Consultant in Anaesthesia were appointed to start in February • Job Planning: Round Two of job planning is continuing. • Medical appraisal rates for January 19: Org L4 Assignment Count Required Achieved Compliance % 276 Clinical Support (Div) 10 10 8 80.00% 276 Eye (Div) 11 11 11 100.00% 276 Oral (Div) 43 43 36 83.72% 276 Perioperative Care (Div) 32 32 27 84.38% 276 Plastics (Div) 57 57 47 82.46% 276 Sleep (Div) 3 3 3 100.00%
Medical Education
Monthly update • Work continued to implement the action plan from the School of Surgery visit to the Plastic Surgery department. • The new facilities in the Education Centre are now open for junior doctors and other staff working at night and at weekends and have been well received. • The next round of local faculty group meetings for educational governance are underway.
Upcoming developments • Preparations are underway for the February rotation, when new anaesthetics and core surgical trainees will be joining the Trust. • The ever-popular Trauma and burns course will be running in March.
Statutory and mandatory training compliance • Work continues to improve compliance rates. Permanent/fixed term medical and dental employees are currently showing 84% compliant, which is around the same as the previous month. Medical and dental bank workers are showing as 63% compliant, which is a big improvement on the previous month.
QVH BoD PUBLIC March 2019 Page 124 of 254 8. Trajectories
Mar-18 Apr -18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Staff Turnover % trajectory 19.51% 19.62% 18.91% 18.46% 18.67% 18.24% 18.32% 18.18% 18.00% 18.41% 18.20% 17.84% 17.87% Actual Rolling Turnover % 19.57% 20.38% 20.43% 19.20% 18.17% 18.42% 19.88% 20.29% 19.52% 19.23% 18.73% 0.00% 0.00% Total Sickness % trajectory 2.99% 2.83% 2.42% 2.32% 2.44% 2.77% 2.75% 3.17% 3.35% 3.09% 3.11% 3.19% 3.05% Actual In Month Sickness % 3.73% 2.74% 3.04% 3.53% 3.29% 3.23% 2.42% 3.02% 3.16% 2.97% 0.00% 0.00% 0.00% Vacancy Rate % trajectory 12.73% 13.17% 12.67% 12.46% 12.39% 12.23% 12.23% 12.68% 12.34% 12.97% 13.08% 12.88% 12.54% Actual In Month Vacancy Rate % 11.55% 13.00% 13.44% 13.17% 12.53% 15.15% 15.40% 13.14% 12.34% 12.81% 12.48% 0.00% 0.00% Non-Medical Appraisal Rate % trajectory 81.16% 80.33% 82.37% 81.18% 81.99% 81.99% 78.22% 75.39% 79.50% 80.70% 80.39% 78.54% 80.77% Actual In Month Non-Medical Appraisal % 81.81% 80.96% 80.96% 88.08% 79.55% 78.71% 76.89% 81.18% 83.76% 85.94% 84.64% 0.00% 0.00% Medical Appraisal Rate % trajectory 72.68% 74.29% 76.33% 79.86% 82.39% 80.63% 81.74% 85.28% 87.69% 86.52% 89.56% 92.37% 95.61% Actual In Month Medical Appraisal % 82.35% 85.42% 91.28% 78.93% 81.75% 80.52% 76.16% 83.54% 82.17% 88.13% 84.62% Mandatory Training % trajectory 90.23% 89.76% 88.81% 89.24% 88.49% 88.52% 89.83% 89.32% 88.73% 88.34% 89.08% 91.09% 90.86% Actual In Month Mandatory Training % 89.59% 90.12% 89.07% 89.56% 89.70% 88.54% 87.70% 87.75% 88.31% 89.79% 90.68% 0.00% 0.00% 21.00% 4.00% 16.00% Turnover plan vs. in month Sickness plan vs. in month Vacancy plan vs. in month 20.00% 3.50% 15.00% 19.00% 3.00% 14.00% 18.00% 2.50% 13.00% 17.00% 12.00% 2.00% 16.00% 11.00% 1.50% 15.00% 10.00% 1.00% 14.00% 9.00% 13.00% 0.50% 8.00% 12.00% 0.00% 7.00%
Actual Rolling Turnover % Staff Turnover % trajectory Actual In Month Sickness % Total Sickness % trajectory Actual In Month Vacancy Rate % Vacancy Rate % trajectory
100.00% 100.00% 95.00% Medical appraisal plan vs. in month Non-Medical appraisal plan vs. in month Mandatory training plan vs. in month 95.00% 95.00% 90.00% 90.00% 90.00% 85.00% 85.00% 85.00% 80.00% 80.00% 80.00% 75.00% 75.00% 75.00% 70.00% 70.00% 70.00% 65.00% 65.00% 65.00%
Actual In Month Medical Appraisal % Actual In Month Non-Medical Appraisal % Actual In Month Mandatory Training % Medical Appraisal Rate % trajectory Non-Medical Appraisal Rate % trajectory Mandatory Training % trajectory
QVH BoD PUBLIC March 2019 Page 125 of 254
9. Organisational Development
• The QVH People and OD Strategy has been approved and has now been published on Qnet and promoted on Connect • Currently developing the Leading the Way programme and sessions for 2019/20 • Staff Survey results 2018 have been released and are covered in a separate report to Board. • Corporate Induction has been redesigned to include Information Governance and Equality & Diversity Training from Feb 2019. • System wide OD work continues and will be of benefit to QVH
QVH BoD PUBLIC March 2019 Page 126 of 254 Appendix One
1. Pay progression
The new pay progression system will come into effect on 1 April 2019 for new starters or those promoted to a new role on or after 1 April 2019. Promotion means moving to a higher banded role. For all other staff in post before 1 April 2019, current organisational pay progression procedures will continue to apply until 31 March 2021, after which time they will also be subject to the new provisions.
(Pay progression is detailed in Annex 23 of the NHS Terms and Condition of Service Handbook, available on the NHS Employers website.)
1.1 Linked to the annual appraisal process
The new pay progression framework is underpinned by the mandatory annual appraisal process and is intended to ensure that all staff within each pay band have the appropriate knowledge and skills they need to carry out their roles, enabling them to make the greatest possible contribution to patient care.
The Workforce and OD teams are currently developing a new and clear policy and procedure on appraisals and pay progression covering line management responsibilities, appraisal timeframes, pay-step review and documentation. Workshops will be delivered to managers/ leaders at QVH entitled ‘Developing our people: one conversation at a time’ to include local induction, probation, appraisals, reviews and stay/leavers.
The local appraisal and pay progression policy will be at the heart of the new system, supported by effective use of the Electronic Staff Record (ESR).
1.2 Transitional arrangements for pay progression up to end March 2021
Staff in post before 1 April 2019 will retain their existing pay step date (previously referred to as incremental date) throughout transition. They will move automatically through their pay journey during this period.
1.3 Pay step points
Under the new pay progression arrangements, pay step points will be closed on the payroll system. This will apply for new starters or those promoted to a new role on or after 1 April 2019, and for all staff from 1 April 2021.
The outcomes of the pay step submission process will be recorded via a new pay progression meeting review. Central inputting into ESR by the Workforce Services team will continue. At the point of the pay step review, the outcome will be recorded and pay progression will be activated or deferred. If a manager has confirmed that an individual is not able to progress (deferred) at this stage, they should record the reason.
ESR will generate notifications to managers and employees to advise when a pay step date is imminent; only in a year where a pay step is due.
QVH BoD PUBLIC March 2019 Page 127 of 254 1.4 My ESR dashboard
To give employees more information about their pay progression, a new portlet will be available on the My ESR dashboard covering the pay step date, when a pay step is due, last appraisal date, next appraisal date, and appraisal or review type.
1.5 Monitoring arrangements
Data on pay step and re-earnable pay outcomes must be collected, audited, published and monitored in partnership with staff side trade unions, including by protected characteristics and contract status. NHSI will use collected data from ESR to support national monitoring of pay progression.
Employers should put in place systems to monitor how well processes around appraisal and pay progression are working in practice, and this will be by the Workforce Services team.
2.Transfer of Band 1 staff to Band 2
The framework agreement introduced the closing of Band 1 to new entrants from 1 December 2018. The NHS Staff Council will agree to support and encourage organisations to upskill roles currently in Band 1 to Band 2 to be completed by 31 March 2021. In terms of pay, the common effective date agreed by the Council will be 1 April 2019 and the pay step (incremental) date will be reset/ backdated to 1 April 2019.
Staff will be given all available information about the impact of transferring to Band 2 or remaining in Band 1 in order to inform the choice exercise and will be given one month (or longer if agreed locally) to decide whether to accept the move or not.
All staff who were in employment before 1 April 2019 will remain subject to existing local pay progression processes until 1 April 2021; as detailed in the Pay progression summary.
At QVH there are 36 (head count) Band 1s – 2 of whom are in Health Records, the remainder are Catering/Facilities.
2.1 Non-consolidated lump sum payment to Band 1 staff
The value of the one-off non-consolidated payment to those in Band 1 will be £194, to be paid in April 2019 payroll.
QVH BoD PUBLIC March 2019 Page 128 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 52-19 Report title: Overview of Staff Survey Results 2018 Sponsor: Geraldine Opreshko, Director of Workforce and OD Author: Annette Byers, Head of Organisational Development and Learning Appendices: Staff Survey Report 2018
Executive summary Purpose of report: The 2018 NHS Staff Survey Results were released publically on 26 February 2019. The attached report provides the Board with an overview of the high level results for QVH. The presentation of the survey has changed this year and is based around 10 key themes as shown in the attached paper. Summary of key QVH has shown small improvements in 9 of the 10 key themes and an improvement issues in our staff engagement scores Recommendation: The committee is asked to discuss the report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework: The challenges are reflected in KSO 5 Organisational Excellence
Corporate risk register:
Regulation:
Legal:
Resources:
Assurance route Previously considered by: Date: Decision: For information Previously considered by: Date: Decision: For information Next steps:
QVH BoD PUBLIC March 2019 Page 129 of 254 Staff Survey 2018 – initial findings
1. Introduction 1.1 In 2017, the Staff Survey Coordination Centre undertook a review of the reporting outputs for the National NHS Staff Survey to establish what worked well and what needed improvement. The findings of the review were addressed by implementing a reduced number of new summary indicators, question-level benchmarking and five- year trend data into the 2018 Staff Survey. A RAG rating has been used throughout the report to indicate areas of improvement and development.
1.2 Response rate to the 2018 NHS Staff Survey This year Queen Victoria Hospital NHS Foundation Trust (QVH) surveyed 958 eligible staff. Of these, 501 responded making a 52% return, a small decrease from 55% the year before. The 2018 benchmarking group for acute specialist trusts has 16 organisations and showed a 53% return rate overall.
1.3 The QVH People & OD strategy 2019 sets out the Trusts vision, ambitions and plans for the development of QVH, through our workforce, and is based around five key workforce and OD goals which link with many of the new themes in the staff survey:
People and OD Goals Staff Survey Themes Engagement and Communication Staff Engagement Attraction and Retention Morale Health and Well-being Health & Well-being and Safe Environment (Bullying & Harassment and Violence) Learning and Education Quality of Appraisals Talent and Leadership Immediate Managers
2. Headline Results 2.1 Of the ten themes agreed for the 2018 NHS Staff Survey, QVH’s results show an improvement in 9 out of 10 themes when compared to 2017.
QVH BoD PUBLIC March 2019 Page 130 of 254 3. Key comparisons 3.1 The ten staff survey themes provide a balanced overview of organisational performance on staff experience. All themes are scored on a 0-10pt scale, and reported as mean scores. A higher score indicates a more favourable result.
3.2 When compared with our comparator group of Specialist Acute Trusts, our scores are average overall. QVH ranks average on 5 and very slightly below average on 5 of the 10 key themes.
3.3 When compared with all the comparator group scores below, QVH can easily identify key themes. QVH best themes are Equality, Diversity & Inclusion, Immediate Managers, Quality of Appraisals and Safe Environment – violence. QVH worst themes are Safe Environment – bullying & harassment and Safety Culture.
4. Key themes in detail 4.1 Theme 1: Equality, Diversity & Inclusion
Related questions: Q14, Q15a, Q15b and Q28b Change from 2017: 0.1% increase Rating compared to benchmarking group: Average
QVH BoD PUBLIC March 2019 Page 131 of 254 4.2 Theme 2: Health & Well-Being
Related questions: Q5h, Q11a, Q11b, Q11c and Q11d Change from 2017: 0.2% increase Rating compared to benchmarking group: 0.1% below average
4.3 Theme 3: Immediate Managers
Related questions: Q5b, Q8c, Q8d, Q8f, Q8g and Q19g Change from 2017: 0.1% increase Rating compared to benchmarking group: Average
4.4 Theme 4: Morale (New)
Related questions: Q4c, Q4j, Q6a, Q6b, Q6c, Q8a, Q23a, Q23b and Q23c Rating compared to benchmarking group: 0.1% below average
4.5 Theme 5: Quality of Appraisals
Related questions: Q19b, Q19c, Q19d and Q19e Change from 2017: 0.4% increase Rating compared to benchmarking group: Average
4.6 Theme 6: Quality of Care
Related questions: Q7a, Q7b and Q7c Change from 2017: 0.2% increase Rating compared to benchmarking group: 0.1% below average
QVH BoD PUBLIC March 2019 Page 132 of 254 4.7 Theme 7: Safe Environment – Bullying & Harassment
Related questions: Q13a, Q13b and Q13c Change from 2017: 0.1% decrease Rating compared to benchmarking group: Average
4.8 Theme 8: Safe Environment – violence
Related questions: Q12a, Q12b and Q12c Change from 2017: 0.1% increase Rating compared to benchmarking group: Average
4.9 Theme 9: Safety Culture
Related questions: Q17a, Q17c, Q17d, Q18b, Q18c and Q21b Change from 2017: 0.2% increase Rating compared to benchmarking group: 0.1% below average
4.10 Theme 10: Staff Engagement
Related questions: Q2a, Q2b, Q2c, Q4a, Q4b, Q4d, Q21a, Q21c and Q21d Change from 2017: 0.2% increase Rating compared to benchmarking group: 0.1% below average
5. Staff engagement 5.1 In line with the national picture, QVH has in previous years struggled with staff engagement scores. This year QVH has seen an improvement particularly in relation to recommending the organisation as a place to work (57.7% vs. 63.0% in 2018).
QVH BoD PUBLIC March 2019 Page 133 of 254 6. 2018 Staff Survey Improvement Themes
Theme 1: Equality, Diversity & Inclusion; Theme 2: Health & Well-Being; Theme 3: Immediate Managers; Theme 4: Morale (New); Theme 5: Quality of Appraisals; Theme 6: Quality of Care; Theme 7: Safe Environment – Bullying & Harassment; Theme 8: Safe Environment – violence; Theme 9: Safety Culture; Theme 10: Staff Engagement
6.1 Questions/areas of improvement – A more in depth analysis of the 2018 Staff Survey question data highlights specific questions/areas where QVH has improved. The coloured themes below, numbered 5, 9 and 10 (Quality of Appraisals, Safety Culture and Staff Engagement) show areas of vast improvement: (note in some areas a lower score is better).
No. Question 2017 2018 Q14 Does your organisation act fairly with regard to career progression / 87.1% 89.0% promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age? Q15a In the last 12 months have you personally experienced discrimination at 7.5% 5.3% work from manager / team leader or other colleagues? Q28b Has your employer made adequate adjustment(s) to enable you to carry 70.1% 78.7% out your work? Q5h The opportunities for flexible working patterns 47.3% 52.8% Q11b In the last 12 months have you experienced musculoskeletal problems 30.4% 30.2% (MSK) as a result of work activities? Q11c During the last 12months have you felt unwell as a result of work related 34.9% 33.9% stress? Q11d In the last three months have you ever come to work despite not feeling 55.9% 50.0% well enough to perform your duties? Q5b The support I get from my immediate manager 69.7% 72.9% Q8f My immediate manager takes a positive interest in my health and well- 69.3% 71.9% being Q8g My immediate manager values my work 72.5% 74.5% Q4c I am involved in deciding on changes introduced that affect my work area 54.3% 57.4% / team / department Q19b It helped me to improve how I do my job 19.1% 24.9% Q19c It helped me agree clear objectives for my work 35.8% 38.2% Q19d It left me feeling that my work is valued by my organisation 31.3% 38.9% Q19e The values of my organisation were discussed as part of the appraisal 34.5% 38.3% process Q19f Were any training, learning or development needs identified? 64.9% 67.7% Q7a I am satisfied with the quality of care I give to patients / service users 82.6% 88.5% Q7c I am able to deliver the care I aspire to 68.6% 71.2% Q12a In the last 12 months how many times have you personally experienced 9.2% 6.6% physical violence at work from patients / service users, their relatives or other members of the public? Q17a My organisation treats staff who are involved in an error, near miss or 55.8% 61.5% incident fairly Q17c When errors, near misses or incidents are reported, my organisation 65.7% 69.1% takes action to ensure that they do not happen again * Q17d We are given feedback about changes made in response to reported 52.9% 57.1% errors, near misses and incidents * Q18b I would feel secure raising concerns about unsafe clinical practice 69.1% 72.6% Q18c I am confident that my organisation would address my concern 56.1% 61.5% Q21b My organisation acts on concerns raised by patients / service users 75.2% 76.7%
QVH BoD PUBLIC March 2019 Page 134 of 254 Q2a I look forward to going to work 57.1% 61.0% Q2c Time passes quickly when I am working 76.4% 77.7% Q4a There are frequent opportunities for me to show initiative in my role 69.5% 75.9% Q4b I am able to make suggestions to improve the work of my team / dept. 73.8% 78.2% Q21a Care of patients / service users is my organisation's top priority 81.0% 85.2% Q21c I would recommend my organisation as a place to work 57.7% 63.0% Q21d If a friend or relative needed treatment I would be happy with the 87.2% 90.8% standard of care provided by this organisation
6.2 Questions/areas for development Further analysis of the question data identifies specific questions/areas where QVH needs to focus its actions for improvement. The coloured themes below, numbered 7 (Safe Environment – Bullying & Harassment) show areas for targeted improvement:
No. Question 2017 2018 Q11a Does your organisation take positive action on health and well-being? 38.6% 38.3% Q8c My immediate manager gives me clear feedback on my work 65.3% 62.6% Q19g My manager supported me to receive this training, learning or 59.1% 55.3% development Q13a In the last 12 months how many times have you personally experienced 24.7% 25.6% harassment, bullying or abuse at work from patients / service users, their relatives or other members of the public? Q13b In the last 12 months how many times have you personally experienced 11.1% 11.9% harassment, bullying or abuse at work from managers? Q13c In the last 12 months how many times have you personally experienced 16.2% 17.5% harassment, bullying or abuse at work from other colleagues? Q12b In the last 12 months how many times have you personally experienced 0.2% 0.5% physical violence at work from managers? Q4d I am able to make improvements happen in my area of work 58.1% 57.8%
6.3 Questions/areas of improvements requires ongoing attention QVH has made some significant improvements in line with the key themes in the 2018 staff survey results when compared with our benchmarking group results. However, there are some specific questions/areas where QVH still requires improvement. (Note in some areas a lower score is better).
No. Question 2017 2018 Q15a In the last 12 months have you personally experienced discrimination at 7.5% 5.3% work from manager / team leader or other colleagues? Q11b In the last 12 months have you experienced musculoskeletal problems 30.4% 30.2% (MSK) as a result of work activities? Q11c During the last 12 months have you felt unwell as a result of work 34.9% 33.9% related stress? Q11d In the last three months have you ever come to work despite not feeling 55.9% 50.0% well enough to perform your duties? Q19d It left me feeling that my work is valued by my organisation 31.3% 38.9% Q7c I am able to deliver the care I aspire to 68.6% 71.2% Q12a In the last 12 months how many times have you personally experienced 9.2% 6.6% physical violence at work from patients / service users, their relatives or other members of the public? Q17a My organisation treats staff who are involved in an error, near miss or 55.8% 61.5%
QVH BoD PUBLIC March 2019 Page 135 of 254 incident fairly Q17c When errors, near misses or incidents are reported, my organisation 65.7% 69.1% takes action to ensure that they do not happen again * Q17d We are given feedback about changes made in response to reported 52.9% 57.1% errors, near misses and incidents * Q21c I would recommend my organisation as a place to work 57.7% 63.0%
7. Themes summary
7.1 Based on the above findings, overall the Trust has managed to maintain largely positive survey results in comparison to the national picture in a challenging environment. There are a number of areas that remain a focus for improvement in order to continue to enhance staff experience.
7.2 QVH will continue to triangulate Key Findings from the NHS staff survey report with the Picker report, Best Place to Work initiative, People & OD Strategy, Staff Friends and Family Test (SFFT) and the stay/exit interviews to ensure we effectively listen and respond to the needs of staff. In particular, we need to look at:
• Staff Engagement – Recommendation as a place to work (People & OD Strategy Goal 1) • Safe Environment – Bullying & Harassment (People & OD Strategy Goal 2) • Health & Well-being (People & OD Strategy Goal 2) • Safety Culture
8. Summary Ongoing Actions:
8.1 Bringing together the key areas throughout the report, the goals outlined in the People and OD Strategy and a full analysis of the data will enable QVH to identify specific interventions to support the areas for development. This will be undertaken in collaboration with key stakeholders including business units, communications, and colleagues in workforce and Organisational Development & Learning. In the meantime we will continue with a range of ongoing QVH interventions already underway or about to commence, including:
• Continuing Leading the Way initiatives throughout 2019/20 • Continuing the delivery of all aspects of the Attraction and Retention Plan, including most recently the overseas nursing campaign • Working with business units in relation to specific team interventions and staff survey themes • Ongoing promotion of a range of wellbeing events • Promotion of Trust benefits • Improving the mover/leavers survey to get qualitative and quantitative data to inform future attraction and retention interventions • Developing a workshop on the importance of meaningful conversations to include local inductions, probation meetings, appraisals (including Agenda for Change reforms) and stay/leave conversations • Launching the Best Place to Work initiative in March/April 2019 to gain insight into staff views on working for QVH • Ongoing promotion of education, learning and development
QVH BoD PUBLIC March 2019 Page 136 of 254 Appendix 1: All scores
No. Question 2017 2018 Q14 Does your organisation act fairly with regard to career progression / 87.1% 89.0% promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age? Q15a In the last 12 months have you personally experienced discrimination at 4.5% 4.4% work from patients / service users, their relatives or other members of the public? Q15a In the last 12 months have you personally experienced discrimination at 7.5% 5.3% work from manager / team leader or other colleagues? Q28b Has your employer made adequate adjustment(s) to enable you to carry 70.1% 78.7% out your work? Q5h The opportunities for flexible working patterns 47.3% 52.8% Q11a Does your organisation take positive action on health and well-being? 38.6% 38.3% Q11b In the last 12 months have you experienced musculoskeletal problems 30.4% 30.2% (MSK) as a result of work activities? Q11c During the last 12 months have you felt unwell as a result of work 34.9% 33.9% related stress? Q11d In the last three months have you ever come to work despite not feeling 55.9% 50.0% well enough to perform your duties? Q5b The support I get from my immediate manager 69.7% 72.9% Q8c My immediate manager gives me clear feedback on my work 65.3% 62.6% Q8d My immediate manager asks for my opinion before making decisions 57.9% 58.2% that affect my work Q8f My immediate manager takes a positive interest in my health and well- 69.3% 71.9% being Q8g My immediate manager values my work 72.5% 74.5% Q19g My manager supported me to receive this training, learning or 59.1% 55.3% development Q4c I am involved in deciding on changes introduced that affect my work 54.3% 57.4% area / team / department Q4j I receive the respect I deserve from my colleagues at work 72.0% Q6a I have unrealistic time pressures 19.5% Q6b I have a choice in deciding how to do my work 53.7% Q6c Relationships at work are strained 46.3% Q8a My immediate manager encourages me at work 70.7% Q23a I often think about leaving this organisation 31.8% Q23b I will probably look for a job at a new organisation in the next 12 months 22.3% Q23c As soon as I can find another job, I will leave this organisation 14.4% Q19b It helped me to improve how I do my job 19.1% 24.9% Q19c It helped me agree clear objectives for my work 35.8% 38.2% Q19d It left me feeling that my work is valued by my organisation 31.3% 38.9% Q19e The values of my organisation were discussed as part of the appraisal 34.5% 38.3% process Q7a I am satisfied with the quality of care I give to patients / service users 82.6% 88.5% Q7b I feel that my role makes a difference to patients / service users 89.1% 89.2% Q7c I am able to deliver the care I aspire to 68.6% 71.2% Q13a In the last 12 months how many times have you personally experienced 24.7% 25.6% harassment, bullying or abuse at work from patients / service users, their relatives or other members of the public? Q13b In the last 12 months how many times have you personally experienced 11.1% 11.9% harassment, bullying or abuse at work from managers? Q13c In the last 12 months how many times have you personally experienced 16.2% 17.5% harassment, bullying or abuse at work from other colleagues?
QVH BoD PUBLIC March 2019 Page 137 of 254 Q12a In the last 12 months how many times have you personally experienced 9.2% 6.6% physical violence at work from patients / service users, their relatives or other members of the public? Q12b In the last 12 months how many times have you personally experienced 0.2% 0.5% physical violence at work from managers? Q12c In the last 12 months how many times have you personally experienced 1.0% 0.7% physical violence at work from other colleagues? Q17a My organisation treats staff who are involved in an error, near miss or 55.8% 61.5% incident fairly Q17c When errors, near misses or incidents are reported, my organisation 65.7% 69.1% takes action to ensure that they do not happen again Q17d We are given feedback about changes made in response to reported 52.9% 57.1% errors, near misses and incidents Q18b I would feel secure raising concerns about unsafe clinical practice 69.1% 72.6% Q18c I am confident that my organisation would address my concern 56.1% 61.5% Q21b My organisation acts on concerns raised by patients / service users 75.2% 76.7% Q2a I look forward to going to work 57.1% 61.0% Q2b I am enthusiastic about my job 74.4% 74.7% Q2c Time passes quickly when I am working 76.4% 77.7% Q4a There are frequent opportunities for me to show initiative in my role 69.5% 75.9% Q4b I am able to make suggestions to improve the work of my team / 73.8% 78.2% department Q4d I am able to make improvements happen in my area of work 58.1% 57.8% Q21a Care of patients / service users is my organisation's top priority 81.0% 85.2% Q21c I would recommend my organisation as a place to work 57.7% 63.0% Q21d If a friend or relative needed treatment I would be happy with the 87.2% 90.8% standard of care provided by this organisation
Appendix 2: Workforce Race Equality Standards (WRES)
QVH BoD PUBLIC March 2019 Page 138 of 254 KSO1 – Outstanding Patient Experience Risk Owner: Director of Nursing and Quality Committee: Quality & Governance Date last reviewed: 13 February 2019 Strategic Objective Risk Appetite The Trust has a moderate appetite for risks that Initial Risk 4(C) x 2(L) = 8 low impact on patient experience but it is higher than the appetite Current Risk Rating 3(C) x 5(L) = 15 mod We put the patient at the heart of for those that impact on patient safety. This recognises that Target Risk Rating 3(C) x 3(L) = 9 low safe, compassionate and when patient experience is in conflict with providing a safe competent care that is provided by service safety will always be the highest priority well led teams in an environment that meets the needs of the Rationale for risk current score Future risks patient and their families. . Compliance with regulatory standards • Unknown impact on patients waiting longer than 52 . Meeting national quality standards/bench marks weeks, CHR in progress . Very strong FFT recommendations • Future impact of Brexit on workforce Risk . Excellent performance in CQC 2017 inpatient surveys, • Generational workforce : analysis shows significant risk 1) Trust is not able to recruit sustained better than national average. of retirement in workforce and retain workforce with • Patient safety incidents triangulated with complaints and • Many services single staff/small teams that lack capacity right skills at the right time. outcomes monthly no early warning triggers and agility. 2) Patients lose confidence in • International recruitment- 48 posts offered 36 accepted • Developing new health care roles -will change skill mix the quality of our services and • National staff shortages of nurses and practitioners in theatres, • STP strategic plans not fully developed critical care impacting on service provision the environment in which we Future Opportunities provide them , due to the • Not meeting RTT18 and 52 week Performance and access standards • Further international recruitment with another local condition and fabric of the Trust estate. Controls / assurance Gaps in controls / assurance . Estates plan and maintenance programme . International recruitment material benefits to workforce . Robust Governance and clinical quality standards managed and monitored at the Q&GC, CGG and the anticipated in Q2 and Q3 2019/20 Controls implemented JHGM, safer nursing care metrics, FFT and annual CQC audits , 6/12 CIP to date have not fully addressed workforce issues Links . External assurance and assessment undertaken by regulator and commissioners to CRR 1094,1077,1035,1035,1126 . Quality Strategy, Quality Report, CQUINS, low complaint numbers . Increase in negative FFT comments re . Benchmarking of services against NICE guidance, and priority audits undertaken appointments/waiting times Links to CRR 1125, . Sub group for theatre workforce/recruitment, proposals approved at HMT June 2017, new theatres . More evidence of embedded learning from serious safety lead in post Feb 2017 incidents being shared throughout the trust. . Trust recruitment and retention strategy mobilised, NHSI nursing retention initiative . Burns and Paediatric services not currently meeting all national guidance. CCG and Regulators fully aware of this, mitigation in place. SOC for inpatient paed burns being taken forward by Darzi Fellow who starts in post April 2018 MOU with BSUH . Developing QVH simulation faculty to enhance safety and learning culture . Clear written guidance for safe staffing levels in theatres and critical care QVH BoD PUBLIC March 2019 Page 139 of 254 KSO2 – World Class Clinical Services Risk Owner: Medical Director Date last reviewed: 14th February 2019
Strategic Objective Risk Appetite. The trust has a low appetite for risks that Initial Risk Rating 5(C)x3(L) =15, moderate We provide world class impact on patient safety, which is of the highest priority. Current Risk Rating 4(C)x3(L)=12, moderate services, evidenced by The trust has a moderate appetite for risks in innovation of Target Risk Rating 4(C)x2 L) = 8, low clinical and patient clinical practice, research and education methodology, if outcomes. Our clinical patient safety is maintained. services are underpinned by our high standards of Rationale for current score Future Risks governance, education • Adult burns ITU and paediatric burns derogation • STP and NHSE re-configuration of services research and innovation. • Paediatric inpatient standards and co-location • Commissioning risks to lower priority services– sleep, • Non -compliance with 7 day services standards orthognathic surgery • Junior doctors – tension between service delivery and training & supervision needs, particularly at spoke sites • Commissioning risks to major head and neck surgery Risk • Spoke site clinical governance. Patients, clinicians & • Never events commissioners lose • Sleep disorder centre staffing of medical staff and sleep Future Opportunities physiologists confidence in services due to • Private practice • Difficulties in recruitment in nursing, administrative and PAM staff inability to show external resulting in poor efficiency of medical workforce. • MoU and collaboration with BSUH assurance by outcome • Non -compliant RTT 18 week position. • STP networks and collaboration measurement, reduction in • Commissioning and STP reconfiguration of head and neck services • Efficient team job planning research output, fall in • Lower limb orthoplastic service provided by QVH and BSUH – • Research collaboration with BSMS teaching standards., or lack inability to meet BOAST4 and NICE guidance. • New CEA scheme and potential for incentive of effective clinical • CCU – network arrangements for CPD and support require further • New services – glaucoma & sentinel node expansion governance. development • Multi -disciplinary education, human factors training and simulation Controls and assurances: Gaps in controls and assurances: Clinical governance leads and reporting structure Limited extent of reporting /evidence on internal and external Clinical indicators ,NICE reviews and implementation standards Spoke visits service specification EKBI data management Limited data from spokes/lack of service specifications Relevant staff engaged in risks OOH and management Scope delivering and monitoring seven day services (OOH) (RR845) Networks for QVH cover-e.g. burns, surgery, imaging Plan for sustainable ITU on QVH site (CRR1059) Training and supervision of all trainees with deanery model Achieving sustainable research investment Creation of QVH Clinical Research strategy Balance service delivery with medical training cost (CRR789) Local Academic Board, Local Faculty Groups and Educational Supervisors Fully addressing GMC National Training Survey results (CRR789) Electronic job planning Detailed partnership agreement with acute hospital (CRR1059) Harm reviews of 52+ week waits QVH BoD PUBLIC March 2019 Sleep disorder centre sustainable medical staffing model & Page 140 of 254 network
Report cover-page References Meeting title: Board of Directors Meeting date: 07 March 2019 Agenda reference: 54-19 Report title: Quality and Governance Assurance report Sponsor: Ginny Colwell Committee Chair Author: Ginny Colwell Appendices: N/A
Executive summary Purpose of report: To provide assurance to the Board to matters discussed at the QGC meeting on the 21February 2019 Summary of key Good assurance was received for most areas. Some areas were asked for further issues clarification as per report Recommendation: The Board is asked to NOTE the contents of the report Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework: No additional areas identified
Corporate risk register:
Regulation:
Legal:
Resources:
Assurance route Previously considered by: Date: Decision: Previously considered by: Date: Decision: Next steps:
QVH BoD PUBLIC March 2019 Page 141 of 254
Report to: Board of Directors Meeting date: 7 March 2019 Reference number: 54-19 Report from: Ginny Colwell, committee chair and NED Author: Ginny Colwell, committee chair and NED Appendices: None Report date: 26 February 2019
Quality and Governance Assurance Report Meeting held on 21 February Areas of particular note for assurance
1. Terms of reference were slightly updated to ensure consistency with other committees. A light touch review will take place.
2. Risk exception report- One formal investigation commenced following the incident of a nasal pressure ulcer. A cluster of these was reported in 2017 and practices changed. The investigation will decide if further changes are required. The 24 hour VTE assessment is to be changed nationally and the Clinical Governance Group will agree how to monitor the new standard. There has been a slight decrease in percentage trend of reported patient safety incidents no harm/near miss. Q&G asked for some further analysis.
3. Corporate risk register- assurance was received that the CRR continued to be used appropriately with 2 new risks added and 1 reviewed. It was agreed that the Board will be updated around recruitment and retention of theatre staff.
4. Infection prevention and control report- An audit of surgical site infections, showed a higher than expected infection rate. The numbers are however low, and nothing significant could be identified. It will be re-audited in May.
5. Patient experience report- following a complaint a volunteer service has been introduced to provide patients with support during eye procedures. No complaints were re-opened or referred to the Ombudsman. Q&G asked whether we could improve the Friends and Family feedback numbers in outpatients and will wait to hear progress.
6. The committee received 3 local governance reports and will assign members further visits as we are behind schedule.
7. 7 Day Service Board Report- clarification and assurance was given on some areas and further detail will be written
QVH BoD PUBLIC March 2019 Page 142 of 254 8. CQUIN- Good progress in most areas. Waiting confirmation of payments for Q2&3. Full year value £1.4 million.
9. Compliance in Practice Q3 report- Noted that actions on improving noticeboards and increasing the availability of wheelchairs was being taken forward
10. Policies ratified; • COSHH policy • Registration Authority Policy • IT access Control Policy
11. Other reports received and are either covered by the executive report or had no significant assurance issues; • KSOs 1&2 • Q&S Board report • Quality account and quality priorities update • NatSSiPs report- National Safety Standards for Invasive Procedures • Safeguarding • Clinical governance Group • Medicines management and optimisation group • Infection prevention and control group • Health and safety group • Nursing quality forum • Strategic safeguarding group
QVH BoD PUBLIC March 2019 Page 143 of 254
Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 55-19 Report title: Corporate Risk Register Sponsor: Jo Thomas, Director of Nursing and Quality Author: Karen Carter-Woods, Head of Risk and Patient Safety Appendices: None Executive summary Purpose of report: For assurance that the Trust risk management process is being followed; new risks identified and current risks reviewed and updated in a timely way. Oversight of key actions undertaken to mitigate risks or actions currently in progress Summary of key The Committee is requested to note the Corporate Risk Register information issues and the progress from the previous report. The key changes this period are: • 2 new Corporate risks added • 1 Corporate risk re-scored: score increased, remained on Corporate Register
Recommendation: Quality & Governance Committee is asked to note the Corporate Risk Register information and the progress from the previous report. Action required Approval Information Discussion Assurance Review
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The entire BAF has been reviewed by EMT alongside the CRR, The corresponding KSOs have been linked to the corporate risks.
Corporate risk register: This document
Regulation: All NHS trust are required to have a corporate risk register and systems in place to identify & manage risk effectively.
Legal: Compliance with regulated activities and requirements in Health and Social Care Act 2008.
Resources: Actions required are currently being delivered within existing trust resources
Assurance route Previously considered by: The Corporate Risk Register is considered monthly by the Executive Management Team. Date: 18.02.19 Decision: Reviewed and updated Previously considered by: Q&GC Date: 21/02/19 Decision: For assurance Next steps: QVH BoD PUBLIC March 2019 Page 144 of 254
Corporate Risk Register Report October and November 2018 Data
Key updates:
Corporate Risks added between 01/12/2018 and 31/01/2019: 2
Risk Risk Risk Description Rationale and/or Score ID Where identified/discussed (CxL)
4x4=16 1136 Evolve IM&T and EDM Board
3x4=12 1139 Risk to patients with complex open lower limb Clinical Governance Group fractures
Corporate risks reviewed and re-scored: 1
Risk Risk Description Previous Risk Updated Rationale for Committee where ID Score Risk Score Rescore change(s) agreed/ proposed
877 Finance Financial 5x5=25 Increased R/V by Director of sustainability forecast Finance deficit: 5.9M
There were no Corporate Risks closed in this period
The Corporate Risk Register is reviewed monthly at Executive Management Team meetings (EMT), quarterly at Hospital Management Team meetings (HMT) and presented at Quality & Governance Committee meetings for assurance. It is also scheduled bimonthly in the public section of the Trust Board.
Implications of results reported 1. The register demonstrates that the trust is aware of key risks that affect the organisation and that these are reviewed and updated accordingly.
2. No specific group/individual with protected characteristics is identified within the risk register.
3. Failure to address risks or to recognise the action required to mitigate them would be key concerns to our commissioners, the Care Quality Commission and NHSI.
Action required 4. Continuous review of existing risks and identification of new or altering risks through improving existing processes. Link to Key Strategic Objectives • Outstanding patient experience • Financial sustainability • World class clinical services • Organisational excellence • Operational excellence QVH BoD PUBLIC March 2019 Page 145 of 254 5. The attached risks can be seen to impact on all the Trust’s KSOs.
Implications for BAF or Corporate Risk Register 6. Significant corporate risks have been cross referenced with the Trust’s Board Assurance Framework.
Regulatory impacts 7. The attached risk register would inform the CQC but does not have any impact on our ability to comply with CQC authorisation and does not indicate that the Trust is not: • Safe • Well led • Effective • Responsive • Caring
Corporate Risk Register Heat map:
Five of the fourteen Corporate Risks fall within the higher grading category:
No harm Minor Moderate Major Catastrophic
Rare 0 0 0 0 0
Unlikely 0 0 0 0 0
Possible 0 0 0 4 0
Likely 0 0 5 3 0 ID: 1035, 1136 1077,
Certain 0 0 0 1 1 ID: 1125, ID: 877
Recommendation: The CRR is presented to the Board for assurance; the Board is asked to discuss / seek clarity in any areas where further assurance is required.
QVH BoD PUBLIC March 2019 Page 146 of 254 ID Opened Title (Policies) Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress/Updates KSO Lead Rating Rating 1139 14/01/2019 Risk to patients with complex Patients with open complex lower limb Current SLA in place for plastic surgery provision to BSUH: Dr Edward Paul Gable Patient 12 6 KSO1 KSO2 open lower limb fractures fractures require time-critical shared care -onsite plastic provision most weekdays Pickles Safety KSO3 between plastics & orthopaedic service, -when possible, patients receive orthopaedic treatment in BSUH prior to transfer to QVH for soft tissue in line with BOAST 4 and NICE surgery recommendations. This is sometimes not achievable with Planned SLA: by end of 2019 the current configuration of services and - 24/7 cover at BSUH for plastic surgery provision to achieve joint operating to comply with BOAST 4 & available personnel & equipment plus NICE recommendations theatre time. - Interim SOP in development for lower limb patients to be transferred to QVH Equipment required: 'C-Arm' in Capital Planning 2019/20
1136 20/12/2018 Evolve: risk analysis has There are a significant risk with the An urgent clinical safety review of EDM was undertaken in May 2018 (version 1.1), this review (version Michelle Jason Patient 16 6 28/1/19 Update: EDM Project Board reviewing options KSO3 KSO4 identified current risk within current provision of the EDM service 2.3) is a follow-up from that document. A new project manager was appointed in August 2018, analysis Miles Mcintyre Safety system processes and within the Trust. The Chief Clinical was undertaken of the extent of the hazards within EDM, and a new team has been built to manage the deployment Information officer has completed a risk business as usual, and to plan further rollout of EDM. A project remediation plan has been developed to analysis which has identified current risk address critical issues and to roll out EDM to all remaining areas. within system processes and Quality assurance of scanning now in place improved administration process. deployment. On-site Documentation availability process has improved with centralisation of pre scan preparation however further work needed to increase collection frequency. There are hazards which remain at level Off-site availability of clinical documentation there has been a rollout of laptops with 4G functionality and 4 and above using the NHS digital clinical remote access in place for those sites that do have native connectivity through the host network. risk management risk matrix indicating Incorrect patient data being uploaded to EDM (Evolve system). Recent centralisation of EDM process has the need for: "mandatory elimination or achieved greater quality assurance of scanning, and has significantly reduced human error of the wrong control to reduce risk to an acceptable referral letter being uploaded to evolve 2: introduction of order communications system is such that there level". is no longer a requirement for reports to be uploaded to evolve. Event packs - With the existing scanning pickup service only being 2 days a week on Tuesday and Unacceptable level of risk have been Thursday it is almost inevitable that notes will not be available in time for review following discharge from identified in the following areas: surgery. To avoid the notes not being available, the event packs are not sent for scanning and made • documentation availability and scanning available physically. quality System speed. There are series of measures being evaluated to address this includes the log on times to • partial rollout of EDM - operating a system could be dramatically reduced by the user of single sign on in "kiosk mode" , the roll out of faster hybrid model pc to clinical areas and longer term the upgrade operating system to windows 10. • event packs not sent for scanning Eform instability. It is possible for a user to finalise the living form at the end of a treatment episode. The • system speed Trust has worked closely with Kainos the provider of the EDM software to develop fixes for the Eform • E form instability instability. The fixes have been tested and have been uploaded to the live environment. Testing being • incorrect patient data being uploaded to completed to verify instability issues have been addressed. EDM (internal scanning)
1133 21/11/2018 Inability to provide full Delays to indirect clinical services (e.g. 1. Recruitment underway for vacant posts. Abigail Judy Patient 12 6 Update: planning underway for x2 maternity leave after March KSO1 KSO3 pharmacy services due to updating policies / guidelines / audit/ 2. Offered band 2 assistant post starting 28/1/19. New to pharmacy so will need significant training input. Jago Busby Safety 2019 KSO5 vacancies and sickness training) Pharmacy vacancy rate is increasing 3. Previous band 2 staff working on bank part-time - but does not cover whole day Lack of trained bank staff to cover 4. Locum pharmacist covering band 7 post until Jan 2018 when going travelling. New locum started Unable to move forward with non-clinical 14/1/19 but needs to complete competancies initiatives e.g JAC (pharmacy IT system) 5. Some part-time staff willing to work additional hours at plain rate. upgrade, compliance with falsified 6. Locum technician helping to cover pharmacist sickness with audits and will cover band 6 vacancy. medicines directive 7. Forward planning for holidays 8. Direct clinical work is priority 9. Medicines management technician working on wards supporting pharmacists 10. Interviewing for band 6 technician post 17/1/19 - 4 good candidates shortlisted 11. Planning for maternity cover but will vary depending on vacancies.
1126 14/09/2018 Recruitment and workforce Hazards are: 1) An audit was undertaken revealing areas for improvement in recruitment KPI delivery. TRAC have Geraldine David Complianc 12 9 1) Monitoring of Dec Update: Improvement evident around recruitment KSO3 KSO5 team constraints and limitations provided some short-term assistance and an improvement plan has been agreed with good progress Opreshko Hurrell e (Targets performance improvement administration; review on-going 1)Lack of compliance with internal made. TRAC are providing tailored training to current recruitment team members 25/26 Sept 2018. / plan 2) DoF monitoring Band 6 Recruitment Manager in post until 31/3/19 (Nov 18) - recruitment KPIs, affecting time-to-hire 2) Discussion with Director of Finance and cost pressures defined. Assessme pressures with DoW case submitted for permanent resource to manage long term and possible impact on clinical services / 3) External support for international recruitment through Yeovil Healthcare NHS Trust agreed nts / 3) Business case for risk (Nov 18) staffing levels 4) Cost pressure for additional part-time Band 7 Nursing Workforce Lead agreed until end of 2018/19 Standards) additional fixed-term / 2) Non-delivery / infeasibility of £55k CIPP financial year to provide additional support permanent strategic 3) Insufficient specialist / strategic resourcing expertise to be support with recruitment and retention made. External support / 4) Lack of coordination with outsourced expertise for Yeovil Healthcare NHS Trust and accommodation to be international campaign candidates sought.
QVH BoD PUBLIC March 2019 Page 147 of 254 ID Opened Title (Policies) Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress/Updates KSO Lead Rating Rating 1125 30/08/2018 RTT Delivery and Performance - The Trust's RTT position is significantly July 18 Abigail Victoria Complianc 20 9 Update (Oct '18): RTT validation programme complete. RTT KSO1 KSO2 below the national standard of 92% of -Comprehensive review of spoke site activity has taken plan to identify all patients that should be included Jago Worrell e (Targets Action Plan in place & being monitored through fortnightly KSO3 KSO4 patients waiting <18 weeks on open in the Trust RTT position / System Task & Finish group, weekly assurance call with KSO5 pathways. This position has reduced Data upload now in place to enable the reporting of PTL data from Dartford spoke site that was previously Assessme NHSI & via internal assurance processes. Revised further in July following the identified of a not identified nts / trajectories being agreed with Commissioners. Clinical Harm cohort of patients that have historically Weekly PTL meeting in place (Chair DOO)) that reviews patient level data for all patients >38 weeks for Standards) Reviews underway. not been included in the RTT waiting list each speciality position - Additional theatre capacity is being identified through PS (McIndoe) and NHS (ESHT Uckfield theatres) - 52 week position has deteriorated Recovery plan in place following identification of additional -4 additional validators to start in post 29th August patients -IST supporting capacity and demand work - commissioners have identified capacity outside of the trust for dental T1/T2 referrals - commissioner are in the process of identifying capacity for other long wait patients
1122 16/08/2018 Sentinel Node Biopsy: increase Rise in demand to perform Sentinel * Extra Clinics Abigail Paul Gable Patient 12 9 February 7th update: Summary Business case to EMT for KSO1 KSO2 in demand Lymph Node Biopsy for skin cancer * Three procedures per week to be undertaken in the McIndoe Unit from September 14th 2018 Jago Safety 1wte skin consultant KSO3 KSO5 Not enough capacity in theatres & clinics *Weekly review of cancer PTL Oct update: outsourced capacity to McIndoe to undertake them all Risk of delayed treatment for cancer 1116 26/06/2018 Inability to provide sufficient Potential loss of medical outpatient 1) Forthcoming AAC appointment process to substantiate 1 WTE post (currently locum basis) Dr Edward Dr Edward Patient 12 4 28/1/19: reviewed at EMT - update requested KSO1 KSO2 medical provision to the Sleep capacity within the Sleep Disorder 2) Approval of funding for clinical fellow post Pickles Pickles Safety November update: advertisement for consultant in sleep KSO3 KSO4 Disorder Centre Centre, with associated effects on waiting medicine closed beginning Dec 18 - no applications KSO5 list and income. Possible detriment to received. follow up of existing patients, particularly To be re-advertised in January 2019 plus explore staffing and those requiring non-invasive ventilation other options. for sleep disorders with a respiratory background. October update: Substantive Consultant leaving post February 2019; worsening picture. Going out to advert November 2018 - partnership working with other Trusts being explored Current discussions with other potential candidates Medical management structure under review.
1094 15/12/2017 Canadian Wing Staffing Current vacancy 12.12 wte in total 1. Use of agency and bank as available and movement of QVH staff to cover shortfall Jo Thomas Nicola Patient 12 12 Discussion with Director of 28.1.19: Improvement in vacancy rate, 9 vacancies, band 5 KSO1 KSO2 registered and unregistered workforce 2. Review of rota to identify new ways of working to address the shortfall in the short term & on-going rota Reeves Safety Nursing wc 18th December recruitment ongoing. Requiring significant resource from ward scrutiny Proactive management of 6-11-18: Update, remains similar situation matron and bank office to cover shifts 3. Line-booked agency if available bed booking 12-10-18: update, vacancies remain around 12WTE, some with qualified nurses leading to constant 4. Redeploying staff from other areas of the hospital to cover Line booking agency staff recruitment successful, turnover remains. national & micro management of off duty rotas. 5. Tailoring trauma and elective demand to establishment available Planning further in advance domestic recruitment continues. Unable to recruit staff to fill all existing to get increased choice of 11-9-18: update, 12.12 vacancies, recruitment ongoing with vacancy agency. some success. Occasionally unable to book sufficient 13/8/18: +/- 45 posts offered: awaiting uptake and detail agency staff to cover the shortfall 4/7/18 - some further leavers but some recruited staff On occasions trauma or elective activity starting. is cancelled or delayed to manage the 14/5 (CGG): some success with international recruitment, shortfall and maintain safe care. minimal success with social media campaign 9/4/18: Update - interest from campaign, small number of applications received 12/2/18: Update - Social media recruitment campaign underway Pegasus) January 2018 update: - enhanced bank rates to include C-Wing - new ward matron in post
1077 22/08/2017 Recruitment and retention in * Theatres vacancy rate is increasing 1. HR Team review difficult to fill vacancies with operational managers Jo Thomas Nicola Patient 16 6 Actions to date October update: some success with recruitment. CCG KSO1 KSO2 theatres * Pre-assessment vacancy rate is 2. Targeted recruitment continues: Business Case progressing via EMT to utilise recruitment & retention Reeves Safety reviewed Theatre services 11/10/18 - no safety or quality increasing via social media issues were identified written report awaited. * Age demographic of QVH nursing 3. Specialist Agency used to supply cover: approval over cap to sustain safe provision of service / 13/8/18: x4 WTE Staff Nurse posts recruited to, all with workforce: 20% of staff are at retirement capacity theatre experience. age 4. Trust is signed up to the NHSI nursing retention initiative Dubai recruitment: +/- 45 posts offered: awaiting uptake and * Impact on waiting lists as staff are 5. Trust incorporated best practice examples from other providers into QVH initiatives detail covering gaps in normal week & therefore 6. Assessment of agency nurse skills to improve safe transition for working in QVH theatres 9/7/18: TUG agreed to pilot different minor procedure staffing not available to cover additional activity at 7. Management of activity in the event that staffing falls below safe levels. model from July '18 weekends Practice Educator in Dubai to interview potential staff June 2018: * loss of theatre lists due to staff 12/6/18: further work on theatre establishment & budget. vacancies Testing feedback from staff re: skill mix 14/5 (CGG): Pre-assessment almost at full establishment 12/2/18: recruitment to pre-op assessment plus social media recruitment drive January 2018 update:all HCA's now in post
QVH BoD PUBLIC March 2019 Page 148 of 254 ID Opened Title (Policies) Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress/Updates KSO Lead Rating Rating 1059 22/06/2017 Remote site: Lack of co- Lack of co-location with clinical SLA with BSUH re: CT scanning, acute medical care, paediatric care and advice Dr Edward Dr Edward Patient 12 10 Actions to date October update: CT onsite will be operational December KSO1 KSO2 location with support services specialities & facilities which may be Guidelines re: pre-assessment & admission criteria, to QVH Pickles Pickles Safety PEG service review 2018 -joint programme manager commenced in post KSO4 for specific services required to manage complications of Skilled and competent medical and nursing staff with mandatory training focused on QVH specific risks September 2018 procdures undertaken at QVH Clinical governance oversight of scope of practice at QVH 13/8/18: reviewed at CGG - plan for instalment September 14/5/2018 (CGG): some progress re: discussions between sites - joint (BSUH & QVH)programme board established and CT procurement process underway
1040 13/02/2017 Age of X-ray equipment in Significant numbers of Radiology All equipment is under a maintenance contract, and is subject to QA checks by the maintenance company Abigail Sheila Patient 12 2 28/01/2019 - For business planning 2019/2020 QVH KSO1 KSO2 radiology equipment are reaching end of life with and by Medical Physics. Jago Black Safety radiology has prioritised key pieces of equipment that require KSO3 multiple breakdowns throughout the last capital investment this financial year. 2 year period. Plain Film-Radiology has now 1 CR x-ray room and 1 Fluoroscopy /CR room therefore patients capacity 1- Replace the Fluoroscopy/CR room - current room has had can be flexed should 1 room breakdown, but there will be an operational impact to the end user as not all multiple failures this year. No Capital Replacement Plan in place at patients are suitable to be imaged in the CR/Flouro room. These patients would have to be out-sourced to 2- Replace one mobile X-Ray machine- QVH has 2 mobile QVH for radiology equipment another imaging provider. machines, both are currently broken (extended period) and one has been replaced by a loan machine supplied by the Mobile - QVH has 2 machines on site. Plan to replace 1 mobile machine for 2019-2020 maintenance company. This loan machine has also recently failed. 3- Replace one of the Ultrasound - the oldest machine that is Fluoroscopy- was leased by the trust in 2006 and is included in 1 of these general rooms. Control would used for Head & Neck work is showing image quality be to outsource all Fluoroscopy work to suitable hospitals during periods of extended downtime. Plan to resolution replace Fluoro/CR room in 2019-2020 October update - included within capital bids for 2018/19 Ultrasound- 2 US units are over the Royal College of Radiologists (RCR)7 year's recommended life cycle 17/7/18: reviewed at CSS meeting - new capital now for clinical use. Plan to replace 1 US machine for 2019-2020 available for this 14/5 (CGG): procurement process continues 13.12.2017- Cone Bean CT scanner in procurement phase 1 Ultrasound machine in procurement phase Business planning 2018-2019 has plan for rolling capital replacement of radiology equipment 06/09/2017- business planning for 2017-2018 agreed for the CBCT and 1 US machine imaging equipment to be replaced.
14/03/2017: Replacement items to be included in Business Plan for 2018/19
1035 09/01/2017 Inability to recruit adequate * Failure to recruit adequate numbers of 1. Burns ITU has a good relationship with 3 nursing agencies. Via these agencies we have a bank of 8 - Jo Thomas Nicola Patient 16 9 Actions update January 2019: KSO1 KSO2 numbers of skilled critical care skilled critical care nurses across a range 10 nurses who regularly work on our unit,and are considered part of our team. Reeves Safety • Increase in staffing moving from agency to bank nurses across a range of of Bands temporary staff are formally orientated to the unit with a document completed and kept on file. • International recruitment plan continues, awaiting dates for Bands * Intensive Care Society recommends 2. A register is kept of all agency nurses working in CCU:they all have ITU Course or extensive candidates to complete required process - recruitment 50% of qualified nurses working on CCU experience delays evident team should have ITU course: this is 3. Concerns are raised and escalated to the relevant agencies where necessary and any new agency staff • 6 new trained staff appointed currently complied with due to existing are fully vetted and confirmed as fully competent to required standards • Re-advertise for Band 6 positions to enhance senior workforce, new staff joining from C-Wing 4. Recruitment drive continues & review of skill mix throughout the day and appropriate changes made leadership within the team and transfer of vacancy rates 5. Review of patient pathway undertaken following move of step-down patients to CCU: for review October • Enhanced bank rates continue for both full and part time * move of step-down beds to CCU has 2017 staff increased the vacancy rate 6. International recruitment undertaken, appropriate staff moving through required checks. Continue to Dec update: further success with agency staff nurses * potential for cases to be cancelled advertise registered staff positions. recruiting into Bank and substantive posts. 7. Paper agreed at HMT to support current staffing issues in CCU. Vacancy remain high with long term October update: Good uptake of offers from Dubai sickness and maternity leave. Must ensure 50:50 split between CCU substantive staff and agency. Staff recruitment; continued scrutiny around use of agency & skill aware of the action. mix to ensure safe care. 13/8/18: Dubai recruitment: +/- 45 posts offered: awaiting uptake and detail 16/7/18: Paper to HMT to agree Risk Appetite for agency usage in Critical Care 9/7/18: Update - Practice Educator in Dubai to interview potential staff 12/6/18: necessity for substantive staff to change / cover shifts at short notice resulting in impact upon health & wellbeing. February 2018: social media recruitment drive launched January 2018 update: - Increased Bank rates implemented -'recommend a friend' staff incentive scheme Dec vacancy rate = 6.01wte
QVH BoD PUBLIC March 2019 Page 149 of 254 ID Opened Title (Policies) Hazard(s) Controls in Place Executive Risk Owner Risk Type Current Target Actions Progress/Updates KSO Lead Rating Rating 968 20/06/2016 Delivery of commissioned -Potential increase in the risk to patient *Paeds review group in place Jo Thomas Nicola Complianc 12 4 To be reviewed in July January 2019: KSO2 KSO3 services whilst not meeting all safety *Mitigation protocol in place surrounding transfer in and off site of Paeds patients Reeves e (Targets following Clinical Cabinet Process underway to finalise business case; currently KSO5 national standards/criteria for -on-call paediatrician is 1 hour away in *Established safeguarding processes in place to ensure children are triaged appropriately, managed / discussions working through the financial model. Burns and Paeds Brighton safely Assessme Paper to be presented at Plan to present business case to commissioners in February -Potential loss of income if burns *Robust clinical support for Paeds by specialist consultants within the Trust nts / Clinical Cabinet in June and final business case to the Trust Board in March. derogation lost *All registered nursing staff working within paediatrics hold an appropriate NMC registration *Robust Standards) 2016 October update: Business case to be developed, activity data -no dedicated paediatric anaesthetic lists incident reporting in place Paediatric review group met available and workforce plans underway. *Named Paeds safeguarding consultant in post in August, paper to private 13/8/18: sub-group convened and meetings commenced *Strict admittance criteria based on pre-existing and presenting medical problems, including extent of burn board in September 2016. 12/7/18: meeting held with Brighton to progress pathway scaled to age. 12/6 update: Darzi fellow in post (1yr), reviewing paediatric *Surgery only offered at selected times based on age group (no under 3 years OOH) inpatient burns *Paediatric anaesthetic oversight of all children having general anaesthesia under 3 years of age. 14/5 update: position paper presented at March HMT - nil *SLA with BSUH for paediatrician cover: 24/7 telephone advice & 3 sessions per week on site at QVH new changes
877 21/10/2015 Financial sustainability 1) Failure to achieve key financial targets 1) Annual financial and activity plan Michelle Jason Finance 25 16 1) Development and January 2019: KSO4 would adversely impact the NHSI 2) Standing financial Instructions Miles Mcintyre implementation of delivery R/V by Exec Lead: increased forecast deficit to 5.9M "Financial Sustainability Risk rating and 3) Contract Management framework plan to address forecast Oct update: reviewed - nil change breach the Trust's continuity of service 4) Monthly monitoring of financial performance to Board and Finance and Performance committee underformance. Review of 05/06/18: Reviewed; updated target risk to reflect BAF licence. 5) Performance Management framework including monthly service Performance review meetings performance against 2)Failure to generate surpluses to fund 6) Audit Committee reports on internal controls delivery plan through PR 3/10/17: reviewed at senior team meeting = no change future operational and strategic 7) Internal audit plan framework with appropriate 06/12/2016: Reviewed by Senior Management Team. DoF to investment escalation policies. review further to ensure score accurately reflects current 2) Development of multi- status. year CIP/ transformational programme which complies with best practice guidelines. 3)Development and embedding of integrated business planning framework
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Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 56-19 Report title: Quality & Safety report Sponsor: Jo Thomas, Director of Nursing and Quality Author: Kelly Stevens, Head of Quality and Compliance Appendices: a) Patient experience report b) Nursing metrics c) Clinical strategy Executive summary Purpose of report: To provide updated quality information and assurance that the quality of care at QVH is safe, effective, responsive, caring and well led. Summary of key The Committee’s attention should be drawn to the following key areas detailed in the issues reports: • Sustained safe staffing levels and provision of high quality care • Update of electronic document management risks and associated action plan • The Macmillan Information and Support Centre retained the Prestigious Macmillan Quality Environment Award (MQEM). Recommendation: The Board is asked to be assured that the contents of the report reflect the quality and safety of care provided by QVH Action required Approval Information Discussion Assurance Review
Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Financial (KSOs): Outstanding World-class Operational Organisational patient clinical excellence sustainability excellence experience services Implications Board assurance framework: The Quality Report contributes directly to the delivery of KSO 1 and 2, elements of KSO 3 and 5 also impact on this.
Corporate risk register: CRR reviewed as part of the report compilation –and the workforce and RTT18 risk impact the most on quality, safety and patient experience.
Regulation: The Quality Report contributes and provides evidence of compliance with the regulated activities in Health and Social Care
Act 2008 and the CQC’s Essential Standards of Quality and Safety.
Legal: As above The Quality and Safety Report uphold the principles and values of
The NHS Constitution for England and the communities and people it serves – patients and public – and staff.
Resources: The Quality and Safety Report was produced using existing resources. Assurance route Previously considered by: Quality and governance committee Date: 21/02/19 Decision:
Next steps:
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Domain Highlights The focus within the Trust remains the provision of safe, high quality care and outstanding patient experience. Whilst the most significant risks to safe provision of care and patient experience remain the trusts workforce recruitment and retention challenges and RTT 52 week breaches progress continues to be made on continuous quality improvements. Examples of these include QVHs Macmillan Information and Support Centre retaining the prestigious Macmillan Quality Environment Award the and the introduction of trained volunteer 'hand holders' in theatres to focus solely on the patient whilst they have a procedure under local anaesthetic. This has been a huge success, the initiative was developed from patient feedback and is a great example of 'you said we did' responsive culture within the Trust.
The theatre quality assurance visit planned for January was undertaken in February due to unforeseen events. The Trust received strong verbal assurance about the sustained improvements and noted the evidence that supported further progress. We await the Director of Nursing formal report which will be presented in full at the Quality and Governance Committee. and Quality The Trust has refreshed the Safeguarding Children, Young People and Vulnerable Adults Assurance Statement and this was reviewed at the Quality and Governance Committee. It is published on the Trusts internet page. We continuously revisit and develop the safeguarding arrangements we have in place as national policy, legal frameworks and research evidence change. The focus for safeguarding training this year has been developed in line with the assurance statement to ensure that the principles and duties of safeguarding adults and children are holistically, consistently and conscientiously applied with the well-being of those adults and children at the heart of all we do. We have used real case studies from QVH in the training to simply how safeguarding is applied to our patients and families at QVH. Safeguarding featured as an agenda item at the last commissioner led clinical quality review meeting and there was strong recognition about the quality of the safeguarding services we provide and the contribution that QVH safeguarding team make to the local network.
QVH BoD PUBLIC March 2019 Page 152 of 254 Working with our senior clinical leaders through the Hospital Management Team, we have documented our clinical strategy with a particular focus on actions planned for 2019/20. This document will be updated in the course of the year to reflect developments our work in the local health system on head and neck cancer and clinical developments in our ongoing partnership work with Western and BSUH.
Several multi-agency meetings regarding the pathways for head and neck cancer across Kent, Surrey and Sussex have been held in January and February. There are currently 4 head and neck MDTs across KSS, served by 5 cancer surgery centres, and these numbers Medical Director may come under review. NHS Specialised Commissioning would ideally like to commission whole cancer pathways (diagnosis, surgery, oncology and follow up) via the Cancer Centre MDTs, and are requesting that QVH is sub-contracted as a surgery provider by the 3 MDTs we serve. The cancer alliances and STPs are also reviewing their respective services within their footprints. Meanwhile, ENT services in Medway and East Sussex, as well as OMFS services in Brighton are facing severe demand, capacity and recruitment challenges. QVH is currently leading the development of a model to network OMFS care (cancer, orthognathic, dentoalveolar and trauma surgery) between QVH, WSHT, BSUH and ESHT, with joint appointments between the trusts to strengthen clinical safety and outcomes across the region.
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Report by ExceptionThe Trust is exploring - Key Messages
Domain Issue raised Action taken What we expect- maintain the Trust's The Trust had an unannounced CQC inspection 29 and 30 January 2019 and the Well Led inspection is CQC rating score of 'good' overall with a booked for 26 and 27 February 2019. The trust Board has prepared for the Well Led inspection 'outstanding' in care. utilising Board seminar time and an external facilitator.
The current SLA for plastic surgery provision by QVH to BSUH provides 5 day per week plastic surgery presence at BSUH to support their major trauma centre work. However, the agreement does not allow for prospective cover or on-call cover. There is also limited nursing and equipment support at What we expect - treatment of lower limb BSUH for free flap reconstructive surgery. QVH has limited resources to support orthopaedic surgery. complex trauma, to be timely and co- Safe: Guidelines stipulate that complex open fractures should be jointly operated on, to establish bone provided by orthopaedic and plastic Orthoplastic fixation and soft tissue cover within 72 hours. BSUH and QVH together are not currently meeting surgeons in joint procedures. Lower Limb these standards. What happens - BSUH and QVH are jointly Trauma Surgery A business case and SLA for 24/7 plastics cover to BSUH, and the supporting staff and facilities for unable to meet current guidelines for this reconstructive surgery is in development and expected to be presented to both boards in March - cohort of patients. May 2019. Whilst in development, cases are being managed as safely and as timely as possible, but outside of national recommendations. Patients may be referred to other MTCs where there is significant risk of delay. Duty of candour will be maintained.
QVH BoD PUBLIC March 2019 Page 154 of 254 Caring: The What we expect- The Macmillan The Macmillan Information and Support Centre at QVH underwent its second Assessment on 4th Macmillan Information and Support Centre to retain February 2019 and is pleased to confirm it has retained the Prestigious Macmillan Quality Information and its prestigious award marking the highest Environment Award (MQEM). The Trust has received verbal confirmation of this achievement and is Support Centre possible standards for cancer care awaiting a full report confirming the award. Macmillan environments, driving forward the design Quality and use of these facilities, based on a The first award to the centre was made in 2016 and reassessment occurs every three years. Environment robust understanding of the needs of Assessment is carried out by an independent organisation appointed by Macmillan Cancer Support. Award (MQEM) people affected by cancer.
Plan to provide separate entrances to the burns and critical care units in order to improve compliance with infection control standards have been delayed as the scope of the project is such Safe: Infection What we expect- Compliance with national that it will require planning permission. Staff have contributed to the plans and the final version is control infection control standards. currently awaiting approval from the Estates Team. This work will also improve facilities for staff and patients; included are improved changing rooms, additional side rooms, additional staff room and a relatives room. This project also includes renewing the ventilation system in the Burns theatre.
QVH BoD PUBLIC March 2019 Page 155 of 254 1. Total uptake and opt-out rates Number of QVH frontline healthcare workers (HCW) 989* Uptake of vaccine by frontline HCW 605 61.2% Opt-out of vaccine by frontline HCW 187 18.9% Total= 80.1% *Due to the size of QVH, to create a meaningful data set we include the entire workforce.
2. Higher-risk areas (only trusts with relevant areas – a minimum of which are set out in 7 September The target for frontline staff vaccinations letter) Flu Immunisation for 2018/19 was 75 % which includes staff QVH has not defined any clinical area as high risk. We will review this with our CCG in anticipation of opt out declarations the 19/20 campaign.
3. Actions taken to reach 100% uptake ambition (all trusts) - Senior clinical role models - Roving clinics - Peer vaccination - MIU vaccination - Reminders at all staff updates - CEO Blog
QVH BoD PUBLIC March 2019 Page 156 of 254 Evolve, the QVH Electronic Document Management system, commenced rollout in the summer of 2015, and is now in use across sleep, maxillofacial and corneoplastic surgery. A progress review was undertaken in 2018/19 which identified potential safety issues, the key one being that we are running both the old and the new systems in the Trust during this partial roll out phase. Other challenges include access and availability at spoke sites, integration with other systems, system Responsive: What we expect- Effective rollout of the speed and standard operating procedures for effective use of the electronic patient record. Evolve electronic Trust's Evolve Electronic Document document Management system. The Trust's Clinical Lead for IT has produced a detailed review of risks and associated action plan management What happened- potential safety issues which was presented at the IM&T, Informatics Clinical Advisory Group and the executive system identified and plan in place to resolve. Management Team. As a result of the medical director has joined the programme board to provide additional leadership , additional resources have been committed to the project and the is risk has been added to the Corporate risk register. Completion of roll out of EDM would address many of the risks related to mixed systems. Plans include training re SOPS, additional specialist resources to support the project.
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12 month Description (Activity per 1000 spells is based on HES Data: the number of inpatients Quarter 4 Quarter 1 Target Quarter 2 Quarter 3 Quarter 4 total/ discharged per month including ordinary, day case and emergency - figure /HES x 1000) 2017/18 2018/19 rolling Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan average Infection Control MRSA Bacteraemia acquired at QVH post 48 hrs after admission 0 0 0 0 1 0 0 0 0 0 0 0 0 1 Clostridium Difficile acquired at QVH post 72 hours after admission 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Gram negative bloodstream infections (including E.coli) 00000000000000
MRSA screening - elective >95% 97% 98% 98% 98% 98% 97% 98% 97% 98% 99% 96% 96% 98% MRSA screening - trauma >95% 96% 98% 97% 95% 97% 96% 95% 96% 95% 96% 95% 96% 96% Incidents Never Events 00000000001001 Serious Incidents 00000001000001 Theatre metrics All patients: Number of patients operated on out of hours 5 2 5 6 5 5 5 5 4 8 3 2 1 48 22:00 - 08:00 Paediatrics under 3 years: Induction of anaesthetic was between 0 0 0 0 0 0 0 0 1 0 0 0 0 1 18:00 and 08:00 WHO quantitative compliance 99% 99% 98% 98% 98% 99% 99% 98% 99% 98% 98% Non-clinical cancellations on the day 31 46 8 13 18 9 6 7 22 14 18 22 214 Needlestick injuries 4 2 1 1 8 Pressure sores 1 0 0 1 2 Paediatric transfers out (<18 years) 000000000201 3 Medication errors
Total number of incidents involving drug / prescribing errors 9 13 6 12 7 8 8 7 16 13 9 7 115 No & Low harm incidents involving drug / prescribing errors 9 13 6 12 7 8 8 7 16 13 9 7 115 Moderate, Severe or Fatal incidents involving drug / prescribing 0 0 0 0 0 0 0 0 0 0 0 0 0 errors Medication administration errors per 1000 spells 3 1.2 1.8 0.6 0.6 1.2 1.2 0.6 2.2 2.2 0 0.5 1.3 Harm free care rate (QVH) >95% 97% 96% 98% 100% 97% 98% 100% 93% 100% 100% 100% 96% 97.9% Harm free care rate (NATIONAL benchmark) - one month delay >95% 94.2% 94.0% 93.9% 94.0% 94.1% 94.1% 93.9% 94.3% 94.1% 94.3% 94.3% 94% Pressure Ulcers Hospital acquired - category 2 or above 15 001101000101 5 VTE initial assessment (Safety Thermometer) >95% 97.3% 96.4% 100.0% 97.4% 97.1% 88.1% 100.0% 100.0% 100.0% 100.0% 97.0% 100.0% 97.8% Patient Falls Patient Falls assessment completed within 24 hrs of admission >95% 92% 96% 95% 100% 100% 95% 98% 100% 97% 100% 100% 100% 97.5% Patient Falls resulting in no or low harm (inpatients) 823342334523 42 Patient Falls resulting in moderate or severe harm or death 0001000000001 (inpatients) Patient falls per 1000 bed days 7.46 1.87 2.61 3.33 3.64 1.79 2.89 2.85 3.39 4.27 2.34 3.34 3.31
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Q1 Quarter 2 Quarter 3 Q4 2018/19
Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Number of deaths on QVH site 0 0 0 0 0 0 1 0 Number of deaths off- site within 30 days of IP or OP procedure 2 1 0 2 0 2 1 0 No of completed preliminary reviews 2 1 0 2 0 2 1 0 No of deaths subject to a Structured Judgement Review 0 0 0 1 0 0 1 0 No of deaths in patients with co-existing learning difficulties 0 0 0 0 0 0 0 0
All off site deaths are subject to preliminary review of the case notes and enquiries with the GP and responsible clinicians. All deaths on Learning from the QVH site, or where a concern has been raised, are subject to a Structured Judgement Review (SJR) of the case notes. The type of deaths SJR differs if the patient had learning difficulties. Where concerns are identified through preliminary case note review or SJR, these are investigated through the Datix and risk mechanisms.
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Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19
Contacts (IP+OP+MIU, 16798 17677 18284 19660 19340 20032 19399 17490 20227 19886 16342 20287 all sites) Complaints 5 4 1 6 8 8 3 4 5 5 3 3 Complaints per 100 0.03 0.023 0.005 0.031 0.041 0.04 0.015 0.023 0.025 0.025 0.018 0.015 contacts Number of complaints referred to the 0 0 1 0 0 0 1 0 0 0 0 0 Ombudsman for 2nd stage review Number of complaints 0 0 1 0 0 1 0 0 0 0 0 0 re-opened
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Caring - Current Compliance - FFT
QVH BoD PUBLIC March 2019 Page 161 of 254 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Nursing Workforce - Current Compliance
Domain Compliance Actions
Staffing according to bed occupancy and acuity with additional staff During December and January there were 2/124 occasions deployed on high acuity days and resources redeployed from other where staffing numbers did not meet planned levels (15/122 in area on one occasion. Below template shift dates have been Ross Tilley October and November). All escalated to site practitioner as per triangulated with Datix safety incidents, ward FFT scores and trust protocol. complaints information. There were no patient safety incidents, falls, pressure ulcers or nursing medication errors on these shifts.
Staffing according to bed occupancy and acuity with additional staff During December and January there were 2/124 occasions where deployed on high acuity days and resources redeployed from other Margaret staffing numbers did not meet planned levels (12/122 in October areas. Below template shift dates have been triangulated with Datix Duncombe and November ). All escalated to the site practitioner as per trust safety incidents, ward FFT scores and complaints information. There protocol. were no falls, pressure ulcers or nursing medication errors on these shifts.
Staffing according to bed occupancy and acuity resources redeployed During October and November there were 5/122 occasions to and from other areas where template was below planned and where staffing numbers did not meet planned levels 5/122 in additional staff required. Below template shift dates have been Burns August and September). All escalated to site practitioner as per triangulated with Datix safety incidents, ward FFT scores and trust protocol. complaints information. No falls, pressure ulcers or nursing medication errors occurred on these shifts.
QVH BoD PUBLIC March 2019 Page 162 of 254 The ward was closed on 5 nights in December due to staff availability, no closures due to staffing in January. In December the During December and January there was 9/124 occasion where ward had 22 inpatients requiring overnight stay on 16 nights. In staffing numbers did not meet planned levels(10/122 in October January the ward had 24 patients requiring overnight stay on 17 Peanut and November). All escalated to site practitioner as per trust nights. Staffing according to bed occupancy and acuity. Below protocol. template shift has been triangulated with Datix safety incidents, ward FFT scores and complaints information, no harms or related complaints to this date.
Staffing according to bed occupancy and acuity resources redeployed to and from other areas where template was below planned and additional staff required. All dates where escalation re staffing During there were 6/124 occasions where staffing numbers did required have been triangulated with Datix safety incidents, ward not meet planned levels 6/122 in October and November). All FFT scores and complaints information. No falls, pressure ulcers or Critical Care (ITU) were escalated to site practitioner as per trust protocol. All nursing medication errors occurred on these shifts. There continues escalated to the site practitioner as per trust protocol. to be daily review of the number of critical care beds open decision is made by the multidisciplinary team at the morning hospital handover meeting. This continues to be monitored throughout the day by the site and senior nursing teams.
There was always a Site practitioner day and night with the Deputy Director of Nursing, Heads of Nursing and critical care providing During December and January there were 8/124 occasions where Site Practitioner additional support as required to the team and the Trust. Twilight staffing numbers did not meet planned levels (21/122 in October Team shifts have been used to provide additional cover at the busiest and November). times of the shift. All new site practitioners have completed supernumerary placements and are now fully orientated to the role.
Data extracted from the workforce score card in appendix 1
QVH BoD PUBLIC March 2019 Page 163 of 254 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Qualified Nursing Workforce - Performance Indicators
QVH BoD PUBLIC March 2019 Page 164 of 254 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Unqualified Nursing Workforce - Performance Indicators
QVH BoD PUBLIC March 2019 Page 165 of 254 Exec summary Exception reports Safe Effective Caring Nursing workforce Medical Workforce Medical Workforce - Performance Indicators
2017/18 Year to Quarter 4 Quarter 1 Metrics total / Target Quarter 2 Quarter 3 Quarter 4 date 2017/18 2018/19 average actual/ Feb Mar April May June July Aug Sep Oct Nov Dec Jan average Medical Workforce 13.98% Turnover rate in month, excluding trainees 12Mth <1% 0.00% 0.00% 85.00% 0.95% 0% 1.31% 1.60% 2.42% 0% 0% 1.16% 3.44% 12.85% rolling 51% Turnover in month including trainees 9% 12Mth 10.21% 0.00% 6.09% 2.12% 0.71% 10.76% 3.15% 2.10% 1.35% 0.68% 2.79% 2.77% 3.95% rolling Management cases monthly 0 0 0 1 1 3 3 1 1 1 1 1 0 13 Available Sickness rate monthly on total medical/dental headcount 2.77% 0.46% 1.29% 1.03% 0.55% 0.88% 0.86% 2.05% 1.18% 0.94% 1.19 1.09 1.09% Mar 19 88.80% Appraisal rate monthly (exclude deanery trainees) 81.76% 75.56% 82.35% 83.60% 90.38% 87.90 82.83% 79.38% 83.54 89.09 88.13% 84.62% 80.91% Mar 17 Mandatory training monthly 95% 85% 82% 85% 84% 83% 84% 81% 77% 78.7% 83% 84% 84% 83% Exception Reporting – Education and Training 0 0 1 0 0 0 0 0 0 0 0 1 2 Exception Reporting – Hours 5 0 0 0 0 1 0 0 0 0 0 0 6
There are currently 103 doctors for whom the QVH is their designated body. The completed appraisal rate for 2017/18 was 83.6%, and appraisal rates have improved to 89%. All doctors are revalidated with a licence to practice. Two positive recommendations for revalidation have been submitted in the previous two months. No doctors are under a deferred decision. Consultant contracts and job planning are currently the subject of planned external audit. A new round of electronic job planning has Medical & Dental commenced, led by the Clinical Directors and Business managers. A new annual leave SOP and process is in development and will be Staffing implemented from April 2019 to improve consistency in medical leave management.
A new policy for the award of Clinical Excellence Awards has been approved by the Local Negotiating Committee and the Nomination and Remuneration committee, and applications for CEAs are now open. A panel will be convened in April 2019.
QVH BoD PUBLIC March 2019 Page 166 of 254 Regular junior doctor forums are held to discuss training opportunities and concerns. There remains a low level of exception reporting. The reporting facility has now been opened up to all junior doctors, not just deanery trainees, and the importance of exception reporting has been reinforced at every possible opportunity. February saw the induction of 19 new doctors in core surgery and anaesthetics. Feedback on induction was extremely positive, particularly Education in core surgery, where previously trainees had flagged some dissatisfaction via the GMC NTS survey.
The estates work has now been completed in the Medical Education Centre, with a refurbished rest room, locker and lavatory facilities, kitchen and outside decking area. The rest facilities move the trust much closer to compliance with the BMAs Charter for Fatigue and Facilities to which we have signed up to work towards.
QVH BoD PUBLIC March 2019 Page 167 of 254 NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries BURNS WARD Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 Quarter 4 Year to No. Indicator Description total/ Target 2017/18 2018/19 2018/19 2018/19 2018/19 Date Trend Comments average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 139 _ 19 8 11 8 12 17 6 8 12 9 8 6 124 2 Total reported - Patient safety 45 _ 8 2 7 2 7 4 2 4 8 6 3 5 58 Incidents 3 Formal internal investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 12 0 5 1 1 0 1 0 1 0 1 0 1 1 12 Jan19: Patient fell in bathroom Falls 6 Falls - With harm 1 0 0 0 0 0 1 0 0 0 1 0 0 0 2 7 Pressure Damage G2 or above (hospital acquired) 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 9 Elective patients 99.5% 95% 100% 94% 93% 100% 94% 100% 100% 100% 100% 100% 100% 100% 98% 10 MRSA Screening Trauma patients 99.3% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 88% 100% 100% 99% Improvement noted 11 Reported cases 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 94% 95% 90% N/S 100% 100% 100% N/S 80% 100% 100% 100% 100% 100% 97% Hand Hygiene 14 Bare below the elbows 100% 95% 100% N/S 100% 100% 100% N/S 100% 100% 100% 100% 100% 100% 100% Discussed staff outstanding with assessments with 15 Drug Assessments 97% 100% 100% 100% 85% 87% 100% 100% 93% 100% 85% 92% 90% 80% 93% % staff compliant Matron paln to address this has been requested 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 Jan19: Self-admistering patient took their evening meds 19 Medication Errors Reported errors 9 0 0 0 1 0 1 0 0 1 1 2 1 1 8 in the morning. Learning continues to be shared with the wider MDT. 20 Harm Free Care % 98.3% 95% 100% 100% 86% 100% 83% 100% 100% 100% 100% 100% 100% 100% 97% Safety Thermometer 21 New Harm Free % 100% 95% 100% 100% 100% 100% 83% 100% 100% 100% 100% 100% 100% 100% 99% 22 Assessment of patients (S. Therm) 99% 95% 86% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 100% 95% VTE (Venous This accounts for 1 patient, Matron addressing this with 23 24 hour follow up (S. Therm) 95.5% 95% 83% 100% 100% 100% 100% 25% 100% 100% 0% n/a 100% 80% 81% staff as a matter of urgency to ensure compliance is thromboembolism) improved. 24 Monthly screening % (Informatics) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
25 Shift meets requirement RN 96.7% 95% 96% 98% 98% 97% 96% 97% 96% 97% 99% 101% 99% 98% 98% Staff skill mix aligned with patient acuity - current 26 Day % 96.6% 95% 100% 100% 100% 100% 64% 97% 93% 97% 84% 94% 95% 100% 94% HCA vacancies are managed with temporary staffing 27 Shift meets requirement RN 95.7% 95% 97% 102% 95% 98% 100% 97% 97% 97% 100% 100% 97% 100% 98% 28 Night % HCA 106.3% 95% 175% 100% 100% 163% 100% 100% 100% 100% 100% 100% 100% 100% 112% EFFECTIVE 29 Nutrition Assessment Initial (Safety Thermometer) 100% 95% 100% 100% 100% 83% 100% 100% 100% 100% 100% 100% 100% 100% 99% 30 (MUST) 7 day review (Safety Thermometer) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Compliance in Practice 31 Inspection score 80% Reported 1/4ly 92.1% Reported 1/4ly Reported 1/4ly Reported 1/4ly 92% (CiP) CARING 32 Patient numbers (eligible to respond) 652 _ 62 56 69 65 74 52 16 17 23 20 24 30 508 Staff continue to encourage patients to complete FFT 33 % return rate 45% 40% 42% 21% 6% 31% 7% 31% 100% 100% 62% 100% 100% 60% 55% Friends & Family Test both on the ward and in EBAC. 34 % recommendation (v likely/likely) 98.3% 90% 100% 92% 100% 85% 100% 100% 100% 100% 100% 100% 100% 95% 98% 35 % unlikely/extremely unlikely 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
QVH BoD PUBLIC March 2019 Page 168 of 254 Nursing Quality Metrics Data RESPONSIVE
36 Complaints No. recorded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELL-LED 37 Full Team WTE 32.46 32.5 Vacancy 38 Vacancy WTE 6.43 10% 5.43 6.03 7.05 6.72 6.72 6.48 7.77 7.51 9.02 8.12 9.02 9.3 7.4 Establishment= 39 Vacancy (hrs) 1044.88 10% 882 979 1145 1092 1092 1053 1263 1220 1465.8 1319.5 1465.8 1511.25 1207.4 40 Temporary Staffing Agency Use 99.1 10% 161 384 226 425 107.5 266.25 280 345 302.25 346.75 382.25 406.75 302.73 41 excluding RMN Bank Use 360.1 10% 444 384.5 233 349 418 587.75 343.8 274.5 332 373.75 418.25 592.5 395.92 42 Hours 103.5 79.25 90 41.5 94.75 154 36.5 170 96.188 Sickness 43 % 3.1% 2% 1.7% 4.6% 1.6% 1.0% 2.1% 1.6% 1.9% 0.9% 1.9% 3.2% 0.7% 3.5% 2.1% All current sickness managed via HR policy 44 Maternity Hours 0 0 45 Budget Position YTD Position >0 166689 249483 41143 62409 -39429 -44803 -40236 -10887 -704 -10195 354 373824 Data not available at this time Matron continues to work with staff to ensure increased 46 Mandatory training 89.6% 95% 91% 89% 91% 89% 89% 91% 92% 93% 96% 97% 94% 94% 92% Statutory & Mandatory training compliance. 47 Appraisal 87.1% 95% 90% 90% 79% 82% 93% 92% 84% 88% 92% 79% 92% 88% 87% Matron working with staff to address the gap 48 Uniform Audit Compliance with uniform policy % 95% 100% 100% 100% 100% 100%
QVH BoD PUBLIC March 2019 Page 169 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries CORNEOPLASTIC OPD Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to No. total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 86 _ 5 11 6 8 3 11 6 7 5 11 2 5 80 2 Total reported - Patient safety 29 _ 2 4 5 2 0 7 1 3 2 2 1 3 32 Incidents 3 Formal internal investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 1 1 0 0 2 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% 100% 100% 100% 100% 100% 93% 100% 100% N/S 100% 100% 100% 99% Hand Hygiene 12 Bare below the elbows 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% N/S 100% 100% 100% 100% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 Jan19: Non-preservative free eye-drops prescibed 16 Medication Errors 18 0 1 2 4 2 0 4 0 1 0 1 1 1 17 Reported errors instead of preservative free drops. EFFECTIVE Compliance in Practice 17 Inspection score 80% Reported 1/4ly 90.7% Reported 1/4ly Reported 1/4ly Reported 1/4ly91% (CiP) CARING 18 Patient numbers (eligible to respond) _ 1633 1819 2007 2165 2020 2288 2044 1846 2292 2262 1830 2218 24424 Staff contnue to encourage patients to complete FFT 19 % return rate 22.8% 20% 22% 20% 21% 21% 20% 24% 21% 20% 19% 19% 26% 21% 21% Friends & Family Test data 20 % recommendation (v likely/likely) 94.7% 90% 95% 94% 92% 93% 93% 91% 92% 95% 93% 95% 95% 93% 93% 21 % unlikely/extremely unlikely 1.3% 0% 0% 2% 3% 2% 2% 4% 3% 1% 3% 1% 2% 3% 2%
QVH BoD PUBLIC March 2019 Page 170 of 254 Nursing Quality Metrics Data RESPONSIVE 22 Complaints No. recorded 4 0 0 1 0 1 1 2 0 0 1 1 0 0 7 WELL-LED 23 Full Team WTE 18.06 18.1 Vacancy 24 Vacancy WTE 10% 1.91 1.91 3.11 2.8 2.48 2.48 2.48 2.24 3.23 3.69 3.69 2.5 2.7 Establishment= 25 Vacancy (hrs) 10% 310.4 310.4 505.4 455 403 403 403 364 524.88 599.62 599.6 406.25 440.38 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 0 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 407.4 206.5 125.5 173.5 170.5 168 168.5 226 222 275 182 312 219.74 28 Hours 27.5 30 0 17 47.5 0 96.5 10 205 163.5 46.5 85 60.708 Sickness Sickness absence all currently managed through Trust 29 2% 0.5% 0.9% 0.0% 0.8% 1.5% 0.0% 3.1% 0.3% 6.6% 5.2% 1.5% 2.9% 1.9% % policy 30 Maternity Hours 0 0 0 0 0 0 0 0 0 0 0 0 0 31 Budget Position YTD Position >0 92109 117732 19631 34880 49650 65400 76928 93558 30102 30917 44629 50376 705912 Data is not available at this time 32 Mandatory training 95% 97% 97% 96% 94% 92% 91% 94.6% 94% 97% 96% 97% 99% 95% Compliance continues with Matron support to team Statutory & Mandatory 33 Appraisal 95% 95% 95% 100% 95% 90% 95% 100% 95% 100% 100% 100% 89% 96% Matron working with staff to maintain compliance 34 Uniform Audit Compliance with uniform policy % 95% N/S 95% 85% 90%
QVH BoD PUBLIC March 2019 Page 171 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries CRITICAL CARE UNIT Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to 2017/18 2018/19 2018/19 2018/19 No. Indicator Description total/ Target 2018/1 Date Trend Comments average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 147 _ 13 9 16 11 16 8 18 25 17 15 7 15 170 2 Total reported - Patient safety 100 _ 8 5 10 6 11 8 17 23 13 12 7 10 130 Incidents 3 Formal internal investigation 4 0 0 0 1 0 0 0 0 0 0 0 0 0 1 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 2 0 0 0 1 0 1 0 0 1 0 2 0 0 5 No falls in month Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 7 Pressure Damage G2 or above (hospital acquired) 4 0 0 0 0 1 0 0 0 0 0 0 0 0 1 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 9 Elective patients 100% 95% 100% n/a 100% 100% n/a n/a n/a 100% 100% n/a n/a 100% 100% 10 MRSA Screening Trauma patients 89.1% 95% 80% 100% n/a 100% 100% 100% 100% 100% 100% 100% 100% n/a 98% 11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 90.4% 95% 78% 90% 100% 100% 90% 93% 100% N/S 100% 100% 100% 92% 95% Hand Hygiene Staff continue to monitor all members of the MDT to 14 98.8% 95% 100% 90% 100% 100% 100% 93% 100% N/S 100% 89% 100% 100% 97% Bare below the elbows ensure compliance is maintained 15 Drug Assessments % staff compliant 95.9% 100% 100% 100% 100% 100% 88% 93% 100% 93% 100% 100% 100% 100% 98% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 19 Medication Errors Reported errors 4 0 0 0 0 2 0 0 0 1 0 0 0 0 3 Pressure ulcer OLD identified, acquired prior to 20 Harm Free Care % 92.5% 95% 67% 50% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 89% Safety Thermometer admission 21 New Harm Free % 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 22 Assessment of patients (S. Therm) 95.5% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% VTE (Venous 23 24 hour follow up (S. Therm) 80% 95% 100% 0% 33% 0% 100% 100% 100% 100% 100% 100% 100% 100% 78% thromboembolism) 24 Monthly screening % (Informatics) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Shifts are met in accordance with patient numbers and 25 Shift meets requirement RN 96.8% 95% 98% 96% 90% 96% 99% 90% 99% 98% 94% 100% 90% 100% 96% acuity to ensure safety and quality care and staffing is Day % mainatined. 26 HCA 96.1% 95% 95% 104% 94% 118% 91% 96% 100% 96% 96% 105% 96% 100% 99% 27 Shift meets requirement RN 88.5% 95% 90% 91% 89% 99% 96% 88% 95% 88% 89% 93% 87% 100% 92% 28 Night % HCA 90.0% 95% 86% 80% 400% 113% 50% 50% 100% 100% 113% 100% 88% 91% 114% EFFECTIVE 29 Nutrition Assessment Initial (Safety Thermometer) 90.9% 95% 100% 50% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93% 30 (MUST) 7 day review (Safety Thermometer) 89.3% 95% n/a 100% 100% n/a 0% n/a n/a n/a n/a 100% 100% 100% 83% Compliance in Practice 31 Inspection score 80% Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly#DIV/0! (CiP) CARING
QVH BoD PUBLIC March 2019 Page 172 of 254 Nursing Quality Metrics Data RESPONSIVE 32 Complaints No. recorded 2 0 1 1 0 0 0 0 0 0 0 0 0 2 WELL-LED 33 Full Team WTE 29.25 27.57 28.4 Vacancy 34 Vacancy WTE 9.32 10% 9.16 11.97 9.66 9.59 11.01 10.48 10.98 11.02 11.92 11.73 10.73 9.44 10.6 Ward Establishment = 29.37 WTE Establishment= 35 Vacancy (hrs) 1514.2 10% 1488 1945 1570 1558 1789 1703 1784 1791 1937 1906 1743.625 1534 1729.1 36 Temporary Staffing Agency Use 595.5 10% 641 846 950 1035 976.5 918 965 940.5 884.5 828 218 347.5 795.83 37 excluding RMN Bank Use 222.9 10% 410 353.5 226 246 172 171 271 327.5 432.25 691.05 667.25 591.75 379.94 38 Hours 360.5 221 187.5 423.5 357 362.5 416.5 332.64 Sickness Long term sickness staff remains, with short term 39 1.9% 2% 3.0% 3.2% 7.7% 7.5% 5.0% 7.7% 4.6% 3.9% 8.9% 7.5% 7.6% 9.3% 6.3% % sickness. All managed within Trust policy 40 Maternity Hours #DIV/0! 41 Budget Position YTD Position >0 93265 69733 -91455 -30308 -33259 -108905 51653 56696 11881 -2451 -118838 -101988 Data unavailable at this time Matron continues to work with HoN to address, picture 42 Mandatory training 88% 95% 90% 87% 85% 86% 86% 87% 86% 88% 87% 84% 90% 96% 88% Statutory & Mandatory improving 43 Appraisal 90.8% 95% 86% 72% 68% 77% 81% 90% 85% 84% 89% 80% 89% 90% 83% Improving picture, work continues to continue 44 Uniform Audit Compliance with uniform policy % 95% 93% 64% 91% 83%
QVH BoD PUBLIC March 2019 Page 173 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MAIN OUTPATIENTS Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to No. total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 134 _ 24 16 11 7 14 12 16 12 15 18 10 20 175 2 Total reported - Patient safety 28 _ 4 3 2 2 1 3 4 2 7 5 5 2 40 Incidents 3 Formal internal investigation 1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 1 0 1 0 0 0 0 1 0 0 0 0 0 0 2 Falls 6 Falls - With harm 1 0 1 0 0 0 0 1 0 0 0 0 0 0 2 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 8 Inoculation Injury Reported incidents 3 0 0 0 0 0 0 0 0 1 0 0 1 1 3 Jan19: Correct protocol follwoed 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Requires continuous montoring of all staff to increase 11 Hand hygiene 84.8% 95% 70% 86% 100% 89% N/S 80% 100% 100% 90% 80% 60% N/S 85% compliance. Staff completing audit advised to ensure Hand Hygiene staff that are non-compliant this is addressed by leads 12 Bare below the elbows 96.3% 95% 100% 100% 100% 100% N/S 100% 100% 100% 100% 100% 100% N/S 100% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Medication Errors Reported errors 1 0 0 1 0 0 0 0 0 0 1 0 0 0 2 EFFECTIVE Compliance in Practice 17 Inspection score 80% 89.1% 90.3% Reported 1/4ly 90.4% Reported 1/4ly90% (CiP) CARING 18 Patient numbers (eligible to respond) _ 11446 11984 12479 12729 12866 12975 12813 11732 11983 13846 11143 14050 150046 Staff continue to respond to encourage patients to 19 % return rate 16.3% 20% 17% 18% 17% 16% 16% 16% 16% 17% 18% 16% 17% 18% 17% Friends & Family Test complete FFT 20 % recommendation (v likely/likely) 94.4% 90% 95% 94% 94% 95% 94% 94% 94% 96% 95% 95% 96% 95% 95% 21 % unlikely/extremely unlikely 2.3% 0% 2% 3% 2% 2% 2% 2% 3% 2% 2% 2% 2% 2% 2%
QVH BoD PUBLIC March 2019 Page 174 of 254 Nursing Quality Metrics Data RESPONSIVE 22 Complaints No. recorded 4 0 1 0 0 0 1 0 1 0 0 0 0 3 WELL-LED 23 Full Team WTE 15.37 15.4 Vacancy 24 Vacancy WTE 10% 1.26 1.22 1.18 1.18 1.81 1.82 1.76 1.32 1.32 1.25 1.25 1.4 Establishment= 25 Vacancy (hrs) 10% 204.75 198.25 191.7 191.7 294.12 295.7 286 214.5 214.5 203.12 203.1 227.04 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 304.5 231.25 310.5 321.75 192.75 287.7 276 184 120.25 91.95 94.95 219.6 28 Hours 139 48 32 0 144 236.5 38 37.5 84.375 Sickness 29 % 2% 5.3% 5.7% 8.9% 5.5% 1.9% 1.3% 0.0% 5.8% 9.5% 1.5% 1.5% 4.3% 30 Maternity Hours 0 0 0 0 0 0 0 0 0 0 0 31 Budget Position YTD Position >0 117894 -7780 -6392 -12043 -8463 -11769 -12216 -8281 -15901 -6350 28699 32 Mandatory training 95% 90% 91% 90% 94% 97% 98% 92% 91% 92% 96% 98% 94% Statutory & Mandatory 33 Appraisal 95% 85% 90% 90% 80% 94% 95% 100% 100% 100% 100% 93% Requires further and sustained improvement. Matron monitoring all members of the MDT to ensure uniform 34 Uniform Audit 95% 70% 80% 90% 80% Compliance with uniform policy % policy is adhered to. Will raise issues with individuals to further address as required.
QVH BoD PUBLIC March 2019 Page 175 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MARGARET DUNCOMBE Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments No. Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 180 _ 15 12 14 13 8 13 14 9 15 20 17 17 167 2 Total reported - Patient safety 118 _ 12 7 9 11 4 9 10 6 13 15 11 10 117 Incidents 3 Formal internal investigation 0 0 0 0 0 1 0 2 0 0 1 1 0 0 5 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 14 0 1 1 0 2 0 2 2 0 1 1 1 1 12 Jan19: Patient fell whilst being helped onto wheelchair. Falls 6 Falls - With harm 4 0 1 0 0 1 0 0 1 0 0 0 1 0 4 7 Pressure Damage G2 or above (hospital acquired) 1 0 0 0 0 0 0 2 0 0 0 0 0 0 2 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 1 0 1 0 0 0 2 9 Elective patients 97.4% 95% 100% 97% 100% 98% 98% 98% 100% 91% 96% 98% 98% 96% 97% 10 MRSA Screening Trauma patients 95.4% 95% 97% 100% 94% 93% 96% 100% 94.8% 97% 96% 93% 95% 96% 96% Improvement from last month. 11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13 Hand hygiene 100% 95% 100% 100% 100% 100% 100% 100% N/S 100% 100% 100% 100% 90% 99% Hand Hygiene Improvement from last month, this is a multidisciplinary 14 94.7% 95% 60% 100% 100% 80% 100% 100% N/S 100% 78% 80% 90% 85% 88% Bare below the elbows audit. 15 Drug Assessments % staff compliant 99.7% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 Jan19: CD Drug discrepency 19 Medication Errors Reported errors 34 0 2 1 3 4 2 0 4 2 3 4 5 1 31 All staff encoouraged to report drug errors via datix. Individual staff members spoken to with each error. 20 Harm Free Care % 99.4% 95% 100% 100% 100% 100% 100% 93% 100% 85% 100% 100% 100% 100% 98% Safety Thermometer 21 New Harm Free % 100% 95% 100% 100% 100% 100% 100% 93% 100% 92% 100% 100% 100% 100% 99% 22 Assessment of patients (S. Therm) 99.1% 95% 100% 89% 100% 92% 100% 87% 100% 100% 100% 100% 100% 100% 97% Imporvement from last month, twice weekly audit VTE (Venous conitnues to capture those staff not completing the 23 24 hour follow up (S. Therm) 89.3% 95% 67% 80% 73% 42% 20% 82% 57% 89% 73% 89% 33% 67% 64% thromboembolism) paperwork, this is the responsibility of the multidisciplinary team. 24 Monthly screening % (Informatics) 97.4% 95% 98% 86% 99% 96% 99% 99% 97% 97% 97% 93% 96% 96% 25 Shift meets requirement RN 97.3% 95% 97% 90% 96% 98% 99% 99% 98% 97% 96% 97% 101% 100% 97% 26 Day % HCA 99.5% 95% 93% 107% 100% 102% 104% 98% 102% 100% 95% 93% 96% 100% 99% 27 Shift meets requirement RN 94.8% 95% 97% 94% 101% 100% 96% 96% 98% 97% 102% 100% 100% 98% 98% 28 Night % HCA 86.4% 95% 88% 85% 94% 103% 86% 82% 100% 88% 90% 88% 90% 100% 91% Dependant upon patient acuity EFFECTIVE 29 Nutrition Assessment Initial (Safety Thermometer) 100% 95% 100% 100% 100% 100% 92% 80% 100% 100% 93% 100% 100% 100% 97% 30 (MUST) 7 day review (Safety Thermometer) 70.8% 95% 100% 0% 100% 100% 100% 80% 33% 100% 100% 100% 100% 100% 84% Compliance in Practice 31 Inspection score 80% 86.8% Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly#DIV/0! (CiP) CARING 32 Patient numbers (eligible to respond) 1737 _ 133 109 144 124 125 128 131 111 140 147 159 144 1595 33 % return rate 60.8% 40% 63% 76% 63% 71% 55% 58% 57% 60% 41% 41% 47% 61% 58% Friends & Family Test 34 % recommendation (v likely/likely) 98.1% 90% 96% 99% 100% 99% 99% 100% 97% 100% 98% 100% 100% 100% 99% 35 % unlikely/extremely unlikely 0.1% 0% 0% 0% 0% 0%QVH 0%BoD PUBLIC0% 0%March 0%2019 0% 0% 0% 0% 0% Page 176 of 254 Nursing Quality Metrics Data RESPONSIVE 36 Complaints No. recorded 1 0 1 0 0 0 0 1 1 2 1 1 0 7 Ward matron regularly reviews complaints WELL-LED 37 Full Team WTE 49.44 49.44 49.44 49.08 48.67 49.04 49.54 49.54 49.54 49.54 49.54 48.66 49.3 Vacancy 38 Vacancy WTE 8.2 10% 8.92 10.02 11.46 11.21 11.13 12.16 12.74 12.12 13.72 13.22 10.67 9 11.4 Establishment= 39 Vacancy (hrs) 1332.9 10% 1450 1628 1862 1822 1808 1976 2070 1970 2229.5 2148.3 1733.9 1462.5 1846.7 40 Temporary Staffing Agency Use 546.7 10% 874 1229 1522.5 1464 1242.5 1207 1789 1775.8 1642.8 1566.5 814 369.5 1291.4 560hrs of used hours below template. 41 excluding RMN Bank Use 485 10% 553 827.5 736 940 899 901 823.5 673 851.75 847.3 717 794.75 796.98 42 Hours 596 448 312.5 121 306 132 165 193 157.75 180.5 310.5 261.5 265.31 Sickness 43 % 3.7% 2% 7.4% 5.6% 3.8% 1.5% 3.8% 1.6% 2.0% 2.4% 2.0% 2.2% 3.9% 3.3% 3.3% 44 Maternity Hours 185 185 185 127 69 69 69 0 0 0 0 80.818 45 Budget Position YTD Position >0 36 -20622 -49366 -72573 -96771 -102720 -214295 -273162 -391542 -419366 -1640381 Improving from previous month. All out of date staff have 46 Mandatory training 95% 95% 96% 93% 95% 93% 90% 91% 91% 92% 94% 96% 95% 93% Statutory & Mandatory been emailed and asked to book training. 47 Appraisal 95% 82% 83% 88% 95% 94% 88% 92% 90% 86% 90% 98% 98% 90% Ward Matron to reguarly spot check staff in relation to 48 Uniform Audit 95% 89% 80% 80% 83% Compliance with uniform policy % complinace with uniform policy.
QVH BoD PUBLIC March 2019 Page 177 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries ROSS TILLEY Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments No. Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 194 _ 16 12 11 15 10 18 10 12 20 12 12 9 157 2 Total reported - Patient safety 111 _ 8 9 7 7 9 8 2 8 15 8 8 7 96 Incidents 3 Formal internal investigation 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 19 0 2 0 1 1 2 0 0 2 1 2 0 1 12 Jan19: Unwitnessed fall. Falls 6 Falls - With harm 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 8 Inoculation Injury Reported incidents 2 0 0 0 0 0 0 0 1 0 0 0 0 0 1 9 Elective patients 97.8% 95% 94% 95% 97% 94% 100% 100% 98% 94.9% 100% 97% 97% 98% 97% Trauma patients are occasionally missed if seen in TC and then straight to theatre. On investigation, patients had 10 MRSA Screening 97.2% 95% 96% 99% 99% 97% 97% 95% 94% 94.9% 93.4% 94.7% 92.9% 98.0% 96% Trauma patients been screened but it had not been documented correctly.
11 Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 All staff reminded of hand hygiene, this is a 13 Hand hygiene 100% 95% 100% 100% 100% 100% 100% 100% N/S 100% 100% 90% 90% 100% 98% Hand Hygiene multidisciplinary audit. Staff encouraged to approach all staff not adhereing to 14 97.4% 95% 100% 100% 87% 80% 100% 100% N/S 100% 100% 70% 90% 100% 93% Bare below the elbows this rule, this is multidisciplinary 15 Drug Assessments % staff compliant 99.7% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 16 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 18 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 Staff encouraged to reoprt incidents. Individual staff 19 Medication Errors 40 0 3 5 3 2 1 3 1 2 7 4 3 0 34 Reported errors members spoken to about errors. 20 Harm Free Care % 99.4% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Safety Thermometer 21 New Harm Free % 99.4% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 22 Assessment of patients (S. Therm) 98.6% 95% 100% 100% 100% 100% 93% 95% 100% 100% 100% 100% 94% 100% 98% VTE (Venous Nursing staff are spoken to individually with regards to 23 24 hour follow up (S. Therm) 87.8% 95% 60% 50% 93% 53% 46% 88% 64% 78% 73% 82% 100% 67% 71% VTE follow up. This document can be completed by both thromboembolism) nurses and Drs, some 24 Monthly screening % (Informatics) 97.8% 95% 99% 94% 98% 96% 94% 97% 94% 94% 94% 94% 92% 95% 25 Shift meets requirement RN 97.8% 95% 97% 93% 98% 96% 98% 100% 98% 97% 97% 97% 99% 100% 98% 26 Day % HCA 97.3% 95% 102% 96% 102% 96% 98% 96% 102% 96% 92% 98% 100% 98% 98% 27 Shift meets requirement RN 93.1% 95% 95% 96% 93% 93% 90% 88% 97% 99% 99% 98% 98% 94% 95% 28 Night % HCA 86.0% 95% 96% 100% 100% 90% 97% 88% 85% 90% 97% 100% 68% 100% 93% EFFECTIVE 29 Nutrition Assessment Initial (Safety Thermometer) 98.9% 95% 94% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 30 (MUST) 7 day review (Safety Thermometer) 84.5% 95% 100% 25% 100% 100% n/a 75% 100% 100% 100% 100% 100% 100% 91% Compliance in Practice 31 Inspection score 80% 86.6% Reported 1/4ly Reported 1/4ly 88.2% Reported 1/4ly88% (CiP) CARING 32 Patient numbers (eligible to respond) 2418 _ 174 174 174 193 203 196 194 204 190 173 184 166 2225 33 % return rate 47.1% 40% 43% 58% 60% 39% 39% 29% 43% 31% 37% 39% 40% 48% 42% Matron continues to promote the importance of this Friends & Family Test 34 % recommendation (v likely/likely) 97.9% 90% 99% 99% 95% 100% 95% 100% 100% 98% 99% 100% 100% 97% 99% 35 % unlikely/extremely unlikely 0.3% 0% 0% 0% 2% 0%QVH 1%BoD PUBLIC0% 0%March 0%2019 0% 0% 0% 1% 0% Page 178 of 254 Nursing Quality Metrics Data RESPONSIVE 36 Complaints No. recorded 2 0 0 1 0 1 0 0 0 1 1 0 0 4 WELL-LED 37 Full Team WTE 49.44 49.44 49.44 49.08 48.67 49.04 49.54 49.54 49.54 49.54 49.54 48.66 49.3 Vacancy 38 Vacancy WTE 8.2 10% 8.92 10.02 11.46 11.21 11.13 12.16 12.74 12.12 13.72 13.22 10.67 9 11.4 Establishment= 39 Vacancy (hrs) 1332.9 10% 1450 1628 1862 1822 1808 1976 2070 1970 2229.5 2148 1734 1463 1846.7 560 hrs were not used over this month due low patient 40 546.7 10% 874 1229 1522.5 1464 1242.5 1207 1789 1776 1643 1566.5 814 369.5 1291.4 Temporary Staffing Agency Use demand. 41 excluding RMN Bank Use 485 10% 553 827.5 736 940 899 901 823.5 673 851.8 847.3 717 794.75 796.99 42 Hours 596 448 312.5 121 306 132 165 193 157.75 180.5 310.5 261.5 265.31 Sickness 43 % 3.7% 2% 7.4% 5.6% 3.8% 1.5% 3.8% 1.6% 2.0% 2.4% 2.0% 2.2% 3.9% 3.3% 3.3% 44 Maternity Hours 185 185 185 127 69 69 69 0 0 0 0 0 74.083 45 Budget Position YTD Position >0 36 -20622 -49366 -72573 -96771 -102720 -214295 -273162 -333679 -391542 -419366 -1974060 Educator and matron rveiweing this and emailing out of 46 Mandatory training 95% 95% 96% 93% 95% 93% 90% 91% 91% 92% 94% 96% 95% 93% Statutory & Mandatory date staff. Educator and Matron booking out of date staff an 47 95% 82% 83% 88% 95% 94% 88% 92% 90% 86% 90% 98% 98% 90% Appraisal appraisal date. Ward Matron undertaking spot checks with uniform 48 Uniform Audit 95% 100% 90% 90% 93% Compliance with uniform policy % compliance.
QVH BoD PUBLIC March 2019 Page 179 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries MAX FAC OUTPATIENTS Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to No. total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 30 _ 5 5 4 5 5 3 4 1 3 4 3 5 47 2 Total reported - Patient safety 8 _ 0 1 2 1 0 0 2 1 3 1 2 1 14 Incidents 3 Formal internal investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 2 0 0 0 0 1 0 0 0 0 0 0 1 0 2 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% 100% 100% 90% 100% N/S 100% 100% N/S 100% 100% 100% 100% 99% Hand Hygiene 12 Bare below the elbows 100% 95% 100% 100% 100% 100% N/S 100% 100% N/S 100% 100% 100% 100% 100% 13 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 14 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Medication Errors Reported errors 2 0 0 0 0 1 0 0 0 1 0 0 0 0 2 EFFECTIVE Compliance in Practice 17 Inspection score 80% 83.3% 90.4% Reported 1/4ly Reported 1/4ly Reported 1/4ly90% (CiP) CARING 18 Patient numbers (eligible to respond) _ 1302 1436 1542 1589 1378 1477 1442 1371 1683 1524 1107 1464 17315 Team aware to encourage patients to complete FFT, often patients may return frequently which proves 19 % return rate 17.9% 20% 17% 17% 18% 18% 17% 17% 19% 16% 19% 17% 17% 17% 17% Friends & Family Test challenging for them to complete on more than one occassion 20 % recommendation (v likely/likely) 92.3% 90% 94% 91% 91% 92% 93% 94% 93% 94% 94% 93% 95% 96% 93% 21 % unlikely/extremely unlikely 3.1% 0% 2% 4% 4% 2% 1% 1% 3% 1% 3% 2% 1% 3% 2%
QVH BoD PUBLIC March 2019 Page 180 of 254 Nursing Quality Metrics Data RESPONSIVE 22 Complaints No. recorded 13 0 2 0 1 2 1 2 0 0 0 2 0 10 WELL-LED 23 Full Team WTE 21.37 21.37 21.37 21.37 21.37 21.4 Vacancy 24 Vacancy WTE 10% 0.79 2.39 0.76 1.76 1.76 1.76 1.76 1.34 3.34 2.42 2.42 3.22 2.0 Establishment= 25 Vacancy (hrs) 10% 128.37 388 123.5 286 286 286 286 218 543 393.25 393.25 523.25 321.22 26 Temporary Staffing Agency Use 10% 0 0 0 0 0 0 0 0 0 0 0 0 0 27 excluding RMN Bank Use 10% 274.37 24 177 214 245 115.5 120.75 162 169.25 117.9 76.75 149.55 153.84 28 Hours 120.5 133.8 33.75 198.5 55.5 171.25 62 219.25 124.32 Sickness All monitored and correct action taken in adherence with 29 2% 5.5% 0.5% 5.0% 2.2% 3.5% 3.8% 0.9% 5.7% 1.6% 4.9% 1.8% 6.3% 3.5% % Trust policy. 30 Maternity Hours 0 0 0 0 0 0 0 0 0 0 0 0 31 Budget Position YTD Position >0 8270 22807 -4197 -913 1333 3754 6041 7423 14672 17258 27014 103462 32 Mandatory training 95% 93% 90% 92% 89% 92% 88% 89% 90% 94% 93% 97% 96% 92% Statutory & Mandatory 33 Appraisal 95% 85% 85% 100% 88% 90% 92% 96% 100% 100% 100% 100% 100% 95% 34 Uniform Audit Compliance with uniform policy % 95% 100% 100% 100% 100% 100%
QVH BoD PUBLIC March 2019 Page 181 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries PEANUT WARD Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to No. total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 100 _ 13 2 7 30 28 25 11 11 16 10 11 13 177 2 Total reported - Patient safety 26 _ 2 0 0 4 3 1 1 2 1 1 1 1 17 Incidents 3 Formal internal investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 Falls 6 Falls - With harm 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 98.8% 95% N/S N/S N/S N/S 70% 44% N/S 70% 90% 90% 90% 80% 76% Has remained consitent this month Hand Hygiene The matron is consistently asking the medical team to 12 98.2% 95% N/S N/S N/S N/S 90% 100% N/S 100% 100% 90% 90% 100% 96% Bare below the elbows follow this rule. 2 staff are due to be reassessed, One is working through 13 Drug Assessments % staff compliant 99.5% 100% 100% 94% 100% 100% 94% 94% 100% 100% 93% 93% 84% 85% 95% the assessment documentation. The other is on long term sick. Also 2 staff have just left. 14 Missed dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 15 Medication Audit Omitted dose Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 16 Total doses Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly Reported 1/4ly 0 17 Medication Errors Reported errors 5 0 0 0 0 1 1 0 0 0 0 1 0 0 3 18 Harm Free Care % 100% 95% n/a n/a 100% 100% 100% 100% 100% 100% n/a n/a n/a 100% Safety Thermometer 19 New Harm Free % 100% 95% n/a n/a 100% 100% 100% 100% 100% 100% n/a n/a n/a 100% 20 Total no. of ward patients _ 194 176 178 226 145 213 210 188 243 199 165 217 2354 21 BMI Monthly No. patients screened & documented _ 187 171 171 208 143 202 201 174 236 194 151 210 2248 Some patients who are seen in trauma clinic and then 22 95% 96% 97% 96% 92% 99% 95% 96% 93% 97% 97% 92% 95% Patients with documented BMI % not admitted for surgery are not screened. 23 Shift meets requirement RN 96.8% 95% 99% 96% 94% 100% 95% 98% 98% 99% 101% 98% 97% 98% 98% 24 Day % HCA 98.0% 95% 103% 100% 108% 97% 103% 96% 100% 96% 97% 97% 97% 95% 99% Changes have been made to the shift patterns of both Band 5 and 6's in order to meet the TW requirements. A 25 RN 61.9% 95% 88% 93% 83% 98% 84% 85% 90% 80% 70% 70% 81% 97% 85% Shift meets requirement staff nurse is currently on sick leave and we another Night % nurse who has been on leave. 26 HCA 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EFFECTIVE Compliance in Practice 27 Inspection score 80% 88.1% 91.1% Reported 1/4ly Reported 1/4ly Reported 1/4ly91% (CiP) CARING 28 Patient numbers (eligible to respond) 2340 _ 192 171 172 224 199 201 199 164 200 185 152 189 2248 29 % return rate 28.2% 40% 34% 40% 42% 37% 33% 28% 38% 45% 31% 32% 36% 49% 37% Staff are reminded regularly to give out FFT. Friends & Family Test 30 % recommendation (v likely/likely) 99.3% 90% 100% 100% 99% 93% 98% 98% 95% 100% 100% 100% 98% 99% 98% 31 % unlikely/extremely unlikely 0.2% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 2% 0% 0%
QVH BoD PUBLIC March 2019 Page 182 of 254 Nursing Quality Metrics Data RESPONSIVE 32 Complaints No. recorded 0 0 0 0 0 0 0 0 0 0 0 0 0 0 WELL-LED 33 Full Team WTE 19.71 19.7 Vacancy 34 Vacancy WTE 3.3 10% 0 0 0.24 1.24 1.5 1.18 1.18 1.08 -0.08 -0.08 -1.08 0.38 0.5 Establishment= 35 Vacancy (hrs) 542.9 10% 0 0 39 201.5 244 191.75 191.8 175.5 -13 -13 -175.5 61.75 75.317 36 Temporary Staffing Agency Use 92.2 10% 10 1 28 110 71 92.5 68.5 69.5 74 69.5 0 48.5 53.542 37 excluding RMN Bank Use 273.8 10% 217 34 192 413 472.5 488.4 366.5 284.5 339.55 321.25 223 189 295.06 38 Hours 161.5 84 24 40 96 181 76 220.25 110.34 Sickness 39 % 5.5% 2% 6.8% 3.6% 4.0% 1.0% 4.9% 2.6% 0.7% 1.2% 3.0% 5.7% 2.4% 6.7% 3.5% 1 staff member on long term sickness. 40 Maternity Hours #DIV/0! 41 Budget Position YTD Position >0 -14325 -6784 99 5968 7514 4051 2932 7797 13962 17375 11940 50529 Emails to each individual lstaff out of date have been 42 Mandatory training 95% 88% 88% 92% 92% 93% 93% 91% 94% 95% 94% 94% 93% 92% Statutory & Mandatory sent to ensure that % is back over 95% by next month 43 Appraisal 95% 77% 72% 80% 83% 91% 91% 91% 96% 96% 92% 92% 83% 87% One staff member on long term sick. 44 Uniform Audit Compliance with uniform policy % 95% 100% 100% 90% 97%
QVH BoD PUBLIC March 2019 Page 183 of 254 Nursing Quality Metrics Data NURSING METRICS - 12 MONTH ROLLING Contact Gavin Ferrigan on ext. 4556 for any formatting queries SLEEP DC Quart Quarter 4 Quarter 1 Quarter 2 Quarter 3 2017/18 er 4 Year to No. total/ Target 2017/18 2018/19 2018/19 2018/19 Date Trend Comments Indicator Description 2018/1 average Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Actual SAFE 1 Total reported - All incidents 26 _ 3 3 3 0 2 3 2 1 1 2 4 1 25 2 Total reported - Patient safety 9 _ 0 2 1 0 0 0 2 0 0 1 2 1 9 Incidents 3 Formal internal investigation 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Serious incidents and Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Falls - All 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Falls 6 Falls - With harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Pressure Damage G2 or above (hospital acquired) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Inoculation Injury Reported incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 MRSA Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 C Difficile Reported cases 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11 Hand hygiene 100% 95% N/S N/S 100% 100% N/S 100% 100% N/S 100% 100% 100% 100% 100% Hand Hygiene 12 Bare below the elbows 98.9% 95% N/S N/S 100% 100% N/S 100% 100% N/S 100% 100% 100% 100% 100% 13 Medication Errors Reported errors 2 0 0 1 0 0 0 0 1 0 0 1 1 0 4 14 VTE Monthly screening % (Informatics) 100% 95% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% EFFECTIVE Compliance in Practice 15 Inspection score 80% 89.0% Reported 1/4ly Reported 1/4ly 90.6% Reported 1/4ly91% (CiP) CARING 16 Patient numbers (eligible to respond) _ 610 903 988 851 919 896 792 653 921 907 559 939 9938 17 % return rate 22.8% 20% 21% 21% 17% 18% 17% 22% 24% 19% 19% 16% 22% 22% 20% Friends & Family Test 18 % recommendation (v likely/likely) 95.3% 90% 94% 93% 93% 99% 96% 97% 97% 97% 98% 97% 95% 96% 96% 19 % unlikely/extremely unlikely 1.7% 0% 3% 4% 4% 0% 2% 1% 1% 1% 1% 2% 2% 2% 2% RESPONSIVE 20 Complaints No. recorded 3 0 0 0 0 0 0 0 0 0 0 1 0 1 WELL-LED 21 Full Team WTE #DIV/0! Vacancy 22 Vacancy WTE 10% #DIV/0! Establishment= 23 Vacancy (hrs) 10% #DIV/0! 24 Temporary Staffing Agency Use 10% #DIV/0! 25 excluding RMN Bank Use 10% #DIV/0! 26 Hours #DIV/0! Sickness 27 % 2% #DIV/0! 28 Maternity Hours #DIV/0! 29 Budget Position YTD Position >0 0 30 Mandatory training 95% #DIV/0! Statutory & Mandatory 31 Appraisal 95% #DIV/0! 32 Uniform Audit Compliance with uniform policy % 95% 100% 100% 100% 100% QVH BoD PUBLIC March 2019 Page 184 of 254 Nursing Quality Metrics Data Delivering Clinical Excellence QVH 2020
The QVH clinical strategy 2019/20
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2019 2019 March PUBLIC BoD QVH
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2019 2019 March PUBLIC BoD QVH
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2019 2019 March PUBLIC BoD QVH
Excellence Excellence
compassionate care through an engaged and motivated workforce. motivated and engaged an through care compassionate
Organisational
led organisation delivering safe, effective and and effective safe, delivering organisation led - well a maintain We
operational and strategic investments. strategic and operational
Sustainability
the Trust due to our ability to create adequate surpluses to fund fund to surpluses adequate create to ability our to due Trust the
Financial Financial
Regulators have confidence in the long term financial sustainability of of sustainability financial term long the in confidence have Regulators
productivity.
Excellence
timely and effective treatment due to low waiting times and high high and times waiting low to due treatment effective and timely
Operational Operational
Patients and commissioners have confidence in our ability to provide provide to ability our in confidence have commissioners and Patients
standards. teaching and
Services Clinical
services because of our excellent safety, clinical outcomes, research research outcomes, clinical safety, excellent our of because services
World Class Class World
Patients, clinicians and commissioners have confidence in our our in confidence have commissioners and clinicians Patients,
Experience them. provide
Patient Patient way in which they are delivered, and the environment in which we we which in environment the and delivered, are they which in way
Patients have confidence in the quality and safety of our services, the the services, our of safety and quality the in confidence have Patients Outstanding Outstanding
Objectives Strategic Key
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and reviewed by the Hospital Management Team. Team. Management Hospital the by reviewed and
s ervice delivery areas and supporting clinical services were brought together together brought were services clinical supporting and areas delivery ervice
In February 2019, the key actions planned for 2019/20 for each of the key key the of each for 2019/20 for planned actions key the 2019, February In •
in the original strategy document strategy original the in . .
which we are implementing alongside the service aims described described aims service the alongside implementing are we which theatres,
w orkstreams around Partnership with BSUH/Western and Productivity in in Productivity and BSUH/Western with Partnership around orkstreams
In November 2018 the strategy was updated to reflect the important important the reflect to updated was strategy the 2018 November In •
infrastructure and capacity constraints, and to prioritise NHS services. NHS prioritise to and constraints, capacity and infrastructure
w orkstream around private and international work, in recognition of estates, estates, of recognition in work, international and private around orkstream
In October 2017 the strategy was updated to remove the strategic strategic the remove to updated was strategy the 2017 October In •
groups.
Management Team and the Board, as well as discussed with wider staff staff wider with discussed as well as Board, the and Team Management
has been regularly reviewed by the Executive Team, the Hospital Hospital the Team, Executive the by reviewed regularly been
The national and local context has changed considerably and this strategy strategy this and considerably changed has context local and national The •
s takeholder engagement in 2014/15. in engagement takeholder
The QVH 2020 strategy was developed with extensive staff and external external and staff extensive with developed was strategy 2020 QVH The •
updates and Context
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shortages which exist in some key areas and professional groups. professional and areas key some in exist which shortages
staff the address to working, of ways new and recruitment
, through through , innovatively work will We being. - well and health staff
to invest in professional and personal development personal and professional in invest to , and to look after our our after look to and ,
meaningful work. We will continue will We work. meaningful by motivated
People People
led, well managed and and managed well led, well are staff ensure will We QVH. of heart the
professionalism of our staff is at at is staff our of professionalism and work hard expertise, knowledge, The
care. patient best the providing in us support
staffing and and staffing our and accurate is data our sure making services, systems systems
both clinically and in support support in and clinically both work we how in efficiencies seek to
reduce the need for patients to travel for appointments. appointments. for travel to patients for need the reduce will continue continue will We
Productivity
outpatients productivity, including consideration of virtual clinics to to clinics virtual of consideration including productivity, outpatients
there are no unnecessary unnecessary no are there ensure improve our our improve will We patients. for delays
We will work to make sure we we sure make to work will We theatre lists and processes processes and lists theatre full have that that
by staff at QVH. at staff by provided care
effective and efficient services, and and services, efficient and effective future for the outstanding outstanding the for future secure a
be focussed on delivering safe, delivering on focussed be will partnership
support services. Our approach to to approach Our services. support and clinical both further align Partnership
Western Sussex Sussex Western and (BSUH) Trust Hospitals to to Trust Foundation Hospitals
We will continue to work work to continue will We with Brighton Brighton with University Sussex and
2019/20 focus trust Our
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pathways and the sustainability of our services. our of sustainability the and pathways
Collaboration commissioners and regulators to ensure safe, effective patient patient effective safe, ensure to regulators and commissioners
We will work in partnership with our patients, STPs, cancer alliances, alliances, cancer STPs, patients, our with partnership in work will We
greater than 52 weeks except through choice, by the end of of end the by choice, through except weeks 52 than greater . . 2019/20
Performance
RTT18, 2WW, 31 and 62 day cancer targets, with no patients waiting waiting patients no with targets, cancer day 62 and 31 2WW, RTT18,
Through improved processes, efficiency and capacity we will meet meet will we capacity and efficiency processes, improved Through
to all diagnostics and interventions whenever they are required. required. are they whenever interventions and diagnostics all to
Services Services
providers in Kent & Sussex to ensure that patients have timely access access timely have patients that ensure to Sussex & Kent in providers
Seven Day Day Seven
We will continue to develop resources on resources develop to continue will We site, and partnerships with with partnerships and site, -
variation, and ensure excellence in clinical care and value for money. money. for value and care clinical in excellence ensure and variation,
GIRFT benchmarking our outcomes, costs and performance, minimising minimising performance, and costs outcomes, our benchmarking
We will participate fully in the Getting It Right First Time programme, programme, Time First Right It Getting the in fully participate will We
the safe and successful roll out of Evolve across all specialties. all across Evolve of out roll successful and safe the
IM&T IM&T through a clinical portal of e of portal clinical a through solutions. Priority for 2019/20 will be be will 2019/20 for Priority solutions. -
We will continue the development of an electronic patient record record patient electronic an of development the continue will We
focus specialty cross
Our QVH clinical clinical QVH Our
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254 of 193 Page l surgery. breast and biopsy node ymph
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• Provide a shared pathway for paediatric burns care with the the with care burns paediatric for pathway shared a Provide care Burns
department department
Directorate/ 2019/20 for Headlines
strategy
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s Brighton at MTC the to support 24/7 including urgery,
2019 2019 March PUBLIC BoD QVH
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surgery commissioners.
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department department
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Research and Development Strategy Development and Research •
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strategies aligned and Enablers
Report cover-page References Meeting title: Board of Directors Meeting date: 07 March 2019 Agenda reference: 57-19 Report title: Brighton and Sussex University Hospitals NHS Trust, Western Sussex Hospitals NHS Foundation Trust and Queen Victoria Hospital NHS Foundation Trust Collaboration Sponsor: Steve Jenkin, Chief Executive Author: Amanda Harrison, Joint Programme Director, BSUH and QVH Appendices: A QVH/WSHT/BSUH joint executive programme ToRs B QVH/WSHT/BSUH joint programme steering group ToRs Executive summary Purpose of report: To update the Board on the programme of work associated with the partnership between BSUH, WSHT and QVH Summary of key • A Programme Director is working two days a week to support this work. issues • The clinical services involved currently are paediatric burns, plastic surgery, head and neck and dermatology. • An agreed approach to closer working for back office functions is under development • An initial Board session has been arranged to bring the Patient First initiative to QVH, following its successful roll out from WSHT to BSUH. • A Joint Executive Programme Board (JEPB) has been established to oversee the programme, with specific management of the projects being overseen by a Joint Programme Steering Group (JPSG) and individual working groups.
Recommendation: The Board is asked to approve the Terms of Reference for the Joint Programme Executive Board and note the programme of work to be overseen by this board and the proposed terms of reference for the Joint Programme Steering Group.
Action required Approval
Link to key KSO1: This KSO2: QVH KSO3: This KSO4: KSO5: The strategic objectives work is retains a work is Partnership QVH workforce (KSOs): planned with a world-class planned to working is key need to be kept view to better expertise in improve the current well-informed
meeting the the clinical sustainability services and and engaged needs of the services of service to the future of with this process regional involved. provision QVH population
Implications Board assurance framework: Corporate risk register: Link to risks 1139 patients with complex open lower limb fractures; 968 Delivery of commissioned services whilst not meeting all national standards/criteria for Burns and Paeds Regulation: Legal: Resources: Assurance route Previously considered by: Next steps: This paper is also being considered by the boards of BSUH and WSHT.
QVH BoD PUBLIC March 2019 Page 199 of 254
Report to: Board Directors Agenda item: 57-19 Date of meeting: 07 February 2019 Report from: Steven Jenkin, Chief Executive Report author: Amanda Harrison, Programme Director Date of report: 31 January 2019 Appendices: Terms of reference
Brighton and Sussex University Hospitals NHS Trust, Western Sussex Hospitals NHS Foundation Trust and Queen Victoria Hospital NHS Foundation Trust Collaboration
1 Introduction 1.1 Brighton and Sussex University Hospitals NHS Trust (BSUH), Western Sussex Hospitals NHS Foundation Trust (WSHT) and Queen Victoria Hospital NHS Foundation Trust (QVH) have been seeking to strengthen collaboration between them. This intention has been encapsulated in a Memorandum of Understanding, agreed between the three organisations in 2018.
2 Executive summary 2.1 In support of closer collaboration a joint programme of work has been agreed between BSUH, WSHT and QVH. A Programme Director has been appointed for two days a week to support this work. 2.2 The programme includes the development of closer working relationships in a number of clinical services (paediatric burns, plastic surgery, head and neck and dermatology) with a view to better meeting the needs of the local population and improving the sustainability of service provision. 2.3 An agreed approach to closer working for back office functions is also under development with steps being taken to identify potential areas for collaboration in order to drive efficiency and improve resilience. In addition, a session has been arranged to share the learning and good practice from the Patient First initiative with QVH following its roll out from WSHT to BSUH. 2.4 A Joint Executive Programme Board (JEPB) will oversee the programme with specific management of the projects being overseen by a Joint Programme Steering Group (JPSG) and individual working groups. The JEPB will meet quarterly and will report to the Boards of the respective organisations following each meeting. The Board is asked to approve the Terms of Reference (TOR) for the JEPB so that the governance of the programme can be established
3 Progress to date
Paediatric Burns 3.1 In 2016 a Strategic Outline Case considered the options for the future provision of the paediatric burns services provided by QVH. The preferred option identified was the location of the inpatient elements of the paediatric burns service at the Royal Alexandra Children’s Hospital (RACH). At the time, this did not progress due to a lack of commissioner support for the additional costs associated with this change. 3.2 Following publication of updated national burns standards in 2018 it was agreed to further develop the preferred option to allow a detailed assessment of the associated cost, risks and benefits. A business case that sets out a potential future service model is being developed by QVH. This has included identifying the elements of the service that would be provided by BSUH under a Service Level Agreement to enable the provision of inpatient care on the RACH site. 3.3 The business case is in its final stages of development and will shortly be used to inform a further discussion with commissioners about the feasibility of the preferred option and how quality, safety, operational and financial risks should be managed in the future model of service provision.
QVH BoD PUBLIC March 2019 Page 200 of 254 Plastic Surgery 3.4 BSUH is working collaboratively with QVH to establish a 24/7 plastics service on the Royal Sussex County Hospital (RSCH) site that will ensure the national service specification for Major Trauma Centre services is met. The proposed service will provide trauma, cardiac surgery, non-trauma and reconstructive services including the provision of free flap surgery for lower limb trauma. This service builds on the existing plastic surgery service that is already provided by QVH to BSUH. 3.5 BSUH is developing a business case for the future provision of this extended service which includes a consultant workforce provided by QVH. This is in its final stages of development and will shortly undergo Executive review within QVH and BSUH prior to being submitted to the BSUH Board for approval.
Head and Neck and Dermatology services 3.6 Three provider led service transformation priorities have been agreed by the STP Executive. These are Oral and Maxillofacial Surgery (OMFS), led by Marianne Griffiths; Ear Nose and Throat (ENT) led by Steve Jenkins and Dermatology led by Adrian Bull. It has been agreed that the transformation of OMFS and ENT will be combined into a single Head and Neck workstream. The objective of the Head and Neck and Dermatology workstreams is to address specific service provision issues that cannot be solved by individual providers and develop a future model of care and service model that will meet the needs of the Sussex population whilst addressing the organisational objectives of providers and commissioners and achieving sustainability.
3.7 The workstreams will both develop a future model of care and options for a future delivery for their respective services. They will address specific issues evident in the current service provision including as appropriate those related to: • Clinical sustainability – including resourcing, workforce recruitment and retention, training and clinical supervision, MDT provision and function, clinical variation and variation in outcomes and achievement of best practice and clinical standards • Operational performance – matching capacity and demand, achieving existing performance targets, responding to changes in national and local performance standards/requirements • Financial sustainability for commissioners and providers
3.8 The approach taken by both workstreams will be aligned to ensure consistency and a common set of outcomes. The work will be clinically led and evidence based. Transformation working groups are being established for each workstream and will include trust and commissioner representatives as well as relevant external stakeholders such as the Cancer Alliance, out of area commissioners and providers and professional and regulatory bodies. Developing and implementing a plan that ensures appropriate clinical and stakeholder engagement will be part of the remit of the working groups.
Back Office Functions 3.9 Potential areas for future back office collaboration have been identified with the objective that these should deliver improvements in one or more of the following: efficiency, resilience, effectiveness and economies of scale. Currently, work is underway to scope the individual service requirements that any collaboration will need to deliver, current resources and potential routes to delivering collaborative arrangements, Consideration will also need to be given to the scope of any collaboration both in terms of geography and number and type of services.
Sharing Learning and Transformation methodologies 3.10 A workshop is being set up to share with QVH the learning and benefits of the Patient First vision and improvement programme that WSHT has rolled out to BSUH. This will explain the benefits of the methodology and the structure and application of the programme.
QVH BoD PUBLIC March 2019 Page 201 of 254 4 Governance 4.1 It is intended that a Joint Executive Programme Board (JEPB) will be established by the Boards of each of the three organisations to oversee the programme of work and ensure the overall objective of increased collaboration and closer working between the three organisations is achieved. The proposed Terms of Reference for the JEPB are attached. The JEPB will meet quarterly. Regular reports will be made by the JEPB to the boards of the three respective organisations following each JEPB meeting.
4.2 The programme will be managed through a clinical and managerial steering group, the Joint Programme Steering Group that will meet every six weeks and will report to the JEPB. Task and Finish working groups will be set up for each clinical and non-clinical workstream as these are established. Currently these exist for paediatric burns and plastics and are being established for head and neck services and dermatology.
4.3 A Programme Director has been jointly appointed for two days a week to work across the programme and ensure the individual projects and overall programme of work are delivered.
5 Recommendation The Board is asked to: • approve the Terms of Reference for the Joint Programme Executive Board and • note the programme of work to be overseen by this board and the proposed terms of reference for the Joint Programme Steering Group.
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Queen Victoria Hospital NHS Foundation Trust and Brighton and Sussex University Hospitals NHS Trust and Western Sussex Hospitals NHS Foundation Trust
Joint Executive Programme Board
Terms of Reference
Title: Joint Executive Programme Board Date approved and Approved by the Board of Queen Victoria Hospital NHS Foundation Trust approving body: (QVH) on XXX, by the Board of Brighton and Sussex University Hospitals NHS Trust (BSUH)on XXXX and by the Board of Western Sussex Foundation NHS Trust (WSHT) on XXX Constitution and The Joint Executive Programme Board (JEPB) has been constituted under the establishment: authority of the Boards of QVH, BSUH and WSHT (the partner organisations) in line with the Memorandum of Understanding which sets out the aims and objectives of the strategic partnership between the three organisations and reflects the current management arrangement between WSHT and BSUH.
Accountability: The JEPB is accountable to the Boards of the three constituting organisations Purpose: To ensure that the clinical, operational and financial benefits of a strengthened strategic partnership between the three partner organisations are delivered by
overseeing a programme of work that both defines and makes recommendations on : i. The scope of the future collaboration (clinical/non-clinical and organisational) ii. The timetable and process for delivering change iii. The transaction vehicle(s) required to facilitate collaboration and change and oversees the implementation of specific priority opportunities for increased collaboration and service improvement.
Membership: • Steve Jenkin – Chief Executive, QVH (Co- Chair) • Marianne Griffiths – Chief Executive, BSUH/WSHT (Co-Chair) • George Findlay – Deputy Chief Executive/Chief Medical Officer, BSUH/WSHT • Ed Pickles – Medical Director, QVH • Rob Haigh – Medical Director, BSUH • Abigail Jago – Director of Operations, QVH • Rab McEwan– Chief Operating Officer, BSUH • Oliver Philips – Director of Strategy and Planning, BSUH/WSHT • Ian Francis – Director Of Strategy, QVH • Amanda Harrison – Programme Director The Co-chairs may agree additional attendees as required in line with the duties of the Board.
Communication: A notice of each meeting, including an agenda and supporting papers, will be available for each member of the JEPB one week prior to the date of the meeting. Additional agenda items should be submitted to the Chair at least three days prior to the date of the meeting. As a principle, the late submission of papers will be discouraged, in order to support group members having adequate time to review.
QVH BoD PUBLIC March 2019 Page 203 of 254 Quorum: A quorum shall consist of at least one third of the membership with all organisations being represented by at least one member. Deputies will count towards the quorum.
Frequency of Routine meetings of the group will be held as a minimum quarterly meetings: Extraordinary meetings may also be scheduled to expedite action in respect of any urgent issues arising in the interim period.
Agenda and The Group shall be supported by the Programme Director with administration notes/action support by BSUH. In this respect, support will include: points: • The agreement of the agenda with the Chair, collation of relevant papers, taking and disseminating the minutes, and keeping a record of matters arising and issues to be carried forward. • Ensuring reports are received from the Programme Steering Group and Workstream Groups in a timely manner. • Ensuring the group’s Terms of Reference are reviewed on an annual basis.
Attendance at Members are expected to attend all meetings of the JEPB. With agreement of meetings: the Chair members unable to attend may send a deputy who is briefed and who will count towards the quorum.
One representative from each organisation must be in attendance at the meeting of the JEPB.
Duties: 1. To consider the opportunities for future strategic, clinical and non-clinical collaboration between the three constituent organisations and across the
broader health economy when required, and make recommendations on the priorities for implementation.
2. To identify the benefits delivered by each opportunity at a patient, system and organisation level; including improvements in sustainability, clinical outcomes and financial and operational performance
3. To identify the risks associated with each opportunity including at a patient, system and organisation level and ensure that acceptable mitigations are in place to manage these during implementation and ongoing delivery
4. To identify priority projects and agree the scope, objectives and priorities of the overall programme of work and the objectives, success measures and timeline for the individual workstreams; making recommendations to the respective Boards for agreement
5. To oversee the implementation of the agreed programme of work, identifying risks to implementation, ensuring that effective actions are identified and taken to address these risks and that the impact of these actions on implementation are monitored.
6. To support internal and external communication about the overall programme and ensure communications plans are developed and delivered in support of specific projects
7. To agree option appraisal criteria for assessing the options for achieving workstream objectives in order that preferred options can be recommended to the individual organisation’s Boards for approval
8. To agree any business case or development proposal arising from the
QVH BoD PUBLIC March 2019 Page 204 of 254 programme in order that these can be recommended to individual organisation’s Boards for approval.
9. To receive reports from the Joint Programme Steering Group in order to monitor the implementation of the programme of work.
10. To agree actions to address any risks and issues that are escalated to them
11. To ensure overall programme governance is linked to individual organisational governance arrangements
12. To escalate any concerns, together with recommendations for action, to the Boards of the partner organisations and act as a point of reporting, communication and dissemination of information to the respective organisations.
13. To approve the Terms of Reference and membership of any sub-group, and oversee the work of those sub-groups, receiving exception reports and acting to facilitate the work of the sub-groups.
Sub-groups: The JEPB will oversee the work of a Joint Programme Steering Group and the working groups established to lead specific collaboration projects.
The JEPB has the power to establish any sub-groups required to ensure the successful delivery of its duties. Reporting A summary report of the matters considered by the JEPB should be submitted responsibilities: to each partner organisation for consideration through their internal governance systems.
The JEPB is not a decision making group. Decisions required must be made through the governance arrangements of the member organisations.
Review: Terms of Reference are due for review in January 2020.
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Queen Victoria Hospital NHS Foundation Trust and Brighton and Sussex University Hospitals NHS Trust and Western Sussex Hospitals NHS Foundation Trust
Joint Programme Steering Group
Terms of Reference
Title: Joint Programme Steering Group Date approved and Approved by the Joint Executive Programme Board on XXX approving body: Constitution and The Joint Programme Steering Group (JPSG) has been constituted under the establishment: authority of the Joint Executive Programme Board in line with the Memorandum of Understanding which sets out the aims and objectives of the strategic partnership between the three organisations and reflects the current management arrangement between WSHT and BSUH. Accountability: The JPSG is accountable to the JEPB Purpose: To oversee the implementation of the specific priority opportunities for increased collaboration identified by the JEPB and agreed by the Boards of the
three partner organisations. Membership: • Programme Director – Amanda Harrison (Chair) • Oliver Phillips – Director of Strategy and Planning, BSUH/WSHT • Ian Francis – Director of Strategy, QVH
• Ali McKinley – Head of Business Development BSUH • Peter Lane – Divisional Director of Ops, Specialist Services, Plastics, BSUH • Dominic Clarke – Divisional Director of Ops, Surgery, OFMS, BSUH • Carly Knell – Divisional Director of Ops, Children and Women’s, BSUH • Paul Gable – Service Lead Burns/Plastics, QVH • Georgina Baidya – Service Lead OFMS, QVH • Nora Nugent – Clinical Lead Burns, QVH • Paul Drake – Clinical Lead Orthoplastics, QVH • Martin Jones – Clinical Lead Plastics, QVH • Ken Sneddon – Clinical Lead OMFS, QVH • Brian Bisase – Clinical Lead OMFS/Head and Neck, QVH • Ryan Watkins – Chief for Children and Women, Paed Burns, BSUH • Marco Maccario – Chief for Specialist Services, Plastics, BSUH • Lisa Leonard – Chief for Surgery, OFMS, BSUH. • Jason McIntyre – Finance Lead, QVH • Adam Shields – Finance Lead, BSUH • Emer Keating – Project Manager Paediatric Burns, QVH
The Chair may agree additional attendees/invitees as required in line with the duties of the Steering Group.
Communication: A notice of each meeting, including an agenda and supporting papers, will be available for each member of the JPSG one week prior to the date of the meeting. Additional agenda items should be submitted to the Chair at least three days prior to the date of the meeting. As a principle, the late submission of papers will be discouraged, in order to support group members having adequate time to review.
QVH BoD PUBLIC March 2019 Page 206 of 254 Deputies With the Chair’s agreement members may nominate deputies or other members to represent them at a meeting.
Quorum: A quorum shall consist of at least one third of the membership with all organisations being represented by at least one member. Deputies will count towards the quorum.
Frequency of Routine meetings of the group will be held as a minimum six weekly. meetings: Extraordinary meetings may also be scheduled to expedite action in respect of any urgent issues arising in the interim period.
Agenda and The Group shall be supported with administration support by BSUH. In this notes/action respect, support will include: points: • The agreement of the agenda with the Chair, collation of relevant papers, taking and disseminating the minutes, and keeping a record of matters arising and issues to be carried forward. • Ensuring reports are received from the Programme Steering Group and Workstream Groups in a timely manner. • Ensuring the group’s Terms of Reference are reviewed on an annual basis.
Attendance at Members are expected to attend all meetings of the JPSG. With agreement of meetings: the Chair members unable to attend may send a deputy who is briefed and who will count towards the quorum.
One representative from each organisation must be in attendance at the meeting of the JPSG.
Duties: 1. To manage the overall programme of work and ensure the programme workstreams are on track to meet their objectives within the required
timeframes
2. To establish and maintain individual project governance and reporting to ensure successful delivery of the overall programme
3. To ensure the process of option development and assessment is robust
4. To develop options appraisal criteria and manage the options appraisal process
5. To identify and address risks and issues with the overall programme delivery and individual workstreams, escalating these as required
6. To ensure short and long term impact on clinical, operational and financial performance and sustainability are incorporated into the work of the workstreams
7. To oversee the development of associated business cases or development proposals arising from the programme
8. To ensure comprehensive implementation plans are developed and that the risks and issues associated with implementation are identified and addressed, escalating these as required
9. To oversee the implementation of agreed collaborative working including service developments and improvements.
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10. To monitor and evaluate the benefits realised by collaborative working.
11. To escalate any concerns, together with recommendations for action, to the JPEB
12. To act as a point of reporting, communication and dissemination of information to the relevant operational teams within their respective organisations.
13. To receive reports from the Workstream Groups in order to monitor the implementation of the programme of work.
14. To approve the Terms of Reference and membership of any sub-group, and oversee the work of those sub-groups, receiving exception reports and acting to facilitate the work of the groups.
Sub-groups: The JPSG will oversee the work of the workstream groups established to lead specific collaboration projects.
Reporting A summary report of the matters considered by the JPSG should be submitted responsibilities: to the JEPB for consideration
The JPSG is not a decision making group. Decisions required must be referred to the JPEB and made through the governance arrangements of the member organisations.
Review: Terms of Reference are due for review in November 2019.
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Report cover-page References Meeting title: Board of Directors Meeting date: Thursday, Agenda reference: 58-19 Report title: Nomination and Remuneration Committee Sponsor: Beryl Hobson, Chair Author: Beryl Hobson, Chair Appendices: N/A
Executive summary Purpose of report: To provide feedback to the board of directors on the recent meeting of the Nomination and Remuneration committee.
Summary of key • Confirmation of appraisals of the CEO and Executive Directors issues • Executive remuneration • An update on the Clinical Excellence Awards and revised policy Recommendation: The board is asked to note the contents of this report
Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence [Tick which KSO(s) this experience services recommendation aims to support] Implications Board assurance framework:
Corporate risk register:
Regulation:
Legal:
Resources:
Assurance route Previously considered by: Date: Decision: Previously considered by: Date: Decision: Next steps:
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Report to: The Board of Directors Meeting date: 07 March 2019 Agenda item reference no: 58-19 Report from: Beryl Hobson, Chair Date of report: Monday, 25 February 2019
Nomination and Remuneration Committee update
1. Purpose
The purpose of this report is to provide feedback to the board of directors on the recent meeting of the Nomination and Remuneration committee.
2. Feedback
i) The committee has only met once in the last financial year, as we were waiting for guidance from NHSI regarding Very Senior Managers (VSM) pay which was eventually received at the end of December. This guidance is now applicable to NHS Foundation Trusts. In the letter to Chairs NHSI also advised that a consolidated VSM pay framework is in development and planned for publication by the Department of Health and Social Care in 2019. This letter had been circulated to committee members in December and was included in the papers.
ii) The committee received confirmation on the appraisals of the CEO and Executive Directors. Non-Executive Directors had provided feedback to the CEO for the Executive Directors’ appraisals and to the Chair for the CEO appraisal. The Executives’ objectives included specific board objectives which were the same as those for the Non-Executive Directors.
iii) The committee was mindful of the QVH financial situation and following discussion the 2018/19 remuneration for CEO and Executive Directors was agreed.
iv) The committee received an update on the Clinical Excellence Awards and the revised policy will be on the February Finance and Performance committee agenda.
v) Following the meeting the committee members were asked to undertake a light touch self- assessment of the committee.
3. Recommendation
The board is asked to note the contents of this report
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Report cover-page References Meeting title: Board of Directors Meeting date: 7 March 2019 Agenda reference: 59-19 Report title: Annual review of board performance, evaluation and development Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Clare Pirie, Director of communications and corporate affairs Appendices: A: Well led action plan B: Development of individual Board members C: Record of Board members time with staff groups D: Board seminar work programme Jan 2018 – Feb 2019 E: Options for Board development in 2019/20 Executive summary Purpose of report: The purpose of this report is to consider the performance of the Board of Directors at QVH and identify any actions needed to ensure that the Board has the skills, experience and approach needed to ensure the Trust remains an innovative and high performing organisation. Summary of key This paper is structured around the eight key lines of enquiry of the Care Quality issues Commission’s well led domain, highlighting Board developments in year. Recommendation: The board of directors is asked to: • AGREE the contents of this evaluation, noting that detail will be included in the 2018/19 annual report and accounts. • CONSIDER areas for further Board development work.
Action required Approval Information Discussion Assurance Review [highlight one only] Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: None
Corporate risk register: None
Regulation: This paper enables the Trust to comply with the FT Code of Governance
Legal: None
Resources: This paper seeks best use of existing resources.
Assurance route Previously considered by: N/A Date: Decision: Next steps: This evaluation will be noted in the Annual Report and Accounts
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Report to: Board of Directors Meeting date: 07 March 2019 Agenda item reference no: 59-19 Sponsor: Clare Pirie, Director of communications and corporate affairs Authors: Clare Pirie, Director of communications and corporate affairs Date of report: 18 February 2019 Appendix: A: Well led action plan B: Development of individual Board members C: Record of Board members time with staff groups D: Board seminar work programme Jan 2018 – Feb 2019 E: Options for Board development in 2019/20
QVH Board of Directors Evaluation and Development
Introduction The purpose of this report is to consider the performance of the Board of Directors at QVH and identify any actions needed to ensure that the Board has the skills, experience and approach needed to ensure the Trust remains an innovative and high performing organisation. It builds on the process of regular review undertaken by each sub-committee of the Board.
This is an annual review in line with the QVH value of continuous improvement.
This paper also enables the Trust to comply with the FT Code of Governance, which requires the Board to undertake a formal annual evaluation of its own performance and that of its committees and individual directors. The Code requires that details of this evaluation are included in the Annual Report and Accounts.
In March 2018, the Board received in public the report from the QVH-commissioned, external Well Led review, and of the Board has worked over the last year to build on that feedback. The latest update of the action plan is attached as appendix A.
This paper is structured around the eight key lines of enquiry of the Care Quality Commission’s well led domain, highlighting developments in year.
Recommedation The board of directors is asked to: • AGREE the contents of this evaluation, noting that detail will be included in the 2018/19 annual report and accounts. • CONSIDER areas for further Board development work.
QVH BoD PUBLIC March 2019 Page 212 of 254 CQC theme Developments at Board level in 2018/19 1. Leadership The most effective Boards are those that In May 2018, Abigail Jago joined the Trust as Director of operations following the departure of drive organisational performance Sharon Jones. Abigail has recruited a strong team of business unit managers ensuring that we especially at times of great stress and have the capacity and capability to support the operational effectiveness of the organisation. change. Sound leadership creates an organisational culture of continuous The full Board dedicates a day each year to a facilitated Board development process. In June improvement, motivated staff, and 2018 this was focussed on building a strong team-working approach, including work on enhancing its long term sustainability. accountability, conflict and commitment. It was an important opportunity to make sure we continue to work together as a unitary Board, with members able to give and receive challenge and support in a constructive manner.
The development actitivites undertaken by individual directors are summarised in Appendix B, and show the breadth of work undertaken to ensure that Board members are well equipped to deliver in their roles.
The Trust has a well-developed appraisal process which is used to identify individual development needs. The Chief Executive has agreed with each executive director a personal development plan (PDP) as part of their individual appraisal. The Chair conducts annual non- executive director appraisals and is herself appraised by the chair of the Council of Governors Appointments committee; the Chair and NEDs also have individual development needs documented and reviewed through this process.
2. Vision and QVH 2020: Delivering Excellence is our In November 2018 the strategy was updated to reflect the important workstreams around strategy shared vision for continued success at Partnership with BSUH/Western and Productivity in theatres, which we are implementing QVH. It is based on the straightforward alongside the service aims described in the original strategy document. belief that delivering excellence is the most effective way of ensuring that QVH In February 2019, the Hospital Management Team reviewed the updated clinical strategy for the continues to thrive. Rebuilding lives is Trust, and agreed priority actions for the next year for each of our key service areas. one of the ways we describe our work as a specialist NHS hospital providing life- The Board has an annual programme for receiving an update from each of the clinical directors changing reconstructive surgery, burns on their specialism in the context of the QVH vision and strategy. care and rehabilitation.
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3. Culture As an effective board we need to shape a QVH has a strong culture of celebrating success, and this includes the staff awards ceremony in culture for the organisation which reflects October 2018. There were an impressive total of 243 nominations across nine categories, QVH’s values and is ambitious, self- including more than 50 nominations from the public for the ‘outstanding patient experience’ directed, responsive, and encourages award. We also presented around 70 educational and vocational achievement certificates and innovation. We have a commitment to 27 NHS long service awards. QVH has a lot to be proud of and the staff awards are an openness and transparency and to put important part of that. There is a clear connection between the engagement and motivation of patients and communities at the centre of staff, and patient care. everything we do. In January 2019, the Trust approved the organisational development strategy which sets out our Board members are also expected to vision, ambitions and plans for the development of QVH through its staff so they can make a exemplify the seven Nolan Principles of difference. It outlines five goals covering engagement and communication, attraction and public life: selflessness, integrity, retention, health and well-being, learning and education, talent and leadership. This work will objectivity, accountability, openness, play an important role in supporting the QVH value and culture. honesty, leadership. All Board member have been subject to the Fit and Proper Persons Test since it was introduced in 2014/15. This declaration is included with all Board papers as a reminder and signed off on appointment and annually by the Chair.
4. Governance Good governance involves clarity about In each of the areas reviewed in the external review of governance, QVH demonstrated areas of structures, processes and systems of good practice as well as areas for improvement, and an action plan was developed which is accountability. At QVH these are attached as appendix A. This is a live document which we continue to update. regularly reviewed and improved and the external well-led review was an additional QVH has a highly successful model for governor engagement, with motivated and supportive positive opportunity to improve our governors and a lead governor role on sub-committees that enables them to see NEDs at work governance effectiveness and leadership and more fully discharge their responsibilities around holding NEDs to account. The external culture. review prompted us to revise the Board level engagement agreement to remove any ambiguity around the role of governors attending committees.
In July 2018, the Board revised and approved its Standing Financial Instructions, Standing Orders and Schedule of Matters Reserved for the Board.
The corporate affairs team have developed and now regularly deliver a minute writing course, raising the standard of minutes across the organisation to ensure that we have a good record of assurance and decision making.
QVH BoD PUBLIC March 2019 Page 214 of 254 5. Risks and The Board continues to ensure that the The board seminar in April 2018 addressed appetite for risk, with the support of an external performance organisation has a robust and effective advisor. This was followed by further refinement of the Board assurance framework (BAF) and risk management system. The corporate Corporate risk register (CRR) to aid clarity of understanding of risk, controls and assurances; risk register is reviewed by the Board at this has also strengthened risk-based discussion which focuses on risk management and not each meeting. Public board agendas are just the risks themselves. structured around the Trust’s five key strategic objectives (KSOs). Each KSO In 2018/19 appropriate challenge in Board meetings has been strengthened via assurance- is prefaced by the relevant part of the based reports which incorporate forward looking actions, timelines and improvement BAF, (with overall BAF summary included trajectories, and which facilitate non-excutives in holding the executive to account. in the Chief executive’s report). Detailed explanations of changes to risk scores During 2018/19 the Board undertook an NHS Improvement Board development session on are provided within each relevant section. seeking assurance around operational performance and received a presentation from Surrey and Sussex Cancer Alliance which included comprehensive discussion of operational performance around cancer data and how this is used to gain assurance.
The audit committee self assessment (reported in December 2017 and followed up in December 2018) identified and actioned a number of receommendations including expanding the review of each key strategic objective to include assurance received by other committees and internal audit assurance relating to that KSO; and the addition of clinical audit to the committee work plan.
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6. Information Informal feedback from NHS On a quarterly basis, the Audit committee continues to undertake a deep dive into an individual Improvement (Quality Governance key strategic objective, seeking assurance in respect of gaps and controls. Associate) suggests that QVH Board papers include a good level of detail on The quality and governance committee (reported in April 2018) identified steps needed to quality, operations and finance and the improve the quality of some papers, this included adding a summary of key points and Board works to ensure these are statement of assurance. The committee also agreed to re-visit the annual work plan in view of considered in a holistic way. There has making routine reports less frequent but with increased assurance; strengthen the process of been additional work this year to improve committee members attending local speciality clinical governance meetings; receiving the the provision of meaningful information to minutes of the clinical governance group in full rather than a summary as it is such a key group the Board. reporting to quality and governance committee.
The finance and performance committee self assessment (reported November 2018) identified the need for a more forward-looking approach in some of the discussions; the chair of the finance and performance committee has noted this and takes it into account during the meetings.
7. Engagement The Board ensures it continues to meet Board engagement with external stakeholders has been mapped, including identification of its responsibility to engage with board level leads. stakeholders through various means including attendance of a QVH patient, The Board has agreed a staff engagement plan which better connects the Board to the Trust, where possible, at each public session to triangulating evidence and raising the profile of Board members with staff. describe their experience of care at the Trust. Where difficult to arrange the There is significant and ongoing work in developing the Trust’s partnership with Western Board receives an update from the Sussex Hospitals NHS FT and Brighton University Hospitals NHS Trust, recognising that co- director of nursing on a recent patient operation and collaboration are key to sustainability of the organisation. experience. There is regular continued scrutiny of Friends and Family Test and The patient experience manager attended the meeting in January 2019 to propose a number of patient experience results. ways of improving board engagement in clinical areas. These are currently being progressed.
The Lead Governor role continues to Board members attended estates strategy public drop in sessions and stakeholder events, enable strong and direct engagement talking to members of the public and staff about our vision for the site and listening to their between governors and the Board. All views. members of the Board attend the quarterly meetings of the Council of Governors.
QVH BoD PUBLIC March 2019 Page 216 of 254 8. Improvement Continuous improvement is one of the On 25 March 2019, Peter Landstrom, Chief Delivery and Strategy Officer for Western Sussex core values of QVH. To support this we Hospitals NHS Foundation Trust and Brighton and Sussex University Hospitals Trust (WSHT have identified a need to adopt a service and BSUH) will visit QVH to deliver a workshop on Patient First. This is the continuous improvement methodology, as described improvement methodology developed by WSHT and used recently at BSUH with very positive below. results. The workshop is planned to include the development of timelines for bringing this approach to QVH and engagement of all our staff. Board committees continue to undertake their annual effectiveness reviews, These self-assessments are aligned to the work of the ‘well led’ review and support the Board’s evaluation of performance. Actions taken as a result are described below.
QVH BoD PUBLIC March 2019 Page 217 of 254 Identifying and resourcing Board development As a small trust the funds available for Board development work are limited. The Trust Board budget includes c£1,000pa for training, supporting a small number of paid for opportunities, and c£2,500 for facilitated whole Board development.
As in all areas of the Trust, personal development is achieved through networks, shadowing, opportunities provided at no cost by national bodies such as NHS Providers, Federation of Specialist Hospitals, Healthcare Financial Management Association, NHS Improvement as well as more specialist professional bodies. Board members at QVH have a strong presence in national and regional professional bodies, both contributing and benefiting from these relationships and opportunities.
Board members work hard to balance the time commitment needed for their role at QVH with identifying time to step outside of the Trust for personal development. The culture at QVH encourages and supports personal development while recognising that for executive directors, creating the time needed is often a challenge.
All individual members of the Board, both executive and non-executive, have participated in development opportunities during 2018/19 and have agreed personal development plans. Appendix B sets out the events attended by NEDs and the paid for opportunities taken up by executive directors. This should not be considered a comprehensive list as executive directors spend a considerable proportion of their time on meetings outside of the Trust, but each executive director has identified what they consider their key personal development opportunities over the year.
New directors attend the two day corporate induction which now has a stronger focus on our values and the nature of the work carried out at QVH, with statutory and mandatory training followed up outside of this. The Deputy Company Secretary also provides a tailored local induction programme for new NEDs and executive directors.
Board seminars and clinician presentations Throughout the year there have been a series of Board seminars providing opportunities to gain an understanding of the services provided by the Trust as well as to review the strategic direction. The details of these are described in appendix D. The AGM included presentations by the clinical leads for psychological therapies as well as facial palsy.
The education department delivers an annual programme of evening clinical lectures which are attended by many Board members. The details of these are described in appendix D.
Board members also regularly attend the joint hospital governance committee which meets every six weeks and has a clinical focus including the findings of clinical audit, learning from national and local issues of clinical safety, clinical innovation.
Statutory and mandatory training All Board members remain up to date with core training in areas like information governance and fire safety.
What Board development do we need in 2019/20? The Board is asked to consider the approach we have taken to date, and the priorities for Board development in the coming year. Some of the options for full Board development activities are set out in appendix E; the costs of these need to be negotiated but as a ball park figure we may expect to pay c. £1000 for a senior partner to prepare and deliver a two hour session.
The Board is also asked to consider the best use of the facilitated Board development session planned for June 2019
QVH BoD PUBLIC March 2019 Page 218 of 254 QVH Well led review: Action plan 2018/19
Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 1. Finalise development of the The QVH strategy QVH 2020: Programme Board Patient First Board workshop EMT agreed medium-term strategy and Delivering excellence and established with BSUH 25 March approach to dev of associated underpinning underpinning strategies (IT, and Western clinical strategy. strategies along with an estates etc) regularly reviewed Programme manager in AJ, EP, CP to pull together options appraisal which and updated, including the post. Met with exec team Clinical Strategy slides for Clinical Director for delivers safe, sustainable removal of objectives around Oct 2018. HMT review, using BSUH MaxFacs presented care, compliant with current private and international work Darzi fellow in post clinical strategy format. 28 Jan to Board Jan 19. and known future to concentrate on core business leading clinical Discussion of steps requirements and aligns with activity and opportunities. engagement for Paed burns business case to needed to develop the STP in the longer term. paediatric inpatient burns EMT Feb and Board March. this into clinical Staff expectations that a new strategy. CEO would mean launch of a Estates strategy work new strategy. well underway with staff Dates fixed for and stakeholder ophthalmology and Partnership approach with engagement. High level of plastics clinical BSUH and Western agreed. staff awareness. directors to Initial focus on paediatric burns, present to Board adding in maxfacs and back OD strategy approved. (March and July). office. Staff awareness high but understanding of ‘what it will mean for me’ limited.
Strong participation of all QVH execs and chair in STP recognised.
QVH BoD PUBLIC March 2019 Page 219 of 254 Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 2. Development of an OD The two main areas of focus of Organisational Complete strategy to support the organisational development development strategy above activities and the work over the previous year developed. Board existing Workforce and were approved Jan 2019. Engagement Plan and to help 1) The Leading the Way with staff retention and programme for people who The Director of fostering a culture of self- manage people, with positive Workforce is also leading learning and improvement. results visible in staff survey, system wide work on 2) Work undertaken as part of leadership and talent the engagement and retention plan.
3. NED challenge to be The reviewers commented that - NHSI Board This item has been closed. Complete strengthened via assurance- they observed good NED development session on Board papers are clear and based reports which challenge, and that this needed seeking assurance around Board members have a full incorporate forward looking to be supported through operational performance understanding of the data actions, timelines and assurance rather than (May 2018). presented and how to seek improvement trajectories reassurance from execs. - Away day in June 2018 full assurance. which facilitate holding to in which areas of account. accountability, conflict and commitment were deliberated. - Board presentation from Surrey & Sussex Cancer Alliance which included comprehensive discussion of operational performance around cancer data and how this
QVH BoD PUBLIC March 2019 Page 220 of 254 Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 is used to gain assurance. (September 2018) - All board reports now include a top level summary setting out key messages.
4. Review the current focus on The Hospital Management HMT and performance Appraisal guidance will be Plan to refresh compliance with a view to Team had been established reviews have continued updated to include KSOs and Performance developing a more devolved relatively recently and, to develop and to deliver support cascade approach to Review meetings framework of accountability alongside the performance this framework of individual objectives derived (AJ, MM) that creates and promotes an review meetings, was beginning accountability. from Trust objectives. Timing environment for learning and to address the accountability of for this is aligned to national continuous improvement at clinical directorates. The medical director has guidance expected early 2019. individual and team levels worked with clinical whilst also clarifying and In a small trust there is a directors on an individual Patient First Board workshop improving the organisation’s relatively high level of devolved basis to ensure they have 25 March ability to hold both accountability. support and training re individuals and teams to accountability for account. The director of Workforce is delivering on activity and leading STP-wide work around budget plans. clinical leadership.
5. Development of a board Board members engage actively Agreed approach to Map existing Board Complete stakeholder engagement with staff in a wide variety of regular and recorded stakeholder engagement and plan which will better forums but this had not been Board engagement with identify lead for specific connect the board to the captured or planned centrally. staff launched October stakeholders (CP). trust, to triangulate evidence 2018. This includes and also raise its profile with QVH has strong relationships establishing opportunities Board review of engagement
QVH BoD PUBLIC March 2019 Page 221 of 254 Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 external stakeholders. with external stakeholders, for NEDs to engage with with staff scheduled for again this had not been specific teams. February seminar. documented centrally.
6. Consider a triumvirate This model had been discussed Operations team now While close management Closed management model which but in a small trust it is not fully recruited; new working between nursing, develops buy-in from practical for each clinical business managers in operational and financial medical staff for their directorate to have a unique post. Medical director has leads is subject to a process of corporate role and invest in nursing lead and business ensured development for continuous improvement, this management teams to manager. Clinical Directors on indiv item is now considered closed operate effectively in their basis. as a discrete action. role.
7. Review the provision of Streamline the amount of Board seminar addressed This item has been closed Complete information to the board to information and number of time appetite for risk (5 April). following a review of BAF and provide greater insight and CRR and BAF are reviewed to September 18 Board: CRR and the implementation forward look including prevent ‘risk fatigue’ Ensure Approved the QVH risk of changes set out here. refinement of the BAF and key risks are considered appetite statement. CRR to aid clarity of collectively as the entire risk to Approved the use of heat BAF and CRR will continue to understanding of risk, achieving a strategic objective maps periodically for receive detailed scrutiny at controls and assurances and not as one individual item visual presentation. executive and Board level. support risk-based discussion Approved a revised BAF focused on risk management format which presented not just risks themselves. data in a more meaningful way. Approved new system to capture BAF updates and evidence that actions have been achieved.
QVH BoD PUBLIC March 2019 Page 222 of 254 Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 Integrated dashboard in use at Board from Nov 2018. 8. Deployment of a continuous As a small trust QVH does not Agreement with Patient First Board workshop Board agreement improvement methodology have a dedicated internal BSUH/WSHFT bringing 25 March that Patient First to facilitate innovation and improvement team. Patient First to QVH as will provide the learning. part of partnership improvement Clinical innovation at QVH is arrangements. methodology nationally and internationally needed, as well as recognised. Oct 18 – Unsuccessful supporting the join application to NHSI up of individual Board Development and team roles Programme, with a with the QVH focus on this issue vision and values.
Ongoing work with Association of Specialist Hospitals on policy levers and funding streams to support adoption and spread of innovation in specialist trusts 9. Development of a realistic This item has been closed on Closed but aspirational plan which this action plan as it is returns the trust to covered in full through regulatory compliance across reports to Board on all operational and financial operational performance. targets.
QVH BoD PUBLIC March 2019 Page 223 of 254 Recommendation Context at time of review Actions since review Actions planned Update 22 Jan 2019 10. Review the role of Governors QVH has a highly successful The Board level Complete on committees to avoid model for governor engagement agreement possible conflicts of interest. engagement, with motivated has been revised to and supportive governors and a remove any ambiguity. lead governor role on sub- This agreement was committees that enables them approved by both Board to see NEDs at work and more and Council at their fully discharge their respective meetings in responsibilities around holding July. NEDs to account. Committee secretaries ensure attendance of governor representatives is correctly recorded in the minutes to ensure clarity of role.
In line with committee work programmes, terms of reference of individual committees have been reviewed to ensure membership status of governor representatives is clear.
QVH BoD PUBLIC March 2019 Page 224 of 254 Appendix B Development of individual board members
EVENT
Beryl Hobson • Good Governance Institute (GGI) - Well-led for the future: Development for NHS Board Members • NHS Providers Chairs and CEO meetings x 2 • NHS Providers Governance conference • NHS Providers dinner with Chair of NHSI, Baroness Dido Harding • HFMA Chair, NED and lay member forum • HFMA Annual Chairs Conference • QVH education session (evening) • Presenting on NHS Providers NED Induction course x2 • Interviewing NEDs on other trusts interview panels (x2)
Ginny Colwell • PWC focus group • NHS providers NED forum
Kevin Gould • NHSI/Good Governance Institute: Well led for the future
John Thornton • NHS Providers NED network • HFMA NED network event
Steve Jenkin • Chris Hopson, NHS Providers visit to QVH • STP Programme board meetings • STP executive group meetings • Sussex & East Surrey urgent and emergency network • Clinical Research Network KSS partnership board away day • Federation of specialist hospitals • ICS leadership group development session • Leading for improvement event, NHSI • STP leadership workshop • NHS Providers Chairs and CEO meetings • NHS Providers dinner with Chair of NHSI, Baroness Dido Harding
Jo Thomas • Executive leadership in safeguarding at Sussex Safety and Safeguarding conference • NHS provider days for nursing and medial directors • Regional directors of nursing meetings • 2-day national Chief Nursing Officers conference (March 2018) • Burns management seminar
QVH BoD PUBLIC March 2019 Page 225 of 254 Ed Pickles • King’s Fund Senior Clinical Leaders Course 2018 (12 days) • Quarterly NHSE / GMC Responsible Officer Network meetings – appraisal & revalidation; responsible officer; responding to concerns • STP Clinical and Professional Cabinet meetings • External NHSE appraisal • Clinical Research Network: regional research meetings • NHS Provider Update meetings • Clinical Continuing Medical Education events, including paediatric and general anaesthesia
Abigail Jago • NHS Providers executive director induction
Michelle Miles • NHS Provider Executive Director Induction • The future of NHS Finance
Geraldine • Every two Months HEKSS and south central/NHS Employers Opreshko supported HR Directors meetings which are a mix of information updates and development • Monthly attendance at SES STP HR Directors forum (deputy chair) and quarterly meeting with SES STP DoN’s • Member of SES STP LWAB, meets every 2 months • Chair of SES STP OD Leads meeting
Clare Pirie • NHS Providers networks for communications, charity and company secretaries throughout the year • Regular attendance at STP communications and engagement meetings • Shadowed staff in day surgery, pre-assessment, hand therapy, medical records; compliance in practice inspection in theatres • Jan 2019 Leading the Way strategy development workshop • Jan 2019 observed WSHFT Board meeting
QVH BoD PUBLIC March 2019 Page 226 of 254 Appendix C
Record of Board members time with staff groups, Oct 2018 - Feb 2019
In September 2018 Board members agreed specific areas in which to focus their staff engagement as below. Directors are still encouraged to also engage with staff elsewhere but the link facilitates Board members ‘dropping in’ more regularly and make it easier for staff to identify and understand the role of a specific Board member. Where appropriate directors also spend time talking to patients in this area to triangulate evidence. The director of nursing facilitated initial meetings for NEDs so that staff knew they were coming and understood the process.
Jo Thomas Ed Pickles Michelle Miles Abigail Jago Clare Pirie Non clinical link; Non clinical link; Clinical link; Clinical link; Clinical link; main admin and clerical estates and Burns and critical Peanut ward and outpatients, Medical records facilities care PAU corneo
Geraldine John Thornton Ginny Colwell Kevin Gould Gary Needle Opreshko Clinical link; Clinical link: Non clinical link; Clinical link; Clinical link; pre-op maxfacs finance and infection control safeguarding and assessment and Non clinical link; procurement; and research consultants peri-op (theatres) iM&T pharmacy meeting; histopathology The Chair and CEO were not been included in this to avoid some areas having more senior connection.
The record of Board member engagement in the five months since this date, reflecting significant engagement with staff such as attendance at team meetings, job shadowing etc has been made visible to staff via a white board in the Jubilee Building and is below.
Beryl Hobson, Chair Kitchens, housekeeping, HR, business managers, radiology, main reception volunteers, patient experience, cashiers, C-wing, physio and OT, theatres, histopathology, library, Peanut ward, breakfast/tea staff drop in sessions Steve Jenkin, CEO Hotel services, pharmacy, C-wing, sleep, burns handover, CCU handover, theatres, breakfast/tea staff drop in sessions Clare Pirie, director of Pre-assessment, hand therapy, medical records (all shadowing), communications and corporate theatres (compliance in practice) affairs Abigail Jago, director of Therapies, plastics secretaries, imagining, pharmacy, TRIPS, pre- operations assessment Michele Miles, director of Burns and critical care, Rycroft, medical records, admissions, finance theatres Geraldine Opreshko, director of Outpatients maxfacs, rehab, day treatment centre, theatres workforce & OD Ed Pickles, medical director Main theatres, day treatment centre, C-wing, Peanut ward, critical care, burns and EBAC, outpatients, pathology, HR Jo Thomas, director of nursing Theatres, Peanut ward, medical records John Thornton, NED Estates, Ross Tilley ward (compliance in practice) Ginny Colwell, NED Pharmacy, procurement, nursing quality forum Kevin Gould, NED Outpatients (compliance in practice), IM&T meeting, Gary Needle, NED Ross Tilley (compliance in practice), histopathology
QVH BoD PUBLIC March 2019 Page 227 of 254 Appendix D Board seminars and presentations in 2018/19
Date Event
01 February 2018 Board seminar • External well-led review feedback, including development of action plan • Strategy development work, building on Dec. 2018 seminar • Update on hospital groups and accountable care organisations, in the context of Sussex and East Surrey STP working • 2017 staff survey
05 April 2018 Board seminar • Risk management workshop, externally facilitated • Presentation on process of investigation led by head of risk and patient safety
20 April 2018 FT Members’ event • The Queen Victoria Hospital archive project, presented by Joanna McConville, Project Archivist • Kiwis, Guinea Pigs, pineapples and Hope: 21st century burns treatment, presented by Baljit Dheansa consultant burns & plastic surgeon
03 May 2018 Clinical presentation to Board Histopathology, delivered by Rachael Liebmann, consultant histopathologist
07 June 2018 Board away day This focussed on building a strong team-working culture, including work on accountability, conflict and commitment (externally facilitated).
27 June 2018 Open evening ‘Why East Grinstead? ‘The story of the WWII Maxillofacial Units and how they came about , presented by Mr Andrew Brown, Retired Consultant Oral and Maxillofacial Surgeon
30 July 2018 AGM/AMM • Making faces: the art and science of facial expressions presented by Charles Nduka, Consultant plastic surgeon • Disfigurement: Making Life Worth Living Again presented by Dr Maja Schaedel & Dr Elizabeth Scott-Gliba
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04 October 2018 Board seminar • Finance and waiting lists • CQC inspection preparation • Presentation from research and development team
17 October 2018 Open evening ‘QVH Abroad! presented by Brian Bisase, Jane Dawson and Sarah Bailey 01 November 2018 Clinical presentation to Board Therapies:, delivered by Marc Tramontin, Therapy Services Manager
20 November 2018 Open evening Clinical presentation on working in Afghanistan, delivered by Col. Tania Cubison, burns consultant
06 December 2018 Board seminar • CQC inspection preparation: Board review of domains • BoD discussions with Chair and CEO of Western to agree how best to progress partnership working arrangements • Review of draft workforce and organisational development strategy
03 January 2019 Clinical presentation to Board Maxillofacial Surgery & Orthodontics, delivered by Ken Sneddon, clinical director, OMFS
February 2019 Board seminar • Review of events which led to Trust waiting list issues • Estates strategy update • Review of board engagement with staff • CQC inspection preparation, (well led) with external facilitator
QVH BoD PUBLIC March 2019 Page 229 of 254 Appendix E Options for Board Development Programme 2019/20
Topic Provider Comments
Corporate manslaughter Eversheds Paul Verrico, partner (recommendation through the CoSec network)
Capsticks David Firth, Partner Proposal for presentation to cover the following, but will be happy to adapt it for our specific requirements: • the consequences of health and safety failings including those resulting in fatalities; • dealing with HSE in the course of their enforcement activity; • corporate manslaughter – summary of the offence, and case update; • other sources of criminal liability, and the distinction between corporate vs individual liability; • Health and Safety at Work Act 1974; Wilful Neglect; CQC fundamental standards; Gross Negligence Manslaughter; • effect of the Sentencing Guidelines in force since 1 February 2016; and • other consequences of prosecution/conviction.
Bribery Act 2010 Local counter fraud Enable Board members to seek assurance on the process to ensure that all contractors have (currently internal a compliant bribery policy. Audit Committee leads on this responsibility. auditors, Mazars but will change in 2019/20)
Overview of legal powers Capsticks Peter Edwards, Partner of FTs in respect of Consideration of the examples of hospital chains, groups and other arrangements in the collaborative context of QVH partnership work with Western/BSUH partnerships
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Report cover-page References Meeting title: Board of Directors Meeting date: 07 March 2019 Agenda reference: 60-19 Report title: Annual approval of board committee terms of reference Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Hilary Saunders, Deputy company secretary Appendices: Statutory committee ToRs: Standing committee ToRs • Audit • Finance and performance • Nomination and remuneration • Quality and governance Executive summary Purpose of report: As part of its annual evaluation process, the Board is asked to review and approve its committees’ terms of reference.
Summary of key • As requested by the Board in 2018, terms of reference for all board committees issues have been reviewed and adjustments made to ensure consistency. The majority of changes are therefore formatting and minor grammatical errors. • Amendments are not shown as tracked changes as the revised formatting would have made this difficult to read. However, key changes are set out in the introductory page to each new set of ToRs to make sure they are easily identifiable. Recommendation: The Board is asked to APPROVE the revised terms of reference for each of its committees. Action required Approval Information Discussion Assurance Review Link to key KSO1: KSO2: KSO3: KSO4: KSO5: strategic objectives Outstanding World-class Operational Financial Organisational (KSOs): patient clinical excellence sustainability excellence experience services Implications Board assurance framework: None Corporate risk register: None Regulation: FT code of governance Legal: NA Resources: NA Assurance route Audit previously considered by: Audit committee Date: 12.12.18 Decision: Recommended for approval N&RC previously considered by: N&RC committee Date: 07.02.19 Decision: Recommended for approval Q&GC previously considered by: Q&GC committee Date: 19.02.19 Decision: Recommended for approval F&PC previously considered by: F&PC committee Date: 25.02.19 Decision: Recommended for approval Next steps: Once approved the respective terms of reference will be implemented and reviewed annually (or more frequently if
necessary). The next scheduled review will take place in January 2019.
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Report to: Board of Directors Meeting date: 07 March 2019 Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Hilary Saunders, Deputy Company Secretary Appendix: Audit ToRs
Audit Committee Terms of reference
Introduction The Audit committee undertook an annual review of its ToRs at its meeting on 10 December 2018. In addition, and as requested by the Board in 2018, terms of reference for all board committees have been reviewed and adjustments made to ensure consistency. Following its self assessment in December the Committee agreed no changes were required to the content of the existing terms of reference, and any changes are formatting and minor grammatical errors ony.
Recommendation The Board is asked to APPROVE the Audit committee terms of reference.
QVH BoD PUBLIC March 2019 Page 232 of 254 Terms of reference
Name of governance body Audit Committee
Constitution The Audit Committee (“the committee”) is a statutory, non-executive committee of the Board of Directors.
Accountability The Committee is accountable to the Board of Directors for its performance and effectiveness in accordance with these terms of reference.
Authority The Committee is authorised by the Board of Directors to: • investigate any activity within its terms of reference. • commission appropriate independent reviews and studies. • seek relevant information from within the Trust and from any employee (all departments and employees are required to co-operate with requests from the committee). • obtain relevant legal or other independent advice and to invite professionals with relevant experience and expertise to attend meetings of the committee.
Purpose The purpose of the Committee is the scrutiny of the organisation and maintenance of an effective system of governance, risk management and internal control. This should include financial, clinical, operational and compliance controls and risk management systems. The Committee is also responsible for maintaining an appropriate relationship with the Trust’s internal and external auditors.
Duties and responsibilities On behalf of the Board of Directors, the Committee will be responsible for the oversight and scrutiny of the Trust’s:
1. Integrated governance, risk management and internal control The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (clinical and non-clinical), that supports the achievement of the organisation’s objectives.
In particular, the Committee will review the adequacy and effectiveness of: • All risk and control related disclosure statements (in particular the annual governance statement), together with any accompanying head of internal audit opinion, external audit opinion or other appropriate independent assurances, prior to submission to the board of directors. • The underlying assurance processes, including the board assurance framework, that indicate the degree of achievement of the Trust’s objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements. • The draft quality accounts, including the rigour of the process for producing the
QVH BoD PUBLIC March 2019 Page 233 of 254 quality accounts, in particular whether the information included in the report is accurate and whether the report is representative of both the services provided by the Trust, and of the issues of concern to its stakeholders. • The Board of Director sub-committees, including terms of reference, workplans and span of reporting on an annual basis. • The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reporting and self-certifications. • The policies and procedures for all work related to counter fraud and security as required by NHS Protect.
In carrying out this work, the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. This will be evidenced through the Committee’s use of an effective assurance framework to guide its work and the audit and assurance functions that report to it.
As part of its integrated approach, the Committee will have effective relationships with other key governance bodies of the Trust (for example, the Quality and Governance Committee) so that it understands processes and linkages.
2. Financial reporting The Committee shall monitor the integrity of the financial statements of the organisation and any formal announcements relating to its financial performance.
The Committee should ensure that the systems for financial reporting to the Board of Directors including those of budgetary control are subject to review as to the completeness and accuracy of the information provided.
The Committee shall review the annual report and financial statements before submissions to the Board of Directors focusing particularly on: • The wording in the annual governance statement and other disclosures relevant to the terms of reference of the Committee. • Changes in, and compliance with, accounting policies, practices and estimation techniques • Unadjusted mis-statement in the financial statements • Significant judgements in preparation of the financial statements • Significant adjustments resulting from the audit • Letters of representation • Explanations for significant variances
The Committee should review the Trust’s standing financial instructions, standing orders and the scheme of delegation on an annual basis and make recommendations for change to the Board of Directors.
Internal audit The Committee shall ensure that there is an effective internal audit function that meets the Public Sector Internal Audit Standards 2013 and provides appropriate independent assurance to the Committee, Chief Executive (as accounting officer) and Board of Directors. This will be achieved by: • Considering the provision of the internal audit service and the costs involved.
QVH BoD PUBLIC March 2019 Page 234 of 254 • Reviewing and approving the annual internal audit plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the assurance framework. • Considering the major findings of internal audit work (and management’s response), and ensuring co-ordination between the internal and external auditors to optimise the use of audit resources. • Ensuring that the internal audit function is adequately resourced and has appropriate standing within the organisation. • Monitoring the effectiveness of internal audit and carrying out an annual review.
External audit The Committee shall review and monitor the external auditors’ independence and objectivity and the effectiveness of the audit process. In particular, the Committee will review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will be achieved by: • Considering the appointment and performance of the external auditors, as far as the rules governing the appointment allow (and making recommendations to the council of governors when appropriate). • Discussing and agreeing with the external auditors, before the audit commences, the nature and scope of the audit as set out in the annual audit plan. • Discussing with the external auditors their evaluation of audit risks and assessment of the organisation. • Reviewing all external audit reports, including the Trust’s annual quality report (before its submission to the board of directors) and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.
Whistle blowing The Committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns raised were investigated proportionately and independently.
Counter fraud The Committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud and security that meet NHS Protect’s standards and shall review the outcomes of work in these areas.
Management The Committee shall request and review reports, evidence and assurances from directors and managers on the overall arrangements for governance, risk management and internal control.
The Committee may also request specific reports from individual functions within the organisation (for example, clinical audit).
Other assurance functions The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications for the governance of the organisation.
These will include, but will not be limited to, any reviews by Department of Health
QVH BoD PUBLIC March 2019 Page 235 of 254 arm’s length bodies or regulators/inspectors (for example, the Care Quality Commission and the NHS Litigation Authority) and professional bodies with responsibility for the performance of staff or functions (for example, Royal Colleges and accreditation bodies).
In addition, the Committee will review the work of other Committees within the organisation whose work can provide relevant assurance to the Committee’s own areas of responsibility. In particular, this will include any clinical governance, risk management or quality committees that are established.
In reviewing the work of a clinical governance committee, and issues around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function.
Meetings Meetings of the Committee shall be formal, minuted and compliant with relevant statutory and good practice guidance as well as the Trust’s codes of conduct.
The Committee will meet quarterly.
At least once a year, the Committee should meet privately with representatives of the external and internal auditors.
The Chair of the Committee may cancel, postpone or convene additional meetings as necessary for the Committee to fulfil its purpose and discharge its duties.
The Board of Directors, Chief Executive (as accounting officer), representative of the external auditor and head of internal audit may request additional meetings if they consider it necessary.
Chairing The Committee shall be chaired by a non-executive director, appointed by the Trust Chair following discussion with the Board of Directors.
If the Chair is absent or has a conflict of interest which precludes his or her attendance for all or part of a meeting, the Committee shall be chaired by one of the other non- executive director members of the Committee.
The representative of the external auditor, head of internal audit, and counter fraud specialist have the right of direct access to the Chair of the Committee to discuss any matter relevant to the purpose, duties and responsibilities of the Committee or to raise concerns.
Secretariat The Deputy Company Secretary shall be the secretary to the Audit Committee and shall provide administrative support and advice to the chair and membership. The duties of the secretary shall include but not be limited to: • Preparation of the draft agenda for agreement with the Chair • Organisation of meeting arrangements, facilities and attendance • Collation and distribution of meeting papers • Taking the minutes of meetings and keeping a record of matters arising and issues to be carried forward
QVH BoD PUBLIC March 2019 Page 236 of 254 • Maintaining the Committee’s work programme.
Membership Members with voting rights The Committee will comprise at least three non-executive directors who shall each have full voting rights. The Chair of the Trust shall neither chair nor be a member of the Committee but can attend meetings by invitation of the Committee Chair.
Ex-officio attendees without voting rights • Chief Executive (as Accounting Officer) who shall discuss with the Committee at least annually the process for assurance that supports the annual governance statement. The Chief Executive should also be in attendance when the Committee considers the draft annual governance statement along with the annual report and accounts. • Representatives of the Trust’s internal auditors. • Representatives of the Trust’s external auditors. • The Trust’s counter fraud specialist who shall attend at least two meetings of the Committee in each financial year.
In attendance without voting rights The following posts shall be invited to attend routinely meetings of the Committee in full or in part but shall neither be a member nor have voting rights: • Executive Director of Finance. • Executive Director of Nursing. • The secretary to the Committee (for the purposes described above). • Designated deputies (as described below). • Any other member of the Board of Directors, senior member of Trust staff or advisor considered appropriate by the chair of the Committee, particularly when the Committee will consider areas of risk or operation that are their responsibility. • Representative of the QVH Council of Governors.
The Chair, members of the Committee and the Governor representative shall commit to work together according to the principles established by the Trust’s policy for engagement between the Board of Directors and Council of Governors.
Quorum For any meeting of the Committee to proceed, two non-executive director members of the Committee must be present.
Attendance Members and attendees are expected to attend all meetings or to send apologies to the chair and Committee secretary at least one clear day* prior to each meeting.
Attendees may, by exception and with the consent of the chair, send a suitable deputy if they are unable to attend a meeting. Deputies must be appropriately senior and empowered to act and vote on behalf of the Committee member.
Papers Meeting papers to be distributed to members and individuals invited to attend at least five clear days* prior to the meeting.
QVH BoD PUBLIC March 2019 Page 237 of 254 Reporting Minutes of the Committee’s meetings shall be recorded formally and ratified by the Committee at its next meeting.
The Committee chair shall prepare a report of each Committee meeting for submission to the Board of Directors at its next formal business meeting. The report shall draw attention to any issues which require disclosure to the Board of Directors including where executive action is continually failing to address significant weaknesses.
Issues of concern and/or urgency will be reported to the Board of Directors in between its formal business meetings by other means and/or as part of other meeting agendas as necessary and agreed with the Trust chair. Instances of this nature will be reported to the Board of Directors at its next formal business meeting.
The Committee will also report to the Board of Directors at least annually on its work in support of the annual governance statement, specifically commenting on: • The fitness for purpose of the assurance framework • The completeness and ‘embeddedness’ of risk management in the organisation • The integration of governance arrangements • The appropriateness of the evidence that shows the organisation is fulfilling regulatory requirements relating to its existence as a functioning business • The robustness of the processes behind the quality accounts
The annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee considered in relation to the financial statements and how they were addressed.
In addition, the Committee shall make an annual report to the council of governors in relation to the performance of the external auditor to enable the council of governors to consider whether or not to re-appoint them.
The Committee chair and governor representative shall report verbally at quarterly meetings of the Council of Governors.
Review These terms of reference shall be reviewed annually or more frequently if necessary. The review process should include the company secretarial team for best practice advice and consistency.
The next scheduled review of these terms of reference will be undertaken by the Committee in December 2018 in anticipation of approval by the Board of Directors at its meeting in March 2019.
* Definitions In accordance with the Trust’s constitution, ‘clear day’ means a day of the week not including a Saturday, Sunday or public holiday.
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Report to: Board of Directors Meeting date: 07 March 2019 Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Hilary Saunders, Deputy Company Secretary Appendix: N&RC ToRs
Nomination and remuneration committee Terms of reference
Introduction The Nomination and remuneration committee undertook an annual review of its ToRs at its meeting on 7 February 2019. In addition, and as requested by the Board in 2018, terms of reference for all board committees have been reviewed and adjustments made to ensure consistency. The majority of changes are therefore formatting and minor grammatical errors.
Key points Amendments are not shown as tracked changes as the revised formatting makes this difficult to read. However, key changes are as follows:
• removal of reference to the governors’ Appointments committee which is not relevant to this Committee. At QVH the Nomination and remuneration committee is entirely separate to the Appointments committee. • removal to reference of the requirement for the Council of Governors to approve the removal of the chief executive; this is not part of their statutory duties.
• Addition of responsibilities in relation to the Clinical Excellence Awards process
Recommendation The Board is asked to APPROVE the Nomination and remuneration committee terms of reference.
QVH BoD PUBLIC March 2019 Page 239 of 254 Terms of reference
Name of governance body Nomination and Remuneration (‘Nom and Rem’ or ‘N&R’) Committee Constitution The Nomination and remuneration committee (the Committee) is constituted as a statutory non-executive committee of the Trust’s Board of Directors. Accountability The Committee is accountable to the Board of Directors for its performance and effectiveness in accordance with these terms of reference.
Authority The Committee is authorised by the Board of Directors to: • Appoint or remove the chief executive, and set the remuneration and allowances and other terms and conditions of office of the chief executive. • Appoint or remove the other executive directors and set the remuneration and allowances and other terms and conditions of office of the executive directors, in collaboration with the chief executive. • Consider any activity within its terms of reference. • Seek relevant information from within the Trust. (All departments and employees are required to co-operate with any request made by the committee). • Instruct independent consultants in respect of executive director remuneration. • Request the services and attendance of any other individuals and authorities with relevant experience and expertise if it considers this necessary to exercise its functions. Purpose The purpose of the Committee is to: • Determine the structure, size and composition (including the skills, knowledge, experience and diversity) of the Board of Directors, making use of the output of the board evaluation process as appropriate, and to make recommendations to the Board, as applicable, with regard to any changes. • Work with the chief executive to identify and appoint candidates to fill all executive director and other positions that report to the chief executive. • Work with the chief executive to decide and keep under review the terms and conditions of office of executive directors and other positions that report to the chief executive, including: • Salary, including any performance-related pay or bonus; • Provisions for other benefits, including pensions and cars; • Allowances; • Payable expenses; • Compensation payments.
• Set the overall policy for the remuneration packages and contractual terms of the
QVH BoD PUBLIC March 2019 Page 240 of 254 executive management team. Duties and responsibilities Duties (nominations) • When a vacancy is identified, evaluate the balance of skills, knowledge and experience on the Board, and its diversity, and in the light of this evaluation, prepare a description of the role and capabilities required for the particular appointment. • Use open advertising or the services of external advisers to facilitate candidate searches. • Consider candidates from a wide range of backgrounds on merit against objective criteria. • Ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interests that could result in a conflict of interest are reported. • Ensure that proposed appointees meet the “fit and proper person test”, and confirm their awareness of the circumstances which would prevent them from holding office. • Consider any matter relating to the continuation in office of any executive director including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract.
Duties (remuneration) • Establish and keep under review the national NHSI VSM pay strategy and associated QVH VSM pay principles in respect of executive board directors and other positions that report to the chief executive. • Establish levels of remuneration which are sufficient to attract, retain and motivate executive directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary for this purpose, and at a level which is affordable for the Trust. • Use national guidance and market benchmarking analysis in the annual determination of remuneration of executive directors and other positions that report to the chief executive, while ensuring that increases are not made where Trust or individual performance do not justify them. • Monitor and assess the output of the evaluation of the performance of individual executive directors, and consider this output when reviewing changes to remuneration levels. • The Committee will work with the chief executive to determine the remuneration of the other executive directors.
Responsibilities On behalf of the Board of Directors, the Committee has the following responsibilities: • To identify and appoint candidates to fill posts within its remit as and when they arise. • In doing so, to adhere to relevant laws, regulations, trust policies and the principles and provisions regarding the levels and components of executive directors’ remuneration as defined by section D of the FT Code of Governance.. • To be sensitive to other pay and employment conditions in the Trust. • To keep the leadership needs of the Trust under review at executive level to ensure the continued ability of the Trust to operate effectively in the health economy. • To give full consideration to and make plans for succession planning for the chief executive and other executive directors taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the
QVH BoD PUBLIC March 2019 Page 241 of 254 future. • To sponsor the Trust’s leadership development and talent management programmes to support succession plans and meet specific recruitment and retention needs. • To ratify the recommendations of the Employer Based Awards Committee for medical and dental Clinical Excellence Awards
Meetings Meetings of the Committee shall be formal, minuted and compliant with relevant statutory and good practice guidance as well as the Trust’s codes of conduct. The Committee will usually meet three times a year. The chair of the Committee may cancel, postpone or convene additional meetings as necessary for the Committee to fulfil its purpose and discharge its duties. The Board of Directors, Chief Executive and Director of workforce and organisational development may request additional meetings if they consider it necessary. Chairing The Committee shall be chaired by the chair of the Trust.
If the chair is absent or has a conflict of interest which precludes his or her attendance for all or part of a meeting, the Committee shall be chaired by the senior independent director of the Trust.
Secretariat The Director of Corporate affairs and communications, working closely with the Director of Workforce and organisational development, shall be the secretary to the Committee and provide administrative support and advice to the chair and membership. The duties of the secretary shall include but not be limited to: • Preparation of the draft agenda for agreement with the chair • Organisation of meeting arrangements, facilities and attendance • Collation and distribution of meeting papers • Taking the minutes of meetings and keeping a record of matters arising and issues to be carried forward. • Maintaining the Committee’s work programme.
Membership Members with voting rights The Committee shall comprise all non-executive directors of the Trust who shall each have full voting rights.
Ex-officio attendees without voting rights • Chief Executive • Director of Workforce and Organisational Development
In attendance without voting rights • The secretary to the Committee (for the purposes described above) • Any other member of the Board of Directors, senior member of Trust staff or external advisor considered appropriate by the chair of the Committee.
QVH BoD PUBLIC March 2019 Page 242 of 254 Quorum For any meeting of the Committee to proceed, two non-executive members of the Committee must be present.
Attendance Members and attendees are expected to attend all meetings or to send apologies to the chair and Committee secretary at least one clear day* prior to each meeting.
Attendees, including the secretary to the Committee, will be asked to leave the meeting should their own conditions of employment be the subject of discussion. Papers Meeting papers shall be distributed to members and attendees at least five clear days* prior to the meeting. Reporting Minutes of the Committee’s meetings shall be recorded formally and ratified by the Committee at its next meeting. The Committee chair shall prepare a report of each Committee meeting for submission to the Board of Directors at its next formal business meeting. Review These terms of reference shall be reviewed annually or more frequently if necessary. The review process should include the company secretarial team for best practice advice and consistency.
The next scheduled review of these terms of reference will be undertaken by the Committee before approval by the Board of Directors at its meeting in March 2020. * Definitions • In accordance with the Trust’s constitution, ‘clear day’ means a day of the week not including a Saturday, Sunday or public holiday.
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Report to: Board of Directors Meeting date: 07 March 2019 Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Hilary Saunders, Deputy Company Secretary Appendix: F&PC ToRs
Finance and performance committee Terms of reference
Introduction The Finance and performance committee undertook an annual review of its ToRs at its meeting on 25 February 2019. In addition, and as requested by the Board in 2018, terms of reference for all board committees have been reviewed and adjustments made to ensure consistency. The majority of changes are formatting and minor grammatical errors. Key points Amendments are not shown as tracked changes as the revised formatting makes this difficult to read. However, key changes are as follows:
• The second paragraph under Constitution has been moved to sit under Meetings • Wording under Accountability has been revised slightly to reflect other ToRs • The order in which Duties and responsibilities were presented has been switched around to match the heading, and to reflect other ToRs • Chairmanship is now Chairing and the wording, whilst still pertinent to F&PC, is now consistent with other ToRs • Ex-officio members should not have voting rights, so wording now shows ‘without voting rights’ • Wording around those in attendance with no voting rights has also been updated for consistency but does not change the context • Attendance requirements updated to maintain consistency with other ToRs • Reporting has been updated to reflect the requirement for the Chair to submit a report on the committee to BoD.
Recommendation The Board is asked to APPROVE the Finance and performance committee terms of reference.
QVH BoD PUBLIC March 2019 Page 244 of 254 Terms of reference
Name of governance body Finance and Performance Committee (F&PC)
Constitution The Finance and Performance Committee (“the Committee”) is a standing committee of the Board of Directors, established in accordance with the Trust’s standing orders, standing financial instructions and constitution.
Accountability The Committee is accountable to the Board of Directors for its performance and effectiveness in accordance with these terms of reference.
Authority The Committee is authorised by the Board of Directors to seek any information it requires from within the Trust and to commission independent reviews and studies if it considers these necessary.
Purpose The purpose of the Committee is to assure the Board of Directors of: • Delivery of financial, operational and workforce performance plans and targets; and • Delivery of the trust’s strategic initiatives.
To provide this assurance the Committee will maintain a detailed overview of: • The Trust’s assets and resources in relation to the achievement of its financial plans and key strategic objective four: financial sustainability. • The Trust’s operational performance in relation to the achievement of its activity plans and key strategic objective three: operational excellence. • The Trust’s workforce profile in relation to the achievement of key performance indicators and key strategic objective five: organisational excellence. • Business planning assumptions, submissions and acceptance/delivery of targets
To fulfil its purpose, the Committee will also: • Identify the key issues and risks requiring discussion or decision by the Board of Directors; • Advise on appropriate mitigating actions; and • Make recommendations to the Board as the amendment or modification of the Trust’s strategic initiatives in the light of changing circumstances or issues arising from implementation
Duties and responsibilities Duties Financial and operational performance • Review and challenge construction of operational and financial plans for the planning period as defined by the regulators. • Review, interpret and challenge in-year financial and operational performance • Review, interpret and challenge workforce profile metrics including sickness absence, people management, bank and agency usage, statutory and mandatory training compliance and recruitment
QVH BoD PUBLIC March 2019 Page 245 of 254 • Oversee the development and delivery of any corrective action plans and advise the Board of Directors accordingly • Review and support the development of appropriate performance measures, such as key performance indicators (KPIs), and associated reporting and escalation frameworks to inform the organisation and assure the Board of Directors. • Refer issues of quality or specific aspects of the Quality and governance committee’s remit, and maintain communication between the two committees to provide joint assurance to the Board of Directors.
Estates and facilities strategy and maintenance programmes • Review the delivery of the Trust’s estates and facilities strategy and planned maintenance programmes as agreed by the Board of Directors. • Consider initiatives and review proposals for land and property development and transactions prior to submission to the Board of Directors for approval.
Information management and technology strategy, performance and development • Review the delivery of the Trust’s IM&T strategy and planned development programmes as agreed by the Board of Directors.
Capital and other investment programmes and decisions • Oversee the development, management and delivery of the Trust’s annual capital programme and other agreed investment programmes.
• Evaluate, scrutinise and approve the financial validity of individual significant investment decisions (that require Board approval), including the review of outline and full business cases. Business cases that require Board approval will be referred to the Committee following initial review by the Executive Management Team and/or Capital Planning Group.
Cost improvement plans • To oversee the delivery of the Trust’s cost improvement plans and the development of associated efficiency and productivity programmes.
Business development opportunities and business cases • Evaluate emerging opportunities on behalf of the Board of Directors.
Consider the merit of developed business cases for new service developments and service disinvestments prior to submission to the Board of Directors for approval.
Responsibilities On behalf of the Board of Directors, the Committee will be responsible for the oversight and scrutiny of the Trust’s: • Monthly financial and operational performance • Estates strategy and maintenance programme • Information management and technology strategy, performance and development.
The Committee will make recommendations to the Board in relation to: • Capital and other investment programmes • Cost improvement plans • Business development opportunities and business cases.
QVH BoD PUBLIC March 2019 Page 246 of 254 Chairing The Committee shall be chaired by a non-executive director, appointed by the Trust Chair following discussion with the Board of Directors.
If the Chair is absent or has a conflict of interest which precludes his or her attendance for all or part of a meeting, the Committee shall be chaired by one of the other non- executive director members of the Committee.
Meetings Meetings of the Committee shall be formal, minuted and compliant with relevant statutory and good practice guidance as well as the Trust’s codes of conduct.
The Committee will meet once in each calendar month, on the fourth Monday of the month.
The chair of the Committee may cancel, postpone or convene additional meetings as necessary for the Committee to fulfil its purpose and discharge its duties.
Secretariat The Executive Assistant to the Director of finance and performance shall be the secretary to the Committee and shall provide administrative support and advice to the chair and membership. The duties of the secretary shall include but not be limited to: • Preparation of the draft agenda for agreement with the chairperson • Organisation of meeting arrangements, facilities and attendance • Collation and distribution of meeting papers • Taking the minutes of meetings and keeping a record of matters arising and issues to be carried forward • Maintaining the Committee’s work programme.
Membership Members with voting rights The following posts are entitled to membership of the Committee and shall have full voting rights: • Three non-executive directors (including Committee chair) • Chief Executive • Director of finance and performance • Director of operations • Director of workforce and organisational development
Ex-officio members without voting rights • The Director of nursing
In attendance without voting rights The following posts shall be invited to attend routinely meetings of the Committee in full or in part, but shall neither be a member nor have voting rights. • Representative of the QVH Council of Governors. • The secretary to the Committee (for the purposes described above). • Any member of the Board of Directors or senior manager considered appropriate by the chair of the Committee.
The Chair, members of the Committee and the Governor Representative shall commit to work together according to the principles established by the Trust’s policy for
QVH BoD PUBLIC March 2019 Page 247 of 254 engagement between the Board of Directors and the Council of Governors.
Quorum For any meeting of the Committee to proceed, two non-executive directors and one executive director of the Trust must be present.
Attendance Members and attendees are expected to attend all meetings or to send apologies to the chair and Committee secretary at least one clear day* prior to each meeting.
Attendees may, by exception and with the consent of the chair, send a suitable deputy if they are unable to attend a meeting. Deputies must be appropriately senior and empowered to act and vote on behalf of the Committee member.
Papers Papers to be distributed to members and those in attendance at least three clear days in advance of the meeting.
Reporting Minutes of the Committee’s meetings shall be recorded formally and ratified by the Committee at its next meeting.
The chair shall prepare a report of each Committee meeting for submission to the Board of Directors at its next formal business meeting. The report shall draw attention to any issues which require disclosure to the Board of Directors including where executive action is continually failing to address significant weaknesses.
Issues of concern and/or urgency will be reported to the Board of Directors in between its formal business meetings by other means and/or as part of other meeting agendas as necessary and agreed with the Trust chair. Instances of this nature will be reported to the Board of Directors at its next formal business meeting.
The Committee chair and governor representative shall report verbally at quarterly meetings of the Council of Governors.
Review These terms of reference shall be reviewed annually or more frequently if necessary. The review process should include the company secretarial team for best practice advice and consistency.
The next scheduled review of these terms of reference will be undertaken by the Committee in February 2019 in anticipation of approval by the Board of Directors at its meeting in March 2019.
* Definitions In accordance with the Trust’s constitution, ‘clear day’ means a day of the week not including a Saturday, Sunday or public holiday.
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Report to: Board of Directors Meeting date: 07 March 2019 Sponsor: Clare Pirie, Director of communications and corporate affairs Author: Hilary Saunders, Deputy Company Secretary Appendix: Q&GCToRs
Quality and governance committee Terms of reference
Introduction The Quality and governance committee undertook an annual review of its ToRs at its meeting on 21 February 2019. In addition, and as requested by the Board in 2018, terms of reference for all board committees have been reviewed and adjustments made to ensure consistency. The majority of changes are formatting and minor grammatical errors. Key points Amendments are not shown as tracked changes as the revised formatting makes this difficult to read. However, key changes are as follows:
• The first line under Authority has been revised to reflect the other ToRs but doesn’t affect the meaning • The order in which Duties and responsibilities were presented has been switched around to match the heading, and to reflect other ToRs • Wording around membership has also been updated for consistency but does not change the context • Under papers I’ve moved the paragraph regarding significant adverse variance to sit under Reporting as it’s more relevant here. • Reporting has been updated to reflect the requirement for the Chair to submit a report on the committee to BoD. • Attendance requirements updated to maintain consistency with other ToRs
Recommendation The Board is asked to APPROVE the Quality and governance committee terms of reference.
QVH BoD PUBLIC March 2019 Page 249 of 254 Terms of reference
Name of governance body Quality & Governance (Q&G) Committee
Constitution The Quality and Governance Committee (“the Committee”) is a standing committee of the Board of Directors, established in accordance with the Trust’s standing orders, standing financial instructions and constitution. Accountability The Committee is accountable to the Board of Directors for its performance and effectiveness in accordance with these terms of reference.
Authority The Committee is authorised by the Board of Directors to seek any information it requires from within the Trust and to commission independent reviews and studies if it considers these necessary. Delegated authority includes: • Approval of specific policies and procedures relevant to the Committee’s purpose, responsibilities and duties. • Engagement with Trust auditors in cooperation with the Audit Committee. • Seeking information from within the Trust and commissioning independent reviews and studies if it considers these necessary. • To protect confidentiality, any concerns directly relating to ‘Whistleblowing’ will, in the first instance, be discussed at the private session of the Board meeting to protect confidentiality, or escalated to the Accountable Officer as appropriate.
Purpose The purpose of the committee is to assure the Board of Directors of: • The quality and safety of clinical care delivered by the Trust at either its hub site in East Grinstead or any other of its spoke sites. • The management and mitigation of clinical risk. • The governance of the Trust’s clinical systems and processes.
In order to provide this assurance the Committee will maintain a detailed overview of: • Health and safety • Clinical and information governance • Management of medicines and clinical devices • Safeguarding • Patient experience • Infection control • Research and development governance • All associated policies and procedures.
To fulfil its purpose, the committee will also: • Identify the key issues and risks requiring discussion or decision by the Board of Directors and advise on appropriate mitigating actions. • Make recommendations to the Board about the amendment of modification of the Trust’s strategic initiatives in the light of changing circumstances or issues arising from implementation. • Work closely with the Audit and Finance & Performance committees as necessary.
Duties and Responsibilities Duties • Support the compilation of the Trust’s annual quality accounts and recommend to the Board of Directors its submission to the Care Quality Commission.
QVH BoD PUBLIC March 2019 Page 250 of 254 • Recommend quality priorities to the Board of Directors for adoption by the Trust. • Ensure that the audit programme adequately addresses issues of relevance any significant gaps in assurance. • Receive a quarterly report on healthcare acquired infections and resultant actions. • Receive and review bi-monthly integrated reports encompassing complaints, litigation, incidents and other patient experience activity. • Ensure that where workforce issues impact, or have a direct relationship with quality of care, they are discussed and monitored. • Review bi-monthly quality components of the corporate risk register and assurance framework and make recommendations on areas requiring audit attention, to assist in ensuring that the Trust’s audit plans are properly focused on relevant aspects of the risk profile and on any significant gaps in the assurance. • Ensure that management processes are in place which provide assurance that the Trust has taken appropriate action in response to relevant independent reports, government guidance, statutory instruments and ad hoc reports from enquiries and independent reviews. • Ensure there are clear lines of accountability for the overall quality and safety of clinical care and risk management. • Hold to account business units and directorates (clinical infrastructure/non clinical infrastructure) on all matters relating to quality, risk and governance.
Responsibilities On behalf of the Board of Directors, the Committee will be responsible for the oversight and scrutiny of: • The Trust’s performance against the three domains of quality, safety, effectiveness and patient experience. • Review all serious incident and never event root cause analysis investigations, (ideally prior to external submission) to ensure assurance about the governance of the process and the appropriateness of actions and improvements identified. If timescales do not allow this, the investigation report may be sent externally provided it has been signed off by the Clinical Governance Group and reviewed by the Chair of the Quality & Governance Committee. • Compliance with essential professional standards, established good practice and mandatory guidance including but not restricted to: o Care Quality Commission national standards of quality and safety o National Institute for Care Excellence (NICE) guidance o National Audit Office (NAO) recommendations. o Relevant professional bodies (e.g. Royal colleges) guidance. • Delivery of national, regional, local and specialist care quality (CQuIN) targets.
Meetings Meetings of the committee shall be formal, minuted and compliant with relevant statutory and good practice guidance as well as the Trust’s codes of conduct.
The Committee will meet once every two months in the calendar month before a Board business meeting. During the month where there is no formal Committee meeting, members will instead attend local governance and departmental meetings of the key business units and clinical infrastructure in order to assess the clinical governance processes in place and to gain a deeper understanding of quality in the local services and departments. Members will provide formal feedback to the Committee on their observations of these meetings.
The Committee will have an additional meeting in July to receive the annual reports from the clinical groups which report to the Committee.
The Chair of the committee may cancel, postpone or convene additional meetings as necessary for the Committee to fulfil its purpose and discharge its duties.
QVH BoD PUBLIC March 2019 Page 251 of 254 Chairing The Committee shall be chaired by a non-executive director, appointed by the Trust Chair following discussion with the Board of Directors.
If the chair is absent or has a conflict of interest which precludes his or her attendance for all or part of a meeting, the Committee shall be chaired by one of the other non-executive director members of the Committee.
Secretariat The Executive Assistant to the Director of Nursing shall be the secretary to the Committee and shall provide administrative support and advice to the chair and membership. The duties of the secretary shall include but not be limited to: • Preparation of the draft agenda for agreement with the chairperson • Organisation of meeting arrangements, facilities and attendance • Collation and distribution of meeting papers • Taking the minutes of meetings and keeping a record of matters arising and issues to be carried forward • Maintaining the committee’s work programme.
Membership
Members with voting rights The following posts are entitled to membership of the committee with full voting rights: • X2 non-executive directors • Chief Executive • Director of Nursing • Medical Director • Deputy Director of Nursing • Director of Finance & Performance • Director of Operations • Director of Workforce and Organisational Development
Designated deputies (as described below) are entitled to temporary membership of the committee with full voting rights.
Ex-officio members with voting rights The following bodies shall be invited to nominate an ex-officio member of the committee to represent their interests:
Without voting rights • The Trust’s internal auditor • Clinical Commissioning Group (CCG) – principle commissioner of the Trust’s services.
In attendance without voting rights The following posts shall be invited to attend routinely meetings of the Committee in full or in part but shall not be a member or have voting rights: • The secretary to the Committee (for the purposes described above) • Business managers • Allied health professional lead • Infection control lead • Head of quality and compliance • Head of risk • Patient experience lead • Pharmacy lead • Director of communications & corporate affairs
QVH BoD PUBLIC March 2019 Page 252 of 254 • Audit and outcomes lead • Representative of the QVH Council of Governors
The chair, members of the Committee and governor representative shall commit to work together according to the principles established by the Trust’s policy for engagement between the Board of Directors and Council of Governors.
Quorum For any meeting of the Committee to proceed, the following combination of members must be present: • one non-executive director • either the director of nursing or deputy director of nursing • one other director with voting rights • four members without voting rights.
Attendance Members are expected to attend all meetings or to send apologies to the chair and Committee secretary at least one clear day* prior to each meeting.
Attendees may, by exception and with the consent of the chair, send a suitable deputy if they are unable to attend a meeting. Deputies must be appropriately senior and empowered to act and vote on the behalf of the Committee member.
Papers Meeting papers shall be distributed to members and attendees at least five clear days* prior to the meeting.
Reporting Minutes of the committee’s meeting shall be recorded formally and ratified by the Committee at its next meeting.
The Committee chair shall prepare a report of each Committee meeting for submission to the Board of Directors at its next formal business meeting. The report shall draw attention to any issues which require disclosure to the Board of Directors including where executive action is continually failing to address significant weaknesses.
Papers will be circulated to all non-executive directors to provide additional assurance.
Issues of concern and/or urgency will be reported to the board of directors in between formal business meetings by other means and/or as part of other meeting agendas as necessary and agreed with the Trust chair. Instances of this nature will be reported to the board of directors at its next formal business meeting.
In the event of a significant adverse variance in any of the key indicators of clinical performance or patient safety, the responsible executive director will make an immediate report to the Committee chair, copied to the Trust chair and chief executive, for urgent discussion at the next meeting of the Committee and escalation to the Trust Board.
Final and approved minutes of Committee meetings shall be circulated to the clinical cabinet and non-executive directors. The Committee chair shall provide an update to the Audit Committee.
The Committee chair and governor representative shall report verbally at quarterly meetings of the Council of Governors.
Review
QVH BoD PUBLIC March 2019 Page 253 of 254 These terms of reference shall be reviewed annually or more frequently if necessary. The review process should include the company secretarial team for best practice advice and consistency.
The next scheduled review of these terms of reference will be undertaken by the Committee in February 2019 in anticipation of approval by the Board of Directors at its meeting in March 2019.
Definitions In accordance with the Trust’s constitution, ‘clear day’ means a day of the week not including a Saturday, Sunday or public holiday.
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