Northern Care Alliance (NCA) NHS Group Salford Royal NHS Foundation Trust (SRFT) The Group Board operates as a Committees in Common and conducts shared meeting of: Group Board (Salford) – established by Salford Royal NHS Foundation Trust; and Group Board (Oldham, Bury and Rochdale) – established by Pennine Acute Hospitals NHS Trust. Group Board Meeting Monday, 28th September 2020 From 10.00am via video-conferencing facility (Microsoft Teams) Agenda Part 1 – held in public
1. Opening Matters: 1.1 Patient Story Member of staff
1.2 Apologies for Absence Chairman
1.3 Declarations of Interest All
1.4 Chairman’s Opening Remarks Chairman
1.5 Minutes of Previous Meeting Chairman - minutes from discussion of non-confidential matters at the meeting on 27th July 2020
2. Matters for Decision 2.1 Constitution Group Secretary
2.2 Group Governance Framework Manual Group Secretary
3. Matters for Review/Discussion 3.1 Integrated Group Board Performance Scorecard - Executive Summary Chief Executive Officer - Care Organisation key risks/actions Care Organisation Chief Officers 3.2 Finance and Activity Report Chief Financial Officer
3.3 Infection Prevention and Control Report Chief Medical Officer
3.4 Harm Reduction: Safety Improvement Chief Nursing Officer
3.5 Learning from Deaths Update Chief Medical Officer - Including Oldham and Fairfield Reviews
3.6 Intentional Inclusion At the Heart of the Communities Chief of People We Serve: Our 10 Year Vision for Change 3.7 Social Value Update Chief of People
3.8 Seasonal Influenza Vaccination Programme Chief of People
3.9 Geoffrey Jefferson Institute for Brain Research ChiefNCA Medical # 274090 Director 09/25/2020 10:33:46 4. Matters for Noting
1/2 1/163 4.1 Chairman’s Report from Council of Governors Chairman - meeting on 23 September 2020 4.2 Audit Committee Chairman of Audit Committee - meeting on 30 July and 24 September 2020 4.3 Group Executive Risk and Assurance Committee Chief Executive - meetings held 24 August & 21 September 2019 4.4 Report from Charitable Funds Committee Chairman of Charitable Funds - meeting held on 6 August and 3 September 2020 Committee
5. Closing Matters 5.1 Any Other Business All
5.2 Date and Time of Next Meeting: Chairman Monday, 26th October 2020 from 10am Via video conference facility.
5.3 Resolution: Chairman To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.
Close.
NCA # 274090 09/25/2020 10:33:46
2/2 2/163 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT) The Group Board operates as a Committees in Common and conducts shared meeting of: Group Board (Salford) – established by Salford Royal NHS Foundation Trust; and Group Board (Oldham, Bury and Rochdale) – established by Pennine Acute Hospitals NHS Trust. Shared Agenda Group Board (Committees in Common) Monday, 27 July 2020 at 10:00am Via video-conferencing facility (Microsoft Teams) Part 1 - held in public
Present: Mr Jim Potter, Chairman Mr Raj Jain, Chief Executive Officer Mrs Judith Adams, Chief Delivery Officer Mr Chris Brookes, Chief Medical Officer Ms Nicky Clarke, Chief People Officer Mr Kieran Charleson, Non-Executive Director Mr Tim Crowley, Non-Executive Director Mrs Carmen Drinkwater, Non-Executive Director Mr Simon Featherstone, Interim Chief Officer/Director of Nursing, Bury Care Organisation Mrs Nicola Firth, Director of Nursing/Chief Officer Oldham Care Organisation Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer Mrs Christine Mayer CBE, Non-Executive Director/Vice Chairman Mr Ian Moston, Chief Finance Officer Professor Chris Reilly, Senior Independent Director Mr Jack Sharp, Chief Strategy Officer Mr Peter Turkington, Medical Director/Chief Officer Salford Care Organisation Mr Steve Taylor, Director of Operations/Chief Officer Bury & Rochdale Care Organisation Mrs Jane Burns, Director of Corporate Services and Group Secretary Mrs Rebecca McCarthy, Deputy Group Secretary
Apologies for Absence: Dr Hamish Stedman, Non-Executive Director
Welcome The Chairman welcomed everyone present to the meeting of the Group Board (Committees in Common). The Chairman confirmed that the meeting would be held in two parts: a first part open to members of the public; and a second part in private session for confidential matters.
1. Opening Matters: 1.1 Patient Stories The Group Board (Committees in Common) watched a presentation highlighting the stories of patients whose care had been disrupted NCAby the # 274090 Covid-19 crisis. 09/25/2020 10:33:46 1.2 Apologies for Absence
1/13 3/163 Apologies for absence were noted as above.
1.3 Declarations of Interest The Chairman requested that officers declared any actual or potential conflict of interest relevant to their role as a member of the Group Board (Committees in Common) and in particular to any matter being discussed at the meeting. There were no interests declared. 1.4 Chairman’s Opening Remarks
Holding Board Meetings in Public The Chairman confirmed that due to the government’s current social distancing rules and guidance from NHS Improvement/England (NHSIE), it was not possible to hold face to face meetings of the Board in public, with Board meetings currently taking place in private via videoconferencing facility. The Chairman stated that throughout the pandemic, all non-confidential papers and summaries of the Board’s non-confidential minutes had been made available publicly, with Board agendas and minutes shared with governors throughout, via the Governor Portal, alongside a Chair’s Feedback to governors after each Board meeting.
The Chairman confirmed the meeting today, was arranged in two parts: o Part 1 - All non-confidential matters, and o Part 2 - All confidential matters.
The Chairman stated that the Part 1 agenda, papers and minutes were available to the public via the websites. The Chairman concluded that, from September 2020, the Board would have arrangements in place for members of the public (and staff) to register to observe the meeting, as it is happening, via MS Teams, and that this would be communicated to staff and the public via the website.
Arrangements - Non-Executive Directors The Chairman confirmed that arrangements were being made for all non- executive directors to connect informally with each of the Care Organisation leadership teams, with similar opportunity with the leadership teams of Diagnostics & Pharmacy, Estates and Facilities, Digital and other corporate functions.
Professor of Nursing The Chairman confirmed the Northern Care Alliance NHS Group (NCA) had developed a proposal with the University of Salford for a Professor of Nursing position, and confirmed that this position had now been established and appointed to. The Chief Nursing Officer confirmed the appointment of Professor Heather Iles-Smith and provided a brief summary of Professor Iles- Smith’s experience.
1.5 Minutes of Previous Meeting The minutes from discussion of non-confidential matters at the meeting on 29th June 2020 were reviewed by the Group Board (Committees in Common) and approved as a true record. NCA # 274090 2. Matters for Decision: 09/25/2020 10:33:46 2.1 Group Board Assurance Framework 2020/21
2/13 4/163 The Chief Executive Officer presented a paper describing the transition from the interim Group Board Assurance Framework, detailing significant high-level risks against the delivery of the interim objectives, to the current Group Board Assurance Framework (BAF) 2020/21 as presented. He confirmed that the Group Board had approved the NCA’s strategic priorities and principal objectives and deliverables for 2020/21 at its meeting in June 2020, and presented the principal risks to the delivery of these objectives, along with controls, assurances and required actions. The Chief Executive Officer confirmed that the newly created Group BAF reflected the updated position of the previous interim principal risks and reassessment of the principal risks identified prior to the pandemic (2019/20).
The Chief Executive Officer confirmed that, in line with the NCA’s principal objectives, the Care Organisations and the Group Diagnostics & Pharmacy (D&P) Business Unit had established their objectives for 2020/21, and from this developed their BAFs. He added that the most significant risks (scored at 12 and above) identified by the Care Organisations and D&P had been aligned to the Group’s principal risks, influenced the risk assessments that had taken place at Group-level, and incorporated explicitly within the Group BAF.
The Chief Executive Officer confirmed that the NCA’s current risk appetite was stated within the Group BAF, and expressed his view that further development, in light of the current context, may be valuable for the Group Board. A Non- Executive Director welcomed the opportunity for further debate with respect to risk appetite. Additionally, the Non-Executive Director sought further information with respect to the Infection Prevention Control (IPC) risk, specifically seeking view on a target risk score of 12 (significant risk), albeit the NCA’s risk appetite was to not tolerate risks to patient safety. The Chief Medical Officer acknowledged this comment, highlighting the suite of measures, controls and assurances in place with respect to IPC, as recognised as compliant via the CQC. The Chief Medical Officer expressed his view that further assurance with respect to the reliability of measures in place was required, therefore the current risk was scored as 13, with a target risk score of 12 by the end of September 2020, in light of the need to ensure reliability throughout the suite of measures beyond this.
The Senior Independent Director highlighted inconsistency in the risk score related to medical education between the summary paper and Group BAF. The Group Secretary confirmed consistency in scoring would be corrected.
The Chairman concluded the discussion, further highlighting the value of Chief Group Board exploring risk appetite with respect to the Group BAF. Executive
The Group Board: reviewed the newly created Group BAF for 2020/21, confirmed that it adequately identified the principal risks that may threaten the achievement of the NCA’s objectives for 2020/21; and confirmed that gaps in controls and/or assurances were adequately identified and appropriate mitigating action plans were in place.
2.2 Group Governance: Board Standing Committees NCA # 274090 The Chief Executive Officer presented a paper advising that the Executive09/25/2020 10:33:46 Team had reviewed the sub-Board executive governance committee structure to ensure it was fit for purpose with respect to assuring the delivery of the
3/13 5/163 2020/21 Annual Plan. The Chief Executive Officer presented the revised structure, including the establishment of the Executive Management Committee (EMC), replacing the previous Executive Development Committee. The Chief Executive Officer presented the terms of reference for EMC and described its broad responsibilities. Additionally, he confirmed that, as part of this review, the Group Risk and Assurance Committee (GRAC) terms of reference had been updated to ensure alignment with the recently approved Interim Single Oversight Framework for 2020/21 and presented for review and approval.
In response to a Non-Executive Director seeking further clarity with respect to key change in the responsibilities of the EMC to that of the Executive Development Committee, the Chief Executive Officer provided contextual information regarding Executive Team meetings conducted during the pandemic, noting that the Executive Development Committee had been stood down. He confirmed that the establishment of the Executive Management Committee, formalised and further developed the arrangements deployed during the pandemic, including increased frequency of meeting. He noted that the key responsibilities of the EMC remained broadly the same as the previous Executive Development Committee.
A Non-Executive Director noted the interaction of EMC with Strategy & Investment Committee and expressed his view that a considered future workplan for Strategy & Investment Committee would be beneficial. The Chief Executive Officer and Chief Strategy Officer acknowledged this comment and suggested that the establishment of the EMC, and its corresponding workplan, would support a mutual annual workplan for Strategy & Investment Committee and strategic matters to be considered by the Group Board.
The Group Board: reviewed and confirmed the sub-Board Executive Governance Committee structure (which disestablishes the Executive Development Committee); appointed an Executive Management Committee and approved the proposed Terms of Reference; and approved the revised Terms of Reference for Group Executive Risk & Assurance Committee.
2.3 NAAS: SCAPE Recommendation (Salford and Oldham) The Chief Nursing Officer presented a paper providing recommendations to the Group Board regarding the three teams attending SCAPE Panel on the 16th July 2020.
The Non-Executive Director member of the SCAPE Panel summarised the adapted process in light of the infection prevention control measures in place, highlighting virtual opportunity to engage with members of the Ward T5 and a virtual ward tour. She confirmed her support for the recommendations.
The Group Board reviewed the recommendations and approved SCAPE status for the following teams: NCA # 274090 Community Integrated Respiratory Team – Salford Care Organisation09/25/2020 10:33:46 Childrens Community Nursing Team – Salford Care Organisation
4/13 6/163 Ward T5 – Oldham Care Organisation
2.4 NCA Picture Archiving Communications System - Full Business Case The Chief Financial Officer presented contextual information, alongside the full business case for the NCA in relation to the Picture Archive Communications System (PACS) 10-year contract/solution committing the necessary financial investment to allow for Manchester University Foundation Trust (MFT), on behalf of Greater Manchester Collaborative Imaging Programme, to formally sign with the supplier.
The Chief Financial Officer confirmed that this solution would bring a great range of benefits to patient care, organisational finances and staff/workforce and provide: A unified, standardised modern imaging archive independent of the stakeholders’ viewing and reporting technology platforms A unified enterprise archive suitable for managing other medical images Capability to provide remote reporting e.g. from home or locations outside the trust A compatible platform for the introduction of AI products Greater ability to participate in local, nationally and international research and clinical trials through VNA transfer of imaging and data
The Chief Financial Officer described the procurement process to date and stated that the full business case for GM now required all organisations to sign by the end of August to enable full contract award. The Chief Financial Officer confirmed that the total cost for the 10 year contract for the NCA was £10.2m inclusive of the additional costs required. He added that productivity improvements were estimated to yield approximately £275k per annum for the NCA as a result of reduced requirement for private sector outsourcing of reporting.
The Senior Independent Director expressed his support for the PACS solution, noting the benefit of GM working. He noted that this innovative solution brought both benefit and risk and queried mitigation in this regard. The Chief Executive Officer confirmed that he was the executive sponsor on behalf of the GM Provider Federation Board (PFB), and highlighted that the fragility of the infrastructure throughout the North East sector Care Organisations was such that the risk to patients must be mitigated. He expressed his view that, from the date of implementation, there would be benefit for patient safety, which remained the priority. The Chief Delivery Officer acknowledged the significant risks associated with the work programme and highlighted the establishment of an Implementation Board to work through the detail and decision-making required with respect to the risks articulated within the business case. In response to the Chief of People querying if the solution would enable the sharing of rotas and imaging across the GM system, the Chief Executive Officer confirmed that the solution would provide a platform to develop the imaging network, with future opportunity to share rotas.
In response to a Non-Executive Director seeking clarity with respect to costs, the Chief Financial Officer confirmed that the total cost for the 10 year contract for the NCA was £10.2m inclusive of the additional costs required, with approximately £275k per annum savings for the NCA against existingNCA # 274090 09/25/2020 10:33:46 expenditure.
5/13 7/163 A Non-Executive Director noted that image storage capacity was expected to reach capacity by June 2020 across the NCA; with go live for the PACS solution scheduled for November 2020, she queried the level of risk to be managed during this interim period. The Chief Financial Officer confirmed that an interim solution had been ordered within the sector to mitigate this risk.
The Group Board: provided approval for the GM Collaborative Imaging Programme FBC based on financial commitment required by NCA for SRFT and PAHT approved the non-recurring costs 20/21 (£352k) accepted the identified major risks and mitigating actions highlighted in the full business case noted the position and deployment plan for SRFT and PAHT noted that the scope of the NCA deployment includes NMGH volumes noted the development of a collaboration agreement with MFT
3. Matters for Review/Discussion: 3.1 Integrated Group Board Performance Scorecard - update on key risks from each Care Organisation The Chief Executive Officer presented the Group Board Performance Scorecard, emphasising the national focus on resuming access standards. The Chief Nursing Officer referred to the patient stories presented at the opening of the Group Board, which had highlighted the impact of Covid-19 on quality, safety and patient experience and emphasised the focussed attention that must be given to access standards.
The Chief Officer for the Bury & Rochdale Care Organisation, Oldham Care Organisation and Salford Care Organisation provided update with respect to current performance against national access standards. Notably, Care Organisation Chief Officers highlighted work taking place with system leaders to ensure plans were in place for the forthcoming winter period with a focus on managing patients at home or in the community where possible. The Bury & Rochdale Care Organisation Chief Officer highlighted concern with respect to the ophthalmology waiting list size, which had seen further growth during the Covid-19 pandemic. He confirmed that a diagnostic review was being undertaken, with the outcome to be reported to Group Executive Risk & Assurance Committee in September 2020.
The Chief Delivery Officer further iterated the challenging period ahead, noting that patient experience and patient safety were at the heart of the plans and trajectories for elective care being developed by the Care Organisations. She confirmed that a number of capital submissions had been made to support capacity and demand challenges, emphasising that the organisation must consider mitigation should capital submissions not materialise. The Chief Delivery Officer offered that this would include consideration of how the estate may be utilised over a 7 day period, and the financial consequences of this. To conclude, the Chief Delivery Officer highlighted the importance of the independent sector to support recovery, noting that national agreement for independent sector usage had been extended to October, with further work to ensure optimum utilisation within the region. The Chief Financial Officer expressed his view that inequalities in independent sector provisionNCA must # be 274090 addressed, noting variability in access across the country. 09/25/2020 10:33:46
The Chief Medical Officer highlighted previous trend, over the winter period, to
6/13 8/163 utilise hospital beds allocated for elective care for non-elective care. He highlighted a paradigm shift for the organisation in this regard, as infection prevention and control measures would prevent this. The Chairman acknowledged the importance of the Group Board remained appraised with respect to independent sector utilisation.
The Vice-Chairman referred to a disparity in mortality between the Salford Care Organisation and the Bury & Rochdale and Oldham Care Organisations, and queried how differences in mortality, including Covid-19 deaths, were being monitored. The Chief Medical Officer acknowledged the differential mortality, confirming that a deep dive had been undertaken at the Fairfield General Hospital and Royal Oldham Hospital to understand differences in Covid-19 mortality in collaboration with the regional mortality cell. He confirmed that the outcome would be reported to the Group Board in September 2020. The Chief Officer for Salford Care Organisation highlighted the correlation between the prevalence of Covid-19 within the community and Covid-19 mortality, and emphasised the importance of public health data to inform the work in local systems, with hospitals requiring the agility to respond to movement within the community.
In response to the Vice-Chairman querying how the Group Board would be alerted to infant mortality as this was not included within the Group Board Performance Scorecard, the Chief Nursing Officer confirmed the recent introduction of a six monthly Maternity Safety Update to ensure the Group Board remained appraised on this matter.
The Chief Delivery Officer confirmed that a new Group Performance Scorecard had also been presented to the Group Based based on the Annual Plan Principal Objectives for 2020/21.
The Group Board reviewed and confirmed the Group Board Performance Scorecard.
3.2 Finance and Activity Report The Chief Financial Officer presented the Finance & Activity Report as at 30th June 2020 (Month 3). He confirmed the following:
SRFT: The Month 3 financial position was a £2.3m surplus (£1.3m deficit year to date). After including the Covid-19 retrospective repayment the SRFT adjusted financial position was break even.
PAT: The Month 3 financial position was a £5.9m deficit (£16.6m deficit year to date). After including the Covid-19 retrospective top up the PAT adjusted financial position was break even.
The Chief Financial Officer commented that, although agreement on a regional control total for capital had not been reached, the Group Executive Capital Committee had agreed to progress the planned programme of life cycling.
A Non-Executive Director recognised that there was no current national requirement for cost improvement programmes, however queried how the organisation was prepared to respond to any further change in the NCAnational # 274090 financial framework should the previous levels of cost improvement be09/25/2020 10:33:46 required. The Chief Financial Officer stated that it was as yet unclear when
7/13 9/163 ‘normal’ financial arrangements would resume, albeit noting that the collective GM control total challenges would require attention. The Chief Financial Officer Chief commented that he intended to provide update to the Group Board regarding Financial key change programmes and the productivity impact in due course. Officer
The Senior Independent Director referred to the significant capital spends on digital and queried if alternative funding streams may be available. The Chief Financial Officer confirmed that capital had been received from national funding streams, however there were no other streams currently available.
Group Board reviewed and approved the reported financial position of each Trust.
3.3 Infection Protection and Control: Assurance Framework The Chief Medical Officer presented the Infection Prevention and Control (IPC) Assurance Framework update, advising that national guidance on required IPC measures to control the risk had to rapidly evolve in response to learning. He informed the Group Board that in May 2020, the NHS England board assurance framework (BAF) was published, providing a systematically reviewed assurance framework based on 10 IPC criteria designed to minimise the risk of infection to service users and staff as set out in the Code of Practice on IPC.
The Chief Medical Officer confirmed that the BAF also supported healthcare providers to effectively self-assess their compliance with national guidance thereby providing assurance on reliability of IPC, and identifying any risks to quality standards. He concluded that engagement meetings had been held between the NCA and the CQC on the 29th May and 16th July 2020, following submission of the NCA BAF, providing opportunity to update the CQC on a number of initiatives and innovations such as the introduction of IPC Safety Officers and Mini-NAAS. The Chief Medical Officer confirmed that the CQC had confirmed compliance with all aspects of the BAF. Notwithstanding this assurance, the Chief Medical Officer highlighted the importance of receiving further assurance with respect to the reliability of the measures in place.
In response to the Vice-Chairman querying if there was any concern with respect to the discharge of patients to care homes, the Chief Medical Officer expressed his view that, although no immediate concerns, this was a matter that required continued attention and work with partners to adopt a whole system approach. The Chief Officer for Bury & Rochdale Care Organisation highlighted work undertaken locally to support the care home sector and agree pathways of care, highlighting that care homes were an integral part of recovery planning. The Chief Delivery Officer confirmed that the ‘Home First’ strategy and establishment of the virtual hospital was set up to support care homes, providing access to digital support and advice.
In response to the Senior Independent Director querying if progress had been made increasing testing capacity, the Chief Medical Officer confirmed that progress had been, made notably with respect to GP testing of patients before they attend hospital. He expressed his view that progress was required with respect to the testing of asymptomatic staff. NCA # 274090 09/25/2020 10:33:46 A Non-Executive Director referred to the introduction of IPC Safety Officers for
8/13 10/163 3 months to help embed culture change with regards to IPC and expressed her view that culture change took time to embed. The Chief Medical Officer acknowledged this comment and expressed view that should evidence show that the IPC Safety Officers were integral to supporting culture change, consideration would be given as to how these positions were utilised beyond 3 months.
The Group Board noted the report and the attached Board Assurance Framework document.
3.4 People Report The Chief of People presented a report providing an overview of work against the KPIs and plan agreed as part of the People Strategy. She highlighted that, in response to Covid-19, a number of work streams had been paused with recovery plans produced and progress reported.
In addition to recovery plans, the Chief of People presented an overview of themes from concerns that had been raised to the Freedom to Speak up Guardians, noting that there had not been an increase during Covid-19. In addition, the Chief of People highlighted support put in place for BAME staff given the increased risks to this population relating to Covid-19.
In response to a Non-Executive Director seeking further information regarding the nursing agency spend in the Oldham Care Organisation, the Chief Officer for Oldham Care Organisation (OCO) confirmed that non Covid-19 agency expenditure continued to reduce, however staffing ratios had been increased in the Emergency Department and Intensive Care during the pandemic which had contributed to the increase. The Chief Officer for OCO confirmed that robust processes with respect to the use of bank and agency staff had been maintained, with an improved position based on the previous year. The Chief of People provided contextual information, highlighting that Salford Care Organisation had a low vacancy rate in comparison to other Care Organisations.
The Vice-Chairman welcomed the inclusion of support provided for BAME staff, and queried how this information aligned with the broader BAME strategy. The Chief of People confirmed that report would be provided to the Group Board in September 2020 with respect to the BAME strategy and ambitions discussed via the Inclusion Committee and Leadership Council. The Chief Financial Officer expressed his support for a wider lens on this work, highlighting opportunity to consider equality matters throughout the supply chain.
The Chairman welcomed the comprehensive report, suggesting a summarised version, with Care Organisation deep dive where required, for future reporting.
The Group Board received and reviewed the content of the report. NCA # 274090 3.5 Quality Improvement and Harm Review Update 09/25/2020 10:33:46 - including the Quality Improvement Dashboard
9/13 11/163 The Chief Nursing Officer presented a paper providing comprehensive update on the projects in the Quality Improvement Strategy including: Recovery Cell - Planned Unadmitted Recovery Cell - Planned Admitted Recovery Cell - Community Recovery Cell - Unplanned Care Quality, Harm & Mortality, and Patient Experience QI Capability Building
In addition, the Chief Nursing Officer presented a Quality Dashboard for July 2020.
The Vice-Chairman referred to the changes in delivering planned care, including the introduction of virtual appointments, and sought assurance that the experience of patients was being considered within such changes. The Chief Nursing Officer confirmed that the patient experience strategy was being reshaped in light of current circumstances, considering how recovery plans could be designed with the patient voice at the fore. The Chief Nursing Officer acknowledged that virtual consultations were a different experience for patients, influenced heavily by the person delivering the consultation. The Chief Nursing Officer expressed her view that training for staff in conducting virtual consultations that met the patient’s needs may be required.
The Senior Independent Director noted that the ‘home first’ strategy would increase the care provided within primary and community care setting and queried how this increase in workload would be managed. The Chief Nursing Officer confirmed that the collaborative had been developed by expert faculties that included primary care clinicans and community services, and highlighted the importance of measuring performance at a locality level therefore keeping abreast of challenges throughout the system.
The Group Board reviewed and confirmed the NCA Quality Improvement and Harm Review Update and Care Organisation Quality Improvement Dashboards.
3.6 CQC Improvement: SRFT and Oldham, Bury & Rochdale The Chief Nursing Officer presented a report providing an update on progress against the CQC ‘should’ do actions for Salford Royal NHS Foundation Trust.
In addition, a report providing an update of the progress made in relation to the action plans developed against the ‘must’ and ‘should’ do requirements following the comprehensive CQC Inspection undertaken across the Pennine Acute Hospitals NHS Trust, North East Sector Care Organisations between 3rd and 26th September 2019.
The Group Board noted and confirmed the content of the reports, and agreed to receive updates on progress against the PAHT action plans four times per year. NCA # 274090 09/25/2020 10:33:46
10/13 12/163 3.7 Patient, Service User & Carer Experience Report The Chief Nursing Officer presented a paper providing a high level update on patient/service user experience and volunteering. The Chief Nursing Officer described: Proposed re-start plans for experience (next 12-18 month) Volunteers - Learning from the pandemic Update on NAAS & CAAS was also provided.
The Vice-Chairman commented that Complaints Review Panel had not taken place since February 2020, and sought confirmation that opportunities for learning were not being overlooked. The Chief Nursing Officer informed Group Board that nationally, response to complaints had been paused, however the NCA had continued to respond to urgent complaints throughout the pandemic and had now recommenced full response. She confirmed plans to reinstate the Complaints Review Panel via virtual meetings, which would include complaints from both pre Covid-19 and the Covid-19 period. The Chief Nursing Officer informed Group Board that the suspension of visiting was a cause of concern for patients and their families.
In response to the Vice-Chairman seeking further information regarding the change in performance against the NAAS within Bury & Rochdale Care Organisation wards, the Chief Nursing Officer described the significant ward and departments changes within the Fairfield General Hospital throughout Covid-19, including wholesale redeployment of staff. She highlighted this as a key piece of learning that had emerged from the Mini-NAAS.
The Group Board reviewed and noted the content of the report.
3.8 Health & Safety Report The Chief Nursing Officer presented the Health & Safety Annual Report 2019/20, providing information on how the health and safety agenda had been delivered across the NCA in the last 12 months.
The Vice-Chairman noted the increase in verbal abuse and physical assault of staff and queried what more could be done to address this. The Chief Nursing Officer explained that this matter received on-going attention, with the Security and Safeguarding Teams working with frontline teams to provide support. The Chief Nursing Officer, again referred to the impact of visiting restrictions, with an increase in verbal abuse over recent months as friends and family were unable to see loved ones. The Chief Nursing Officer confirmed that, where the member of the public/patient had capacity, there were occasions where criminal charges had been made. The Chief of People provided her experience that staff were not always willing to press charges. She reiterated the impact of visiting restrictions and suggested coordinated communications / messaging to support in addressing this.
The Group Board received and confirmed the content of the Health & Safety Annual 2019/20 report.
3.9 Estate Due Diligence Update NCA # 274090 09/25/2020 10:33:46 The Chief Delivery Officer presented a paper that provided an overview of the progress made since the completion of the estates ‘deep dive’ surveys,
11/13 13/163 backlog works completed in 2019 – 2020 and an update on revised backlog costs. She highlighted that estates risks had been reduced and mitigated and provided an outline of the works still required and associated backlog costs now identified as a result of the deep dive analysis.
In addition, the Chief Delivery Officer sought approval to make a Year 2 emergency loan application to NHSI/E for £13.1m to continue to address the high and significant backlog elements of the Pennine estate.
The Group Board: Noted that the estates risks initially identified in the Group Board paper of January 2019 were being adequately addressed and that the deep dive surveys had provided sufficient information and assurance to confirm that whilst the infrastructure still required significant investment, enough was now known to provide assurance that its condition remained stable. Noted that NHS Estate code requested that Trusts eradicate all high risk and significant backlog works within a 12 – 24 month period. Given the extent of work required, the Group Board acknowledged that the NCA was entering year 2 of a planned 5 year approach due to the extent of the investment and effort required in the Pennine Estate. Approved another £13.1m emergency loan application to NHSI/E to continue with the work previously highlighted in order to further reduce the estates risks and improve infrastructure. Noted that the working relationship between the operational estates teams at NCA and MFT remained positive with sharing of information, key risks and programme of works in readiness for a safe handover when the commercial transaction was undertaken
3.10 Northern Care Alliance Fundraising Strategy Update The Chief Strategy Officer presented a paper advising that the Fundraising Strategy, approved in November 2019, had set out a strategic approach for the NCA to develop fundraising over the five years from 2020/21, enabling it to diversify and increase its income. He confirmed that the strategy was now being mobilised, and summarised the progress that had been made to date, including recruitment to key posts, infrastructure developments, and progress against key financial targets and timescales.
The Chief Strategy Officer also provided information on recent fundraising activities related to the Covid-19 pandemic.
The Group Board: Noted the progress that had been made in respect of the implementation of the Fundraising Strategy and endorsed the extension of the mobilisation plan. Noted the fundraising activities that had been undertaken for Covid-19. NCA # 274090 09/25/2020 10:33:46 4. Matters for Noting:
12/13 14/163 Reports from Standing Committees: 4.1 Executive Group Risk and Assurance Committee Group Board reviewed key matters and decisions made at the meeting held on 20th July 2020
4.2 Charitable Funds Committee Group Board reviewed key matters and decisions made at the meeting held on 21st July 2020. Group Board ratified the terms of reference for the SRFT Charitable Funds Committee
5. Closing Matters: 5.1 Any Other Business No other business. 5.2 Date and Time of Next Meeting: Monday, 28th September 2020 from 10am Venue: MS Teams
5.3 Resolution: To exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. The press and public are requested to leave at this point.
Close.
NCA # 274090 09/25/2020 10:33:46
13/13 15/163 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Proposed Changes to Foundation Trust’s Constitution
Meeting Group Board (Committees in Common) Rebecca McCarthy, Deputy Trust Secretary Author Jane Burns, Group Secretary Presented by Jane Burns, Group Secretary Date 28th September 2020
Executive All Foundation Trusts are required to have a Constitution. Presently, SRFT’s Summary Constitution describes the structure of an SRFT membership and the composition of a statutory SRFT Council of Governors.
To reflect the acquisition, SRFT’s Constitution must be revised to include a representative membership that spans Salford, Oldham, Bury and Rochdale and a statutory Council of Governors with representation from the broader membership base (i.e. Salford, Oldham, Bury and Rochdale) and the broader stakeholder relationships that the acquisition brings.
The Northern Care Alliance NHS Group has consulted with its shadow Group Council of Governors in setting a revised membership structure and a revised composition of the Council of Governors. This proposal was presented and approved by the Council of Governors at its meeting on 23rd September 2020.
Furthermore, required changes have been made to the Foundation Trust’s Constitution, reflecting changes to the membership structure and composition of the Council of Governors. The Constitution has also been amended to: Revise quorum of the Council of Governor to 11 Governors (i.e. approximately one third of the Council) regardless of type (public, staff or appointed) shall form a quorum Restrict a person from becoming or continuing as a Director or Governor of the Foundation Trust if they are a person in relation to whom a moratorium period under a debt relief order applies (under Part 7A of the Insolvency Act 1986), Revise the membership of the Board to include: not less than four and not more than seven other Non-Executive Directors who are to be appointed (and removed) by the Council of Governors at a General Meeting
A list of all amendments is included as Appendix 1.
The amendments to the Constitution were approved by the Council of Governors at its meeting on 23rd September 2020.
The full Constitution with tracked changes is available from the Group Secretary’s office if required by any member of the Group Board.
Recommendations The Group Board is asked to approve the proposed amendments to the Trust’s Constitution with effect from the date of the legal acquisition.
NCA # 274090 09/25/2020 10:33:46
1/5 16/163 Appendix 1: Proposed Changes to the Trust’s Constitution
Deleted text has been striked through; additional text is underlined.
1. “areas of the Foundation Trust” means the two areas specified in Annex 1 which are (1) Salford and (2) Rest of England and Wales 2. “Bury Care Organisation” means the Fairfield General Hospital and community and/or other services provided by the Foundation Trust within the area covered by Bury local 3. Oldham Care Organisation” means the Royal Oldham hospital and community and/or other services provided by the Foundation Trust within the area covered by Oldham local authority; 4. “Rochdale Care Organisation” means the Rochdale Infirmary and community and/or other services provided by the Foundation Trust within the area covered by Rochdale local authority; 5. “Salford Care Organisation” means the Salford Royal hospital and community and/or other services provided by the Foundation Trust within the area covered by Salford local authority 6. “staff constituency” means (collectively) those members of the four classes comprising the staff constituency; 7. “University Governor” means a Governor appointed by University of Manchester or University of Salford. 8. There are two five public constituencies corresponding to the five two areas of the Foundation Trust specified in Annex 1. 9. The staff constituency is divided into classes as follows: Oldham – comprising all those eligible to become a member of the staff constituency whose primary site of work is within the Oldham Care Organisation; Salford Health and Social Care; Surgery and Neurosciences; Clinical Support Services and Tertiary MedicineBury – comprising all those eligible to become a member of the staff constituency whose primary site of work is within the Bury Care Organisation; Corporate and General ServicesRochdale - comprising all those eligible to become a member of the staff constituency whose primary site of work is within the Rochdale Care Organisation; and Salford - comprising all other individuals who are eligible to become a member of the staff constituency, including, but not limited to, those individuals whose primary site of work is within the Salford Care Organisation.
10. The Foundation Trust is to have a Council of Governors. It is to consist of Public Governors, Staff Governors, a Local Authority Governors and a University Governors. 11. The Council of Governors of the Foundation Trust is to comprise: sixteenseven Public Governors from the following public constituencies: Salford – five Public Governors; Oldham – four Public Governors Bury – two Public Governors; Rochdale – three Public Governors and Rest of England and Wales – two Public Governors; NCA # 274090 09/25/2020 10:33:46 four eleven Staff Governors from the following classes; SalfordOldham Health and Social Care – one three Staff Governors; Surgery and NeurosciencesBury – one two Staff Governors; Clinical Support Services and Tertiary MedicineRochdale – twoone Staff Governors;
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2/5 17/163 Appendix 1: Proposed Changes to the Trust’s Constitution
Salford – four staff Governors. Corporate and General Services – one Staff Governor.
two Local Authority Governors appointed jointly by Salford City Council, Bury Council, Rochdale Council and Oldham Council;
one University Governor appointed by University of Manchester; and. one University Governor appointed by University of Salford.
12. Local Authority Governor The Secretary, having consulted Salford Cityeach of the Councils is to adopt a process for agreeing the appointment of thea Local Authority Governors with those local authorities with that local authority. 13. University Governor The Secretary, having consulted with University of Manchester and the University of Salford, is to adopt a process for agreeing the appointment of eacha University Governor with that University 14. Eligibility to be a Governor A person may not become a Governor of the Foundation Trust, and if already holding such office will immediately cease to do so, if: they are a person in relation to whom a moratorium period under a debt relief order applies (under Part 7A of the Insolvency Act 1986), they have a formal role with within athe Salford Clinical Commissioning Group with whom the Trust holds one or more contracts.
15. Eight Eleven Governors (i.e. approximately onetwo thirds of the Council) regardless of type (public, staff or appointed) shall form a quorum 16. The board is to include: the following non-executive Directors: a Chairman, who is to be appointed (and removed) by the Council of Governors at a General Meeting; not less than four and not more than sevenix other non-executive Directors who are to be appointed (and removed) by the Council of Governors at a General Meeting; 17. Only a member of one of the public constituencies or an individual exercising functions for University of Manchester or University of Salford is eligible for appointment as a non-executive Director. 18. A person may not become or continue as a Director of the Foundation Trust if: they are a person in relation to whom a moratorium period under a debt relief order applies (under Part 7A of the Insolvency Act 1986), in the case of a non-executive Director, they are no longer a member of one of the public constituencies or exercising functions for University of Manchester or University of Salford; 19. Every unresolved dispute which arises out of this constitution between the Foundation Trust and: a member; or any person aggrieved who has ceased to be a member within the six months priorNCA to # the 274090 date of the dispute; or any person bringing a claim under this constitution; or 09/25/2020 10:33:46 an office-holder of the Foundation Trust; is to be submitted to an arbitrator agreed by the parties or in the absence of agreement to be nominated by the Strategic Health AuthorityNHS England. The arbitrator’s decision will be binding and conclusive on all parties
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20. Transition Schedule relating to the amendments to this constitution made in 2020
INTERPRETATION For the purposes of paragraphs 34 to 36, the “Date of Approval” shall mean the date on which either the Board of Directors or Council of Governors approves the amendments to this Constitution made in 2020 in accordance with paragraph 22 of this Constitution, whichever is the later.
MEMBERS The members of the Rest of England and Wales constituency who, immediately before the Date of the Transaction, live within the following areas as defined in this Constitution as amended in 2020 shall transfer on the Date of the Transaction as follows: Bury, shall transfer to the Bury public constituency; Oldham, shall transfer to the Oldham public constituency; Rochdale, shall transfer to the Rochdale public constituency. All other members of the Rest of England and Wales constituency shall remain in that constituency.
GOVERNORS Any Staff Governor in post immediately prior to the Date of the Transaction who, under the provisions of this Constitution as amended in 2020, will remain eligible to continue as a Staff Governor as a member of the Salford class of the Staff Constituency after the Date of the Transaction, will automatically transfer on the Date of the Transaction to the Salford class of the Staff Constituency and continue in post until the end of their elected term.
Following the Date of the Transaction, elections shall be held to elect the requisite number of Staff Governors for each class of the Staff Cconstituency as set out in this Constitution (other than the Salford class), who shall assume office following their election. In respect of each such class of the Staff Constituency, not less than one half of those Staff Governors who polled the highest votes will serve a term of office ending at the conclusion of the annual members meeting in 2023; all remaining Staff Governors of those classes will serve a term of office ending at the conclusion of the annual members meeting in 2022. .
Any Public Governor in post immediately prior to the Date of the Transaction for the public constituencies of either Salford or the Rest of England and Wales who, under the provisions of this Constitution as amended in 2020, will remain eligible to continue in that position after the Date of the Transaction, may do so until the end of their elected term.
Subject to paragraph 37.3, following the Date of the Transaction, elections shall be held to elect the requisite number of remaining Public Governors for the public constituency of the Rest of England and Wales and the requisite number of Public Governors for the Bury, Oldham and Rochdale public constituencies as set out in this Constitution, who shall assume office following their election. In respect of each such public constituency, not less than one half of those Public Governors who polled the highest votes will serve a term of office ending at the conclusion of the annual members meeting in 2023; all remaining Public Governors of those public constituencies (who were so elected) will serve a term of office ending at the conclusion of the annual members meeting in 2022.
Following the Date of the Transaction, the University of Salford, Salford City Council, Bury Council, Rochdale Borough Council and Oldham Council shall be asked to appoint Governors in accordance with this Constitution, who shall assume office from their appointment until the conclusion of the annual members’ meeting in 2022. NCA # 274090 09/25/2020 10:33:46
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21. Annex 1
AREAS OF THE FOUNDATION TRUST
Salford – the electoral area covered by the wards of Claremont, Weaste, Seedley, Ordsall, Langworthy, Irwell Riverside, Kersall, Broughton, Swinton, Pendlebury, Walkden North, Walkden South, Little Hulton, Winton, Barton, Eccles, Irlam, Cadishead, Worsley and Boothstown & Ellenbrook
Bury – the electoral area covered by the wards of Besses, Church, East, Elton, Holyrood, Moorside, North Manor, Pilkington Park, Radcliffe East, Radcliffe North, Radcliffe West, Ramsbottom, Redvales, St Mary's, Sedgley, Tottington, Unsworth
Rochdale – the electoral area covered by the wards of Balderstone & Kirkholt, Bamford, Castleton, Central Rochdale, East Middleton, Healey, Hopwood Hall, Kingsway, Littleborough Lakeside, Milkstone & Deeplish, Milnrow & Newhey, Norden, North Heywood, North Middleton, Smallbridge & Firgrove, South Middleton, Spotland & Falinge, Wardle & West Littleborough, West Heywood, West Middleton
Oldham – the electoral area covered by the wards of Alexandra, Chadderton Central, Chadderton North, Chadderton South, Coldhurst, Crompton, Failsworth East, Failsworth West, Hollinwood, Medlock Vale, Royton North, Royton South, Saddleworth North, Saddleworth South, Saddleworth West & Lees, St James', St Mary's, Shaw, Waterhead, Werneth
Rest of England and Wales – the electoral areas covered by the remainder of England and Wales other than the electoral areas of the Salford, Bury, Rochdale and Oldham public constituencyies as described above.
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5/5 20/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Group Governance Framework Manual
Meeting Group Board (Committees in Common) Author (s) Jane Burns, Director of Corporate Services/Group Secretary Presented by Jane Burns, Director of Corporate Services/Group Secretary Date 28th September 2020
Executive This paper presents the Group Governance Framework Manual (GGFM), which Summary has been updated to reflect NCA governance arrangements from 1 April 2020.
Background At the end of March 2020, the SRFT Board reviewed and approved a revised governance structure in light of the establishment of an independent Board of Directors for the Pennine Acute Hospitals NHS Trust. As part of this, the SRFT Board approved the following key governance documents: Terms of Reference for the Group Board (Salford) Group Standing Orders (Board) Reservations of Powers to the Board and Scheme of Delegation Terms of Reference for the Audit Committee and Nominations, Remuneration and Terms of Service Committee. Terms of reference for SRFT’s Charitable Funds Committee have subsequently been developed, approved via Group Board and are now included within the revised GGFM..
Updated GGFM The GGFM has been updated to reflect the above arrangements. The key changes are: Revised composition of Executive Team, removing Executive Director of Improvement – effective as at 1 April 2020 Group Board Committee Structure – revised July 2020 Group Standing Orders (Board) – revised April 2020 Terms of Reference for Group Board (Salford) – revised April 2020 Terms of Reference for Group Board (Oldham, Bury and Rochdale) – established by the Pennine Acute Hospitals NHS Trust from 1 Apr 20 Terms of Reference for the Shadow Group Council of Governors – revised September 2020 Standing Financial Instructions, Reservations of Powers to the Board and Scheme of Delegation – revised April 2020 Inclusion of the responsibilities of the Executive Management Committee (and removal of the dis-established Executive Development Committee) within the Board’s Scheme of Delegation. The revised GGFM was reviewed and supported by Audit Committee at its meeting in July 2020 and is included within ‘papers for information’.
Recommendations Group Board is asked to approve the revisions to the Group Governance Framework Manual, noting that these revisions haveNCA been # 274090 reviewed in detail by Audit Committee. 09/25/2020 10:33:46
1/1 21/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Group Board Integrated Performance Scorecard
Meeting Group Board (Committees in Common) The Executive Team Author (s) Emma Wright – Director of Information & Business Intelligence Ivan Conyon – Head of Planning & Performance
Presented by Raj Jain, Chief Executive Officer
Date 28th September 2020
Executive Scorecard Overview Summary The emergent picture evident across the different scorecard pages is that process outputs were disrupted during, and since, the covid surge with KPIs being significantly different from baseline normality. The Board will note that the SPC charts show consecutive dots on one side of average performance and in some cases dots outside of the upper and lower control limits. Both of these results indicate that there is a very high statistical probability that changes were due to special causes and were not just typical random variation. These patterns are repeated across many scorecard KPIs with some KPIs gradually returning towards the old normal patterns.
In some cases the changes due to the system disruption were desirable outcomes because they support organisational goals, (e.g., Partnerships in Place page time patients are away from home), whereas others were not (e.g., Caring for our Staff S&A, and Cancer Care waiting times). Where the outcomes are desirable the aim is to maintain the “new normal” through improvement action that embeds, develops, and sustains new ways of working – I.e. proactively act to keep new processes under control and stop them returning to the old normal. Where the outcomes are undesirable the aim is to return to the required level of performance. In the first instance, returning to pre-covid normality as soon as possible, recognising that in some cases new system contingencies such as IPC, finances, and higher levels of demand uncertainty determine the extent to which this is possible and the time it will take to get there – I.e., the aim here is to take action to move performance to the desired level, without adversely affecting other objectives (broadly: our people, our safety, our money, our patient experience [e.g., anxiety over waits]).
It is also worth noting that the delivery of the NCA’s objectives to improve pre- covid performance has been delayed or accelerated due to the significant disruption, and there are backlogs of tasks to be completed in addition to BAU tasks, within the same baseline resources envelope. The Annual Plan previously submitted to the Board, and to which the CiC Scorecard is aligned, described the priorities for the remainder of this financialNCA year. # 274090 09/25/2020 10:33:46
1/3 22/163 The scorecard covers a wide array of KPIs with a commentary for each area. The following items have been highlighted for more detailed attention:-
Inspiring and Caring For Our Staff S&A is a critical metric in measuring staff wellbeing, satisfaction, and operational capacity. S&A has returned to pre-covid normal levels, with good (low) SCO S&A, following the peak including self-isolating staff returning to work: However these levels are just starting to creep up reflecting the increased infection rates locally as well as self-isolation due to children being sent home. CF2 compliance has reduced as a result covid. The process has been adapted to help our staff to catch up whilst supporting their wellbeing. The WHO wellbeing index was run as part of the quarterly pulse survey. Broadly the results were similar to 2019, however with some evidence that our staff were feeling less energetic and not waking up refreshed. This is perhaps unsurprising given the circumstances they have been and are working in.
Urgent Care & Partnerships in Place Demand has remained below historical levels, but is increasing to the lower end of the pre-covid range of natural variation:- o Bed occupancy in zoned areas is reaching threshold levels o A&E Attendances and waiting times are increasing o Time away from home remains better than historical averages across COs, but stranded patients are increasing suggesting an elevated risk that beds will fill up above desired levels unless system-wide action is taken All Care Organisations are evaluating winter plans and performance against trigger thresholds – Elective care activity restoration is dependent on managing winter pressures better than in the past and covid levels remaining relatively stable.
Planned Care & Cancer Care Lengths of patient waits have continued to increase due to capacity constraints for both routine and urgent cancer pathways. The cancer waiting list KPIs show delays in patients receiving diagnostic tests (mainly endoscopy) have increased as a result of the reduction in capacity below baseline levels during, and since, the covid surge – It is anticipated that the growth in waits will slow and then reduce as diagnostic capacity is incrementally restored – This high priority action on endoscopy is needed in order to reduce cancer waiting times and patient anxiety. Plans to safely restore elective activity are below the national ask (90% to 100% of 19-20 baselines) due to IPC related capacity constraints (see Phase 3 Planning paper for further details). Full restoration of activity would also be insufficient to recover the backlog of long waits for routine treatment that has accrued during this year. NCA # 274090 09/25/2020 10:33:46
2/3 23/163 Diagnostics & Pharmacy Covid testing is a key enabler to allow staff with symptoms to return to work as soon as possible, and restore elective activity whilst minimising patient infection risks. Covid testing turn-around times remain within target but increased during August, averaging 26 hours, primarily due to unplanned analyser downtime. The turn-around times have since returned to within target. Whilst testing capacity is being maintained, demand continues to increase.
Infection Prevention & Control Two or more cases of nosocomial COV19 infection constitute an outbreak. In August and September there have been several (localised) outbreaks in 2 wards at FGH and 1 ward at TROH. Similar outbreaks have occurred at Salford Care Homes Practice and The Maples. Remedial action plans were instituted, agreed with NHSI and implemented. There remains concern around C difficile rates in SCO and intensive focus is being applied to antibiotic stewardship as a consequence. A report detailing the approach of SCO to antibiotic stewardship was received at GRAC in September 2020. In May 2020 there was a case of MRSA in SCO- a SI was declared and a comprehensive remedial action plan implemented and monitored via the SCO governance. Annual Plan The Group Board’s Integrated Performance Scorecard is aligned to the 2020/21 Objective Annual Business Plan and agreed priorities. Associated Risks As described within the commentary and Executive Summary.
Recommendations The Group Board is asked to: Consider the KPIs where (1) it is desirable to take action to maintain control around the “new normal,” and (2) where it is desirable to take action to return to the “old normal” Invite updates from the Care Organisation Chief Officers about emerging risks and mitigating actions, supported by triangulation of information contained within the CiC scorecard. Note that work to develop and refine the scorecard is continuing (e.g., a data quality kite mark process)
Equality Does this paper relate to a matter where equality issues may arise? Y/N Freedom of This document does not contain confidential information and can be Y Information made available to the public. Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
NCA # 274090 09/25/2020 10:33:46
3/3 24/163 Committee in Common Integrated Performance Scorecard Inspiring & Caring for Our Staff Wellbeing
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar WHO - Five Well-Being Index o o o o o o o o o Quarterly Measure from Pulse Survey Contribution Framework o o o o o o o o o o o o o o o o o o o o o Target: 90% Staff Turnover o o o o o o o o o o o o o o o o o o o o o
KeyMetrics KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Sickness Absence (All) 8.00% 10.00% 8.00% 12.00% 7.00% 7.00% 10.00% 6.00% 6.00% 8.00% 5.00% 5.00% 4.00% 4.00% 6.00% 0.00% 3.00% 3.00% 4.00% Percentage of staff absent from work due to sickness. 2.00% 2.00% 2.00% This excludes medical suspensions and COVID related 1.00% 1.00% 0.00% 0.00%
absences. 0.00%
Jul-19 Jul-20 Jul-20 Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19
Jan-20 Jan-21
Apr-20 Apr-19 Apr-20 Apr-19
Jun-20 Sep-20 Feb-21 Sep-19 Feb-20 Jun-19 Sep-19 Feb-20 Sep-20 Feb-21
Oct-19 Oct-20 Dec-20 Dec-19 Dec-19 Dec-20
Apr-19 Apr-20
Aug-19 Aug-19 Aug-20 Aug-20
Sep-20 Sep-19 Feb-20 Feb-21
Nov-19 Nov-19 Nov-20 Nov-20
Dec-20 Dec-19
Aug-19 Mar-20 Mar-21 Mar-21 Aug-20 Mar-20
Nov-19 Nov-20
May-19 May-20 May-20 May-19
Mar-21 Mar-20
May-19 May-20 Lower is Better Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Sickness Absence (COVID-Related) 14.0% 20.0% 14.0% 14.0% 12.0% 12.0% 12.0% 10.0% 10.0% 10.0% 10.0% 8.0% 8.0% 8.0%
6.0% 0.0% 6.0% 6.0% 4.0% 4.0% 4.0% Percentage of staff absent from work due to COVID 2.0% 2.0% 2.0%
related sickness. 0.0% 0.0% 0.0%
Jul-19 Jul-20 Jul-19 Jul-20
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20
Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Feb-20 Sep-20
Jan-20 Jan-21
Jun-20 Jun-19
Dec-20 Dec-19 Dec-20 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20
Oct-19 Oct-20
Apr-19 Apr-20
Nov-19 Nov-20 Nov-19 Nov-20
Sep-19 Feb-20 Sep-20 Feb-21
Mar-20 Mar-21 Mar-20 Mar-21
Dec-19 Dec-20
Aug-19 Aug-20
Nov-20 May-19 May-20 May-19 Nov-19 May-20
Mar-21 Mar-20 May-20 Lower is Better May-19 Actual Mean - Rolling Actual Mean - Rolling Actual Mean - Rolling
Nursing Fill Rates (Days) 104% 98% 104% 104.0% 96% 100% 94% 100% 100.0% 92% 96.0% 96% 90% 96% 88% 92.0% 92% 86% 92% 88.0% 84% 88% 82% 88% 84.0% 84% 80% 84% 80.0% 78% Percentage of registered nurses on duty for a day shift. 80% 80% 76.0% 72.0% 76% 76% 68.0% 72% 72% 64.0% Fill rates were not recorded during the height of the COVID 68% 68% 60.0%
pandemic.
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Leading & Signal Metrics Signal & Leading Higher is Better Actual Mean UCL LCL
Nursing Fill Rates (Nights) 98% 98% 110% 98% 96% 94% 94% 106% 94% 92% 102% 90% 90% 90% 88% 98% 86% 86% 94% 86% 84% 90% 82% 82% 82% 80% 86% Percentage of registered nurses on duty for a night shift. 78% 78% 82% 78% 74% 78% 74% 74% 70% 70% 70% Fill rates were not recorded during the height of the COVID 66% 66% 66%
pandemic.
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL Higher is Better
Sickness Absence (COVID-19)
as at 18/08/2020 Benchmarking of National Metrics England North West GM Salford Pennine Staff Absence 5.8% 6.3% 5.7% 5.1% 5.9% Benchmarking data in development Of these COVID related absences 1.5% 1.7% 1.5% 1.0% 1.9%
Note: Due to corporate services allocation, breakdown by CO does not provide an valuable benchmark
Comparison Source: NHSi Analytics https://analytics.improvement.nhs.uk/#/views/COVID-19Workforceanalysis
Principal Risk Score Principal Risk Score Principal Risk Score
3.1 IF we fail to have in place a process to Associated Principal Risks improve the experience our staff THEN we may not achieve a reliable and resilient BAF 12 workforce and our operational performance and service developments will not be delivered
Current levels of staff engagement with our Contribution Framework process is around 60% across all Care Organisations. There is an organisational commitment to refocus on this important area, which has been impacted by the pandemic.
Sickness absence has returned to pre-pandemic levels across all Care Organisations and COVID-related sickness also continues to reduce Commentary despite increased infection rates in ourNCA localities. # 274090 Context Nursing fill rates have also improved at Salford and all Care Organisations are at similar09/25/2020 levels to those prior to10:33:46 the pandemic with some improvements on this across Bury & Rochdale and Oldham.
1/9 25/163 Committee in Common Integrated Performance Scorecard Partnership in Place Home First
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Stranded Patients (7 days+) o o o o o o o o o o o o o o o o o o o o o Target: Virtual & Telephone Consultations o o o o o o o o o o o o o o o o o o o o o Target: 60% New Metric - Awaiting Data New Metric - Awaiting Data No Data Received Successful Reablement o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Target: New Metric - Awaiting Data New Metric - Awaiting Data No Data Received Permanent Care Home Placements o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Target: KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Time Away from Home 14 14 14 12 12 12 10 10 10 8 8 8 The average amount of time our patients spend away from 6 6 6 4 4 4 their homes as a result of an emergency admission. 2 2 2 0 0 0
This measure only includes patients discharged back to
Jul-19 Jul-20 Jul-19 Jul-20
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20
Jan-20 Jan-21
Apr-19 Apr-20 Apr-19 Apr-20
Jun-19 Jun-20 Sep-19 Feb-20 Sep-20 Feb-21 Sep-20 Feb-21 Sep-19 Feb-20
Oct-19 Oct-20
Dec-20 Dec-19 Dec-20 Dec-19
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Mar-20 Mar-21 Mar-20 Mar-21
Aug-20 Aug-19
Nov-19 Nov-20
May-19 May-20 May-20 May-19
Mar-20 Mar-21
May-19 May-20 their own homes who have had at least a stay of one night Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL or more.
Discharges to Usual Place of Residence 98% 98% 98% 97% 96% 96% 96% 94% 94% 95% 92% 92% 94% 90% 90% The proportion of our patients who we discharge back to 93% 88% 88% 92% 86% 86% their own homes after an emergency admission. 91% 84% 84%
90% 82% 82%
Jul-20 Jul-19 Jul-20
Higher is Better Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20
Oct-20 Oct-19 Oct-19 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20
Jan-20 Jan-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Jun-20 Jun-19
Dec-19 Dec-19 Dec-20 Dec-20
Oct-19 Oct-20 Aug-19 Aug-20 Aug-20 Aug-19
Apr-20 Apr-19
Nov-19 Nov-20 Nov-19 Nov-20
Sep-19 Feb-20 Feb-21 Sep-20
Mar-20 Mar-21 Mar-21 Mar-20
Dec-19 Dec-20
Aug-19 Aug-20
Nov-19 May-19 May-20 Nov-20 May-20 May-19
Mar-20 Mar-21
May-19 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
No Right to Reside 35% 35% 35% 30% 30% 30% 25% 25% 25% A daily discharge review process has been in place since 20% 20% 20% April to understand the proportion of our patients who no 15% 15% 15% longer require hospital care. This metric shows the 10% 10% 10% percentage of patients at the end of each month who 5% 5% 5% could continue their care outside of the hospital or could 0% 0% 0%
be discharged home.
Jul-19 Jul-20 Jul-19 Jul-20 Jul-20 Jul-19
Jan-20 Jan-21 Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-19 Jun-20 Jun-19 Jun-20 Jun-19
Oct-20 Oct-20 Oct-19 Oct-19 Oct-19 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-19 Apr-20
Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Dec-19 Dec-20 Dec-19 Dec-19 Dec-20 Dec-20
Aug-19 Aug-20 Aug-19 Aug-20 Aug-20 Aug-19
Nov-19 Nov-19 Nov-20 Nov-19 Nov-20 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-21 Mar-20
May-19 May-20 May-19 May-20 May-20 May-19
Actual % Rolling Mean Actual % Rolling Mean Lower is Better Actual % Rolling Mean
Discharge to Assess 13.4 1.0 1.0 12.4 0.9 0.8 0.8 11.4 0.7 10.4 0.6 0.6 0.5 9.4 0.4 0.4 8.4 0.3 0.2 Metrics in Development 0.2 7.4 0.1 6.4 0.0 0.0
These metrics are in development
Jul-19 Jul-20 Jul-19 Jul-20 Jul-20 Jul-19
Jan-20 Jan-21 Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-19 Jun-20 Jun-19 Jun-20 Jun-19
Oct-20 Oct-20 Oct-19 Oct-19 Oct-19 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-19 Apr-20
Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Dec-19 Dec-20 Dec-19 Dec-19 Dec-20 Dec-20
Aug-19 Aug-20 Aug-19 Aug-20 Aug-20 Aug-19
Nov-19 Nov-19 Nov-20 Nov-19 Nov-20 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-21 Mar-20
May-19 May-20 May-19 May-20 May-20 May-19 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Stranded Patients & Time Away from Home Lower is Better
Benchmarking of National Metrics
Principal Risk Score Principal Risk Score Principal Risk Score
2.1 IF demand for critical non-COVID 19 Associated Principal Risks services is not met whilst capacity is diverted to COVID response THEN there is 13 increased likelihood of patient safety harm and mortality incidents arising
NCA # 274090 Patients delayed in our hospitals remain at low levels as we focus on ensuring people can09/25/2020 stay safe and well in their10:33:46 own homes. Time spent away from the home continues at a lower levels than before the pandemic. Commentary There are some increases in the number of patients staying in our hospitals beyond 7 days and Salford in particular has seen an increase in the number of patients that could be safely discharged from hospital with the right level of support.
2/9 26/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Infection Prevention & Control
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Clostridium Difficile o o o o o o o o o o o o o o o o o o o o o Target: Methicillin-Resistant Staphylococcus Aureus o o o o o o o o o o o o o o o o o o o o o Target: Zero Tolerance Nosocomial COVID-19 o o o o o o o o o o o o o o o o o o o o o Target: Zero Tolerance
Key Metrics Key KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Critical Care Occupancy 100% 100% 100%
80% 80% 80%
60% 60% 60%
40% 40% 40%
20% 20% 20% Bed Occupancy within our Critical Care Units.
0% 0% 0%
Jul-19 Jul-20 Jul-19 Jul-20
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20
Jan-20 Jan-21
Apr-19 Apr-20 Apr-19 Apr-20
Sep-19 Feb-20 Sep-20 Feb-21 Feb-21 Jun-19 Jun-20 Sep-19 Feb-20 Sep-20
Oct-20 Dec-19 Dec-19 Dec-20 Oct-19 Dec-20
Apr-19 Apr-20
Aug-19 Aug-20 Aug-19 Aug-20
Feb-20 Sep-20 Feb-21 Sep-19
Nov-19 Nov-20 Nov-19 Nov-20
Dec-19 Dec-20
Mar-20 Mar-21 Mar-20 Mar-21
Aug-19 Aug-20 Nov-20
Lower is Better Nov-19
May-19 May-20 May-19 May-20
Mar-20 Mar-21
May-19 May-20 Actual IPC Threshold Actual IPC Threshold Actual IPC Threshold
Zoned Occupancy - Green 100% 100% 100%
80% 80% 80%
60% 60% 60%
40% 40% 40% Bed Occupancy within our "Green" zones. These areas are 20% 20% 20% regarded as 'COVID Secure' and are used by patients with
negative test results 0% 0% 0%
Jul-20 Jul-20 Jul-19 Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-21 Jan-20
Jun-19 Jun-20 Jun-20 Jun-19
Oct-19 Oct-19 Oct-20 Oct-20
Apr-19 Apr-20 Apr-20 Apr-19
Sep-20 Feb-21 Feb-20 Sep-20 Jan-20 Jan-21 Sep-19 Feb-20 Sep-19 Feb-21
Jun-19 Jun-20
Dec-20 Dec-19 Dec-19 Dec-20
Aug-19 Aug-19 Oct-19 Oct-20 Aug-20 Aug-20
Apr-20 Apr-19
Nov-19 Nov-20 Nov-20 Nov-19
Sep-19 Feb-20 Sep-20 Feb-21
Mar-20 Mar-21 Mar-21 Mar-20
Dec-19 Dec-20
Aug-19 Aug-20
Nov-19 Nov-20 May-20 May-19 May-19 May-20
Mar-20 Mar-21
May-19 May-20 Lower is Better Actual IPC Threshold Actual IPC Threshold Actual IPC Threshold
Zoned Occupancy - Yellow 100% 100% 100%
80% 80% 80%
60% 60% 60%
40% 40% 40% Bed Occupancy in our "Yellow" zones. These areas are 20% 20% 20% used by patients who's COVID status is still to be 0% 0% 0%
determined.
Jul-19 Jul-20 Jul-20 Jul-20 Jul-19 Jul-19
Jan-20 Jan-21 Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-20 Jun-19 Jun-20 Jun-19
Oct-19 Oct-19 Oct-19 Oct-20 Oct-20 Oct-20
Apr-19 Apr-19 Apr-20 Apr-20 Apr-20 Apr-19
Feb-20 Sep-20 Sep-20 Feb-21 Feb-20 Sep-20 Sep-19 Feb-21 Sep-19 Feb-20 Sep-19 Feb-21
Dec-20 Dec-20 Dec-19 Dec-19 Dec-19 Dec-20
Aug-19 Aug-20 Aug-19 Aug-19 Aug-20 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-20 Nov-19
Mar-21 Mar-20 Mar-21 Mar-20 Mar-21 Mar-20
May-19 May-20 May-20 May-19 May-19 May-20 Actual IPC Threshold LeadingMetrics & Signal Lower is Better Actual IPC Threshold Actual IPC Threshold
Zoned Occupancy - Blue 100% 100% 100%
80% 80% 80%
60% 60% 60%
40% 40% 40% Bed Occupancy in our 'Blue' zones. These areas are for 20% 20% 20%
patients with a confirmed diagnosis of COVID-19. 0% 0% 0%
Jul-19 Jul-20 Jul-20 Jul-20 Jul-19 Jul-19
Jan-20 Jan-21 Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-20 Jun-19 Jun-20 Jun-19
Oct-19 Oct-19 Oct-19 Oct-20 Oct-20 Oct-20
Apr-19 Apr-19 Apr-20 Apr-20 Apr-20 Apr-19
Feb-20 Sep-20 Sep-20 Feb-21 Feb-20 Sep-20 Sep-19 Feb-21 Sep-19 Feb-20 Sep-19 Feb-21
Dec-20 Dec-20 Dec-19 Dec-19 Dec-19 Dec-20
Aug-19 Aug-20 Aug-19 Aug-19 Aug-20 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-20 Nov-19
Mar-21 Mar-20 Mar-21 Mar-20 Mar-21 Mar-20
May-19 May-20 May-20 May-19 May-20 Lower is Better May-19 Actual IPC Threshold Actual IPC Threshold Actual IPC Threshold
Clostridium Difficile
Lower is Better
June to June (13 Months) Organisation name 2018-19 2019-20 % Var % Variance in all C-Diff cases, year on year comparison Source: https://www.gov.uk/government/statistics/c-difficile-infection-monthly-data-by-prior-trust-exposure Bolton 83 113 36% 36% 36% Wrightington, Wigan & Leigh 73 99 36% 40% Benchmarking of National Metrics 27% Salford Royal 70 89 27% 30% 20% Manchester University 250 260 4% 7% 10% 4% 6% Pennine Acute Hospitals 214 200 -7% 0% Stockport 117 106 -9%
Comparison -10% Tameside Hospital 65 58 -11% -7% -20% -9% -11% GM 872 925 6% Bolton WWL SRFT NMFT PAT Stockport Tameside GM National National 12962 13933 7%
Principal Risk Score Principal Risk Score Principal Risk Score
Associated Principal Risks
BAF
Both Oldham and Salford Care Organisations had occurrences of MRSA during August. CDiff rates at Salford have reduced but still remain higher than the previous year.
Commentary There were no nosocomial (hospital onset) COVID-19 infections during the month. NCA # 274090
Context Occupancy levels remain with infection control recommendations, with increases in COVID-secure (green) wards as we increase our elective activity. 09/25/2020 10:33:46
These scorecards are designed to be reviewed on screen. For printing, consider A3.
3/9 27/163 Committee in Common Integrated Performance Scorecard Clinical and Operational Excellence Cancer Care
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 62 Day Referral to Treatment o o o o o o o o o o o o o o o o o o o o o o o o Target: 85% 31 Day Treatment o o o o o o o o o o o o o o o o o o o o o o o o Target: 96% Standard 2 Week Referral o o o o o o o o o o o o o o o o o o o o o o o o Target: 93% 28 Day Faster Diagnosis o o o o o o o o o o o o o o o o o o o o o o o o Target:
Key Metrics Key KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Deteriorating (No Target), Improving (No Target) , Stable (No Target)
Total Size of 62 Day List 2500 3000 2500 (Number of patients) 2000 2500 2000 2000 1500 1500 1500 1000 1000 1000 500 500 This shows the total number of patients currently on a 62 day urgent cancer pathway. Not all patients on 500 0 0
these pathways will be diagnosed with cancer. An increase in the size of the waiting list can indicate 0
Jul-20 Jul-19 Jul-19 Jul-20
Jul-19 Jul-20
Jan-21 Jan-20 Jan-20 Jan-21
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20
Jan-20 Jan-21
Apr-19 Apr-20 Apr-19 Apr-20
Jun-19 Feb-21 Jun-20 Sep-19 Feb-20 Sep-20 Sep-19 Feb-20 Sep-20 Feb-21
Oct-19 Oct-20 Dec-19 Dec-20 Dec-19 Dec-20
Apr-19 Apr-20
Aug-19 Aug-20 Aug-19 Aug-20
Sep-19 Feb-20 Sep-20 Feb-21
Nov-19 Nov-20 Nov-19 Nov-20
Dec-19 Dec-20
Mar-20 Mar-21 Mar-20 Mar-21
Aug-19 Aug-20
Nov-19 Nov-20
May-20 May-19 May-19 May-20 Mar-21
potential capacity issues for the future. Mar-20 Actual Mean UCL LCL
May-19 May-20 Actual Mean UCL LCL Actual Mean UCL LCL
62 Day Backlog - Diagnosed 30 30 30 (Number of patients) 25 25 25 20 20 20 15 15 15 This shows the total number of patients who have already waited more than 62 days on an urgent cancer 10 10 10 pathways and have had a cancer diagnosis confirmed and a decision to treat has been made. This is 5 5 5 0 0
indicative of future breaches of the standard. 0
Jul-19 Jul-19 Jul-20 Jul-20
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-19 Jun-20 Jun-19
Oct-19 Oct-19 Oct-20 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20
Jan-20 Jan-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Jun-19 Jun-20
Dec-19 Dec-20 Dec-19 Dec-20
Aug-20 Aug-19 Aug-20 Aug-19
Oct-19 Oct-20
Apr-19 Apr-20
Nov-20 Nov-19 Nov-20 Nov-19
Feb-20 Feb-21 Sep-19 Sep-20
Mar-20 Mar-20 Mar-21 Mar-21
Dec-20 Dec-19
Aug-19 Aug-20
Nov-19 Nov-20 May-19 May-20 May-19 May-20
Mar-20 Mar-21
May-19 May-20 Lower is Better Actual NHSE Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
62 Day Backlog - Undiagnosed 2500 800 600 700 2000 500 (Number of patients) 600 400 1500 500 400 300 1000 300 200 This shows the total number of patients who have already waited more than 62 days but have not yet had 200 500 a diagnosis of cancer confirmed. These patients may or may not be confirmed as cancer. This is 100 100
indicative of the potential risk of breaches for the future. 0 0 0
Jul-19 Jul-19 Jul-20 Jul-19 Jul-20 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-20 Jun-19 Jun-19 Jun-20 Jun-19
Oct-19 Oct-19 Oct-20 Oct-19 Oct-20 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-19 Apr-20
Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Dec-19 Dec-20 Dec-19 Dec-20 Dec-19 Dec-20
Aug-19 Aug-20 Aug-20 Aug-19 Aug-20 Aug-19
Nov-20 Nov-20 Nov-19 Nov-19 Nov-20 Nov-19
Mar-21 Mar-20 Mar-20 Mar-20 Mar-21 Mar-21
May-19 May-20 May-19 May-20 May-19 May-20 Actual Mean UCL LCL Lower is Better Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Leading Metrics & Signal
Average Diagnostic Waiting Time 70 70 70 60 60 60 Time from first appointment to decision to treat 50 50 50 40 40 40 30 30 30 This shows the time between first appointment following a TWW referral and a decision to treat being 20 20 20 made for patients receiving first treatment for cancer. It is indicative of the time taken to complete 10 10 10 0 0 0
diagnostics investigations prior to deciding on a course of treatment.
Jul-19 Jul-19 Jul-20 Jul-19 Jul-20 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21 Jan-20 Jan-21
Jun-20 Jun-20 Jun-19 Jun-19 Jun-20 Jun-19
Oct-19 Oct-19 Oct-20 Oct-19 Oct-20 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-19 Apr-20
Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21 Sep-19 Feb-20 Sep-20 Feb-21
Dec-19 Dec-20 Dec-19 Dec-20 Dec-19 Dec-20
Aug-19 Aug-20 Aug-20 Aug-19 Aug-20 Aug-19
Nov-20 Nov-20 Nov-19 Nov-19 Nov-20 Nov-19
Mar-21 Mar-20 Mar-20 Mar-20 Mar-21 Mar-21
May-19 May-20 May-19 May-20 May-19 May-20 Lower is Better
62 Day Referral to Treatment
Performance (National Rank) Total Indicator Data Period Regional National Providers Benchmarking of National Metrics Pennine Acute Salford Royal
Cancer 62 days Jun-20 56.4% (135) 82.4% (38) 68.2% 75.2% 147
Comparison Key: = Salford, = Pennine, |= National Average
Principal Risk Score Principal Risk Score Principal Risk Score
2.1 IF demand for critical non-COVID 19 Associated Principal Risks services is not met whilst capacity is diverted
BAF to COVID response THEN there is increased likelihood of patient safety harm and mortality incidents arising
13
The latest cancer performance is based on July 2020 and is variable across all Care Organisations. The 62 day waiting list continues to grow however the numbers of diagnosed patients waiting more than 62 days has plateaued. Commentary Diagnostics waiting times and capacity continue to impact on cancer waiting times and all cancer diagnostics are being prioritised.
Context
NCA # 274090 09/25/2020 10:33:46
4/9 28/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Maternity & Children
Oldham Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Gestational Age at Delivery (Proportion of deliveries considered full term) Still Birth Rate (Still births per 1,000 deliveries) Term Admission to NICU (Babies born at 37weeks+ ) Non-Clinical Paed Transfers (Transfers for bed capacity reasons) Key Metrics KEY: Normal Variation, Special Cause Improving, Special Cause Getting Worse
Gestational Age at Booking 70% 65% (% > 10 weeks) 60% 55% Lower is Better 50% 45% NICE guidance recommends that initial booking 40% appointments as part of ante-natal care should take 35% 30% place before pregnancy has reached ten weeks. Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21
Lower is Better Actual Ambition Mean UCL LCL
1:1 Care in Established Labour 100.0%
98.0%
96.0% NICE recommends one to one care for women in 94.0% established labour. One-to-one care correlates with 92.0% good experience of care and reduces the likelihood of Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 problems for either mother or baby. Actual Mean UCL LCL Higher is Better
Placeholder - Experience Measure 100.00% 100.00% Maternity Children
50.00% 50.00% Metrics in Development
0.00% 0.00%
Actual NHSE Mean UCL LCL Actual NHSE Mean UCL LCL
Children's A&E Attendances 4,000 Oldham 3,000 Salford
2,000
Leading & Signal Metrics 2,000 1,000
Number of children (under 16yrs) attending our A&E 0 0 departments
Actual Mean UCL LCL Actual Mean UCL LCL
Children's Average A&E Waiting Time 300 Oldham 300 Salford
200 200
100 100 Average waiting time in minutes from attendance to discharge for children in our A&E departments. 0 0
Lower is Better Actual Mean UCL LCL Actual Mean UCL LCL
Benchmarking of National Metrics Benchmarking in Development
Comparison
Principal Risk Score
Associated Principal Risks
BAF
Improvements continue to be made in earlier booking appointments for birth. NCA NICE guidance # 274090 states that bookings should take place within the first ten weeks of pregnancy and currently, 38% of bookings are after 10 weeks. All other maternity indicators are within normal variation. 09/25/2020 10:33:46 Commentary Children's attendances at our A&E departments continue to increase but are still low when compared to attendance levels
Context before the pandemic. Waiting times as a result remain lower than usual and there were no transfers to other hospitals for non- clinical reasons during August.
5/9 29/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Diagnostics & Pharmacy
Diagnostics & Pharmacy
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Imaging Diagnostics o o o o o o o Target: 99% COVID Testing Turnaround o o o o o o o Target: 48hrs Prescription Turnaround (TTOs) o o o o o o o Target: 90% within 90 minutes
KeyMetrics KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Imaging Diagnostic Activity 35,000 30,000 25,000 20,000 15,000 10,000 Elective imaging activity for main modalities of MR, CT, 5,000 Non-Obstetric Ultrasound and DEXA scans. 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21
Higher is Better Actual Mean UCL LCL
Imaging Diagnostic Waiting List Shape 2,500
2,000
1,500
1,000 The shape of the imaging waiting list over time to 500 demonstrate changes in waiting times. The blue shape in the current month with the red and orange lines showing 0 0-1wks 1-2wks 2-3wks 3-4wks 4-5wks 5-6wks 6-7wks 7-8wks 8-9wks 9-10wks 10-11wks 11-12wks 12-13wks 13-14wks 14-15wks 15-16wks 16-17wks 17-18wks 18-19wks 19-20wks 20-21wks 21-22wks 22-23wks 23wks+ the shape of the list a month and two months earlier
respectively Current Month Previous Month Two Months Ago
Cancer Turnaround Times 15 Target: 14 Days 12 9
6 Average waiting times from test to reporting in days for 3 priority cancer cases. 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21
Lower is Better Actual Mean UCL LCL Target
Pathology Activity - COVID Testing 7,000 6,000 5,000
Leading & Signal Metrics Signal & Leading 4,000 3,000 2,000 1,000 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 The number of COVID tests performed during the month. Actual
Pathology Activity - All Other Testing
1 1 1 1 1 1 1 New Metrics - Awaiting Data 1 1 The volume of pathology testing during the month 1 (excluding COVID testing) 1 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21
Actual Mean UCL LCL
Imaging Diagnostics Higher is Better
Performance (National Rank) Total Indicator Data Period Regional National Pennine Acute Salford Royal Providers Benchmarking of National Metrics
6 week Diagnostic Waits (MRI, CT, Non Obstetric Jun-20 79.8% (45) 61.5% (108) 61.7% 60.7% 238 Ultrasound)
Comparison Key: = Salford, = Pennine, |= National Average
Principal Risk Score
Associated Principal Risks
BAF
Clinical reviews of those patients who had their imaging appointments deferred at the beginning of the pandemic were completed during August and those patients still requiring scans haveNCA been added # 274090back to the waiting list but with their original referral date to ensure their treatment is prioritised. This has caused09/25/2020 a spike in longer waiting 10:33:46 patients, which can be seen the chart above. Commentary Cancer reporting continues to be prioritised and although waiting times have been increasing over the last three
Context months, they remain lower than the 14day tolerance.
COVID testing turn-around times remain within target but have increased during August, averaging 26 hours.
6/9 30/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Planned Admitted Care
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar RTT Performance o o o o o o o o o o o o o o o o o o o o o Target: 92% RTT List Size o o o o o o o o o o o o o o o o o o o o o Target: 52wk Breaches o o o o o o o o o o o o o o o o o o o o o Target:
KeyMetrics KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Admitted Activity 7,000 4,000 16,000 6,000 3,500 14,000 5,000 3,000 12,000 2,500 10,000 4,000 2,000 8,000 3,000 1,500 6,000 2,000 1,000 4,000 1,000 500 2,000
0 0 0
Jul-19 Jul-20 Jul-20 Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19
Jan-20 Jan-21
Apr-20 Apr-19 Apr-20 Apr-19
Jun-20 Sep-20 Feb-21 Sep-19 Feb-20 Jun-19 Sep-19 Feb-20 Sep-20 Feb-21
Oct-19 Oct-20 Dec-20 Dec-19 Dec-19 Dec-20
Apr-19 Apr-20
Aug-19 Aug-19 Aug-20 Aug-20
Sep-20 Sep-19 Feb-20 Feb-21
Nov-19 Nov-19 Nov-20 Nov-20
Dec-20 Dec-19
Aug-19 Mar-20 Mar-21 Mar-21 Aug-20 Mar-20
Nov-19 Nov-20
May-19 May-20 May-20 May-19
Mar-21 Mar-20
May-19 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Waiting List Shape 600 1,200 800 700 500 1,000 600 800 400 500 300 600 400 The shape of the admitted waiting list over time to 300 200 400 demonstrate changes in waiting times. The blue shape in 200 100 200 the current month with the red and orange lines showing 100 0 0 0
the shape of the list a month and two months earlier
0-3wks 3-6wks 3-6wks 6-9wks 6-9wks 0-3wks
0-3wks 3-6wks 6-9wks
70wks+ 70wks+
70wks+ 9-12wks
respectively 9-12wks
9-12wks
15-18wks 21-24wks 27-30wks 33-36wks 39-42wks 45-48wks 52-55wks 55-58wks 61-64wks 64-67wks 67-70wks 12-15wks 15-18wks 18-21wks 24-27wks 30-33wks 36-39wks 42-45wks 48-51wks 55-58wks 61-64wks 67-70wks 12-15wks 18-21wks 24-27wks 30-33wks 36-39wks 42-45wks 48-51wks 21-24wks 27-30wks 33-36wks 39-42wks 45-48wks 52-55wks 64-67wks
12-15wks 15-18wks 18-21wks 24-27wks 27-30wks 30-33wks 39-42wks 42-45wks 52-55wks 55-58wks 64-67wks 67-70wks 21-24wks 33-36wks 36-39wks 45-48wks 48-51wks 61-64wks
58-61wks% 58-61wks% Current Month Previous Month Two Months58-61wks% Ago Current Month Previous Month Two Months Ago Current Month Previous Month Two Months Ago
Average Waiting Time by Priority 30 35 30.0
25 30 25.0 25 20 20.0 20 Average waiting time in weeks by priority category: 15 15.0 15 10 10.0 P2: Aim to treat within 4wks 10 5 5.0 P3: Aim to treat within 12wks 5 0 0 0.0
P4: Treatment beyond 13wks
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20
Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-20 Aug-19 Aug-20 Aug-19 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20
Leading & Signal Metrics Signal & Leading Lower is Better P2 P3 P4 P2 P3 P4 P2 P3 P4
Overdue Planned Patients 1,500 1,500 1,500
Planned patients are those scheduled to come in at a 1,000 1,000 1,000 specific time as part of a course of treatment or a 500 500 500 surveillance programme. These charts show the number
of patients who have been waiting more than six weeks 0 0 0
past their expected planned date.
Jul-19 Jul-20 Jul-19 Jul-20 Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-19 Sep-20 Feb-21 Feb-20 Sep-20
Dec-19 Dec-20 Dec-20 Dec-19 Dec-20 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-20 May-19 May-19 May-20 May-20 Actual Lower is Better Actual Actual
RTT Performance
Benchmarking of National Metrics
Comparison
Principal Risk Score Principal Risk Score Principal Risk Score
Associated Principal Risks
BAF
At the end of August, 2324 of our patients had been waiting for more than a year and are still yet to receive treatment. These numbers will increase over course of the year but trajectories are in place to monitor and reduce levels of growth. Long waiting times are increasing overall, as can be seen by the changing shape of the waiting list.
Commentary Activity continues to increase and waiting times for higher priority patients are starting to reduce in Bury & Rochdale and Oldham. However waiting times for routine surgery continues to increaseNCA across # all our274090 services.
Context Demand for elective surgery has also started to increase again as can be seen in the09/25/2020 shape of the waiting list 10:33:46 above, with an increase in patients recently added to the waiting list compared to previous months.
7/9 31/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Planned Non-Admitted Care
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar RTT Performance o o o o o o o o o o o o o o o o o o o o o Target: 92% RTT List Size o o o o o o o o o o o o o o o o o o o o o Target: To reduce based on January 2020 52wk Breaches o o o o o o o o o o o o o o o o o o o o o Target: Zero Tolerance
KeyMetrics KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Non-Admitted Activity 30,000 25,000 80,000 70,000 25,000 20,000 60,000 20,000 15,000 50,000 15,000 40,000 10,000 30,000 10,000 20,000 5,000 This represents all of our outpatient appointments that 5,000 10,000
have taken place. 0 0 0
Jul-19 Jul-20 Jul-20 Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19
Jan-20 Jan-21
Apr-20 Apr-19 Apr-20 Apr-19
Jun-20 Sep-20 Feb-21 Sep-19 Feb-20 Jun-19 Sep-19 Feb-20 Sep-20 Feb-21
Oct-19 Oct-20 Dec-20 Dec-19 Dec-19 Dec-20
Apr-19 Apr-20
Aug-19 Aug-19 Aug-20 Aug-20
Sep-20 Sep-19 Feb-20 Feb-21
Nov-19 Nov-19 Nov-20 Nov-20
Dec-20 Dec-19
Aug-19 Mar-20 Mar-21 Mar-21 Aug-20 Mar-20
Nov-19 Nov-20
May-19 May-20 May-20 May-19
Mar-21 Mar-20
May-19 May-20 Higher is Better Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Waiting List Shape 2,500 2,500 2,000
2,000 2,000 1,500 1,500 1,500 1,000 1,000 1,000 The shape of the non-admitted waiting list over time to 500 500 500 demonstrate changes in waiting times. The blue shape in
the current month with the red and orange lines showing 0 0 0
0-3wks 3-6wks 3-6wks 6-9wks 0-3wks
the shape of the list a month and two months earlier 6-9wks
0-3wks 3-6wks 6-9wks
70wks+ 70wks+
70wks+
9-12wks 9-12wks
9-12wks
15-18wks 21-24wks 27-30wks 33-36wks 39-42wks 45-48wks 52-55wks 55-58wks 61-64wks 64-67wks 67-70wks 12-15wks 15-18wks 18-21wks 24-27wks 30-33wks 36-39wks 42-45wks 48-51wks 55-58wks 61-64wks 67-70wks 12-15wks 18-21wks 24-27wks 30-33wks 36-39wks 42-45wks 48-51wks 21-24wks 27-30wks 33-36wks 39-42wks 45-48wks 52-55wks 64-67wks
12-15wks 15-18wks 18-21wks 24-27wks 27-30wks 30-33wks 39-42wks 42-45wks 52-55wks 55-58wks 64-67wks 67-70wks 21-24wks 33-36wks 36-39wks 45-48wks 48-51wks 61-64wks
58-61wks% 58-61wks% respectively 58-61wks% Current Month Previous Month Two Months Ago Current Month Previous Month Two Months Ago Current Month Previous Month Two Months Ago
Non-Face-to-Face Attendances 80% 80% 70.0% 70% 70% 60.0% 60% 60% 50.0% 50% 50% 40.0% 40% 40% 30.0% 30% 30% This represents the percentage of our outpatient 20% 20% 20.0% appointments that take place in a non-face-to-face method 10% 10% 10.0% 0% 0% 0.0%
of delivery, such as by telephone or video call.
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20 Actual Target Leading & Signal Metrics Signal & Leading Higher is Better Actual Target Actual Target
Did Not Attend Rates 40% 15% 20%
30% 15% 10% 20% 10% 5% This represents the percentage of outpatient appointments 10% 5%
where our patients do no attend. 0% 0% 0%
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19 Oct-20 Oct-19
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-19 Aug-20 Aug-19 Aug-20 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20 Lower is Better Total Face to Face Non-Face to Face Total Mean Total Face to Face Non-Face to Face Total Mean Total Face to Face Non-Face to Face Total Mean
RTT Performance (Higher is Better)
Performance (National Rank) CO Performance Data Total Indicator Bury & Regional National Period Pennine Acute Salford Royal Oldham Providers Benchmarking of National Metrics Rochdale
Referral To Treatment Jun-20 52.8% (88) 55.6% (74) 59.2% 53.2% 51.3% 52.0% 159 Incomplete Pathways
Comparison Key: = Salford, = Pennine, |= National Average
Principal Risk Score Principal Risk Score Principal Risk Score
Associated Principal Risks
BAF
At the end of August, 2324 of our patients had been waiting for more than a year and are still yet to receive treatment. These numbers will increase over course of the year but trajectories are in place to monitor and reduce levels of growth. Long waiting times are increasing overall, as can be seen by the changing shape of the waiting list. Commentary Activity has reduced during August which is expected seasonal variation. The proportionNCA of #non-face 274090 to face attendances has also reduced
Context but the numbers of appointments offered through telephone and video09/25/2020 consultation remain 10:33:46 high.
These scorecards are designed to be reviewed on screen. For printing, consider A3.
8/9 32/163 Committee in Common Integrated Performance Scorecard Clinical & Operational Excellence Urgent Care
Bury & Rochdale Oldham Salford Care Organisation Care Organisation Care Organisation
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar A&E Performance o o o o o o o o o o o o o o o o o o o o o Target: Local Trajectories Ambulance Turnaround o o o o o o o o o o o o o o o o o o o o o o o o (Waits over 60 minutes) 12hour+ Wait for Admission o o o o o o o o o o o o o o o o o o o o o Target: Zero Tolerance
KeyMetrics KEY: Achieving Target, Not Achieving Target - Special Cause Variation, Not Achieving Target - Normal Variation, Getting Worse (No Target Set) , Getting Better (No Target Set), Performance Stable (No Target Set)
Average (Mean) Waiting Times 300 300 300 (Minutes) 250 250 250 200 200 200 Lower is Better 150 150 150 100 100 100 Average waiting times are one of the proposed new 50 50 50 0 0
indicators for A&E following the NHS England review of 0
Jul-19 Jul-20 Jul-20 Jul-19
Jul-19 Jul-20
Jan-20 Jan-21 Jan-21 Jan-20
Jun-20 Jun-19 Jun-19 Jun-20
Oct-19 Oct-20 Oct-20 Oct-19
Jan-20 Jan-21
Apr-19 Apr-20 Apr-20 Apr-19
Jun-20 Sep-20 Feb-21 Sep-19 Feb-20 Jun-19 Sep-19 Feb-20 Sep-20 Feb-21
Oct-19 Oct-20
Dec-20 Dec-19 Dec-20 Dec-19
Apr-19 Apr-20
Aug-19 Aug-19 Aug-20 Aug-20
Sep-20 Sep-19 Feb-20 Feb-21
Nov-19 Nov-20 Nov-19 Nov-20
Dec-20 Dec-19
Aug-19 Mar-20 Mar-21 Mar-21 Aug-20 Mar-20
Nov-19 Nov-20
May-19 May-20 May-20 May-19 Mar-21
performance targets. Mar-20
May-19 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
A&E Attendances 15000 15000 15000 (Attendances) 13000 13000 13000 11000 11000 11000 Lower is Better 9000 9000 9000 7000 7000 7000 5000 5000 5000 This measures the number of A&E attendances as an 3000 3000 3000
indicator of demand on the service.
Jul-19 Jul-20 Jul-19 Jul-20
Jul-19 Jul-20
Jan-20 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20
Apr-19 Apr-20 Apr-20 Apr-19
Jan-20 Jan-21 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Feb-20 Sep-20
Jun-20 Jun-19
Dec-20 Dec-19 Dec-20 Dec-19
Oct-19 Oct-20 Aug-19 Aug-20 Aug-19 Aug-20
Apr-19 Apr-20
Nov-19 Nov-20 Nov-19 Nov-20
Sep-19 Feb-20 Sep-20 Feb-21
Mar-20 Mar-21 Mar-20 Mar-21
Dec-19 Dec-20
Aug-19 Aug-20
Nov-20 May-19 May-20 May-19 Nov-19 May-20
Mar-21 Mar-20
May-19 May-20 Actual Mean UCL LCL Actual (exc WiC) Mean UCL LCL Actual Mean UCL LCL
Time to Treatment 120 140 250 120 100 200 Lower is Better 100 80 80 150 60 60 100 40 40 50 20 20 This measures the average time from assessment to 0 0 0
treatment within an A&E attendance
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20 Oct-19 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-20 Aug-19 Aug-20 Aug-19 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 May-20 Actual Mean UCL LCL Actual Mean UCL LCL Actual Mean UCL LCL
Leading & Signal Metrics Signal & Leading
Straight to Specialty 70% 60% 70% 60% 50% 60% Higher is Better 50% 50% 40% 40% 40% 30% 30% 30% 20% 20% 20% This measures the percentage of patients referred 10% 10% 10% 0% 0% 0%
straight to a relevant specialty as part of their A&E
Jul-20 Jul-19 Jul-20 Jul-19 Jul-19 Jul-20
Jan-20 Jan-20 Jan-21 Jan-21 Jan-20 Jan-21
Jun-19 Jun-20 Jun-19 Jun-20 Jun-19 Jun-20
Oct-19 Oct-20 Oct-19 Oct-20 Oct-19 Oct-20
Apr-19 Apr-20 Apr-19 Apr-20 Apr-20 Apr-19
Sep-19 Feb-20 Sep-19 Sep-20 Feb-21 Sep-19 Feb-20 Feb-21 Sep-20 Feb-21 Feb-20 Sep-20
Dec-20 Dec-20 Dec-19 Dec-20 Dec-19 Dec-19
Aug-20 Aug-19 Aug-20 Aug-19 Aug-19 Aug-20
Nov-19 Nov-20 Nov-19 Nov-20 Nov-19 Nov-20
Mar-20 Mar-21 Mar-20 Mar-21 Mar-20 Mar-21
May-19 May-19 May-20 May-19 May-20 attendance. May-20 Actual NHSE Mean UCL LCL Actual Mean UCL LCL NHSE Actual NHSE Mean UCL LCL
A&E Performance
Performance (National Rank) CO Performance Data Total Indicator Bury & Regional National Period Pennine Acute Salford Royal Oldham Providers Benchmarking of National Metrics Rochdale
Accident & Emergency 4 hours Jul-20 88.3% (105) 90.8% (91) 91.2% 93.0% 128
Comparison Key: = Salford, = Pennine, |= National Average
Principal Risk Score Principal Risk Score Principal Risk Score
2.1 IF demand for critical non-COVID 19 Associated Principal Risks services is not met whilst capacity is
BAF diverted to COVID response THEN there 13 is increased likelihood of patient safety harm and mortality incidents arising
Our Care Organisations could not deliver the A&E standard to treat 95% of our patients within 4hrs of arrival. Waiting times remain lower at both Bury & Rochdale and although Oldham's waiting times are still low, they are increasing. Salford's waiting time are higher and at pre- pandemic levels but within normal variation. Commentary NCA # 274090 Attendance levels have plateaued across all Care Organisations and deflection schemes09/25/2020 are in place to ensure 10:33:46 patients are treated in the
Context most appropriate care setting.
9/9 33/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Finance & Activity Report as at 31st August 2020 (Month 5 ) Meeting Group Board (Committees in Common) Author Care Organisations Finance Management Presented by Ian Moston, Chief Finance Officer Date 28th September 2020 Executive Summary SRFT : The month 5 financial position was a £34.7m deficit. After including the COVID-19 retrospective repayment the SRFT adjusted financial positon is break even. The in month deficit position includes a retrospective adjustment for 4 months of duplicate ASC payments totalling £36.2m. PAT : The position for month 5 was a £8.5m deficit. After including the COVID-19 retrospective top up the PAT adjusted financial positon is break even. Within the month 5 position PAT has recognised the stakeholder repayment to GMH&SC of £3.4m in full which is driving the increase in month of £2.7m compared to trend. Annual Plan Objective We will work with partners to ensure financial plans are sustainable and deliver on our annual income and expenditure budgets Principal Associated 3.2.1 IF we do not generate sufficient cash over a 3 year period THEN we may not Risks be able to support the planned investment and meet operational costs 3.2.2 IF the planned activity and income levels and/or expenditure controls are exceeded leading to NHSI Use of Resources rating lower than planned THEN this will increase regulatory investigation & intervention and put at risk Provider Sustainability Funding Recommendations Group Board (Committees in Common) is asked to review and approve the reported financial position of each Trust. Equality N/A Freedom of This document does not contain confidential information and can be X Information made available to the public. Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
NCA # 274090 09/25/2020 10:33:46
1/22 34/163 Contents Page Group Performance Summary as at 31st August 2020 4 1. PAT : Summary Dashboard as at 31st August 2020 10 2. SRFT : Summary Dashboard as at 31st August 2020 11 Appendix A PAT Income and Expenditure Position as at 31st August 12 2020 Appendix B PAT Income and Expenditure Run Rate 13 Appendix C PAT Balance Sheet as at 31st August 2020 14 Appendix D PAT Cash Flow as at 31st August 2020 15 Appendix E PAT Capital Expenditure as at 31st August 2020 16 Appendix F SRFT Income and Expenditure Position as at 31st August 18 2020 Appendix G SRFT Income and Expenditure Run Rate 19 Appendix H SRFT Balance Sheet as at 31st August 2020 20 Appendix I SRFT Cash Flow as at 31st August 2020 21 Appendix J SRFT Capital Expenditure as at 31st August 2020 22
NCA # 274090 09/25/2020 10:33:46
2/22 35/163 Group Performance Summary as at 31st August 2020
Bury and North Oldham Group PAHT Salford Group SRFT SRFT Group Rochdale Manchester Functions Functions Hosted Including Hosted) £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Income 82,150 76,310 95,580 82,097 336,137 269,776 62,897 48,319 380,993 717,130 Expenditure (67,596) (66,850) (77,097) (112,990) (324,533) (248,430) (74,207) (48,382) (371,020) (695,553) EBITDA 14,554 9,460 18,483 (30,893) 11,604 21,346 (11,310) (63) 9,973 21,577 Depreciation and (9,162) (9,162) 0 (6,192) 0 (6,192) (15,354) Amortisation Financing Costs (2,531) (2,531) 0 (3,901) 0 (3,901) (6,432) Cumulative surplus/(deficit) 14,554 9,460 18,483 (42,586) (89) 21,346 (21,403) (63) (120) (209) Technical Adjustment 89 89 120 120 209 surplus/(deficit) post technical 14,554 9,460 18,483 (42,497) 0 21,346 (21,283) (63) 0 0 adjustments
Cash Balance £85.2m £179.8m £265.0m
Note - North Manchester General Hospital is managed by MFT
NCA # 274090 09/25/2020 10:33:46
3/22 36/163 Group Financial Commentary as at 31st August 2020
1.1 Post COVID-19 arrangements
In response to the exceptional circumstances arising from the impact of the COVID-19 pandemic, NHSE/I issued a new financial framework for all NHS foundation and non foundation trusts for the period 1 April to 31 July which was subsequently extended through to the end of September 2020. The financial performance to end of August set out in these papers is prepared under these arrangements.
Phase 3 financial regime – October 2020 to March 2021
Further details on the financial framework for second half of the year were issued as this paper was being prepared in the document “Contracts and payment guidance October 2020 – March 2021” (Copy available on request). It confirms the details previously notified in relation to a system level fixed financial envelope and the need to achieve nationally set activity targets. Key components of the framework are: Whilst systems will be expected to breakeven, organisations within them will be permitted by mutual agreement across their system to deliver surplus and deficit positions. Retrospective top-up funding will no longer be available from October, and unless specifically identified, all system costs will need to be met from the envelope, including additional COVID- related expenditure on primary care, mental health and community services and delivery of the mental health investment standard. Separate funding streams or access to resources are available for PPE, testing, the hospital discharge programme, the national independent sector contract, and some national transformation and service development objectives. The elective incentive scheme which adjusts the financial payment for variance to national targets is confirmed. System funding envelopes are based on the expectation that organisations will return non-NHS income to the levels seen in 2019/20 and will make all reasonable efforts to do so as quickly as possible. (Recognising the challenge this poses, when assessing financial performance the impact of non-NHS income will be isolated to allow further discussion with Government if appropriate) The notified Greater Manchester envelope is currently being clarified to ensure all funding streams are clearly defined and understood. At this stage however it is expected that there will be a significant gap to forecast expenditure which will be compounded by adjustments for projected delivery of lower than target levels of activity.
NCA # 274090 09/25/2020 10:33:46
4/22 37/163 1.2 SRFT Financial Position The year to date position pre retrospective COVID-19 top up payment is a deficit of £34.66m. This is a deterioration of £34.71m compared to the £0.05m surplus at month 4. The significant deterioration in the M5 positon is due to a reduction in the top up figure received from NHSI/E of £36.2m to reflect the over payment of ASC income for months 1-5. After recognising the net retrospective top up for month 1 and 5, and repayments for months 2, 3 and 4 the adjusted financial position on a control total basis is break even.
£m £m £m £m £m £m
M1 M2 M3 M4 M5 YTD
NHSI Assumed Position Post Block & Top 0 0 0 0 0 0 Note Up
COVID-19 Additional cost 5.5 11.3 5.4 2.75 2.9 27.9 1
Mitigating Underspends -1.7 -2.7 -2.4 0.3 0.7 -5.8 2
Reference Period Issues 0.9 0.5 0.7 0.7 1.0 3.8 3
Non Clinical Commissioner Income 1.2 -14.5 -6.5 -6.5 29.7 3.4 4
Loss Of Commercial Income 0.5 0.6 0 0.6 0.8 2.5 5
Additional 20/21 Costs 1.5 0.5 0.4 0.9 -0.4 2.9 6
Deficit Pre Final COVID-19 Top Up 7.9 -4.3 -2.4 -1.3 34.71 34.66
The key drivers behind the cumulative £34.7m difference to the block / top up calculation are:- 1. COVID-19 expenditure; £27.9m YTD. The in month COVID-19 expenditure for M5 is £2.9m which is a small increase of £0.1m from the previous month with underlying run rates remaining similar. The biggest areas of COVID-19 spend are the backfill of staff due to sickness / isolation and an expansion of the workforce to support the Trust’s response to the pandemic. Non pay COVID-19 expenditure includes some local procurement of PPE in early months and costs from contracts and business cases originally to be funded via benefits. £12.9m of one off charges for contractual provisions remain to be confirmed by NHSE/I. 2. There has been £5.8m of cumulative underspends due to a reduction in the run rate due to the suspension of the Trust’s planned elective programme as part of the COVID-19 response and other reductions to usual levels of activity. The majority of the savings are on medical and surgical purchases. In month 4 and 5 however this moved to an overspend position of £0.3m in M4 and £0.7m in M5. This is due to an increase in the level of PBR excluded drugs spend from the early months of the year which in months 1-3 was low due to patients receiving LSD treatment temporarily shielding and not receiving treatment. PBR excNCA drug # spend 274090 is now £1.5m higher per month than months 1-3 and back inline with 19/20 levels. The09/25/2020 month 5 position 10:33:46 also includes an adverse backdated adjustment of £0.4m related to unfunded LHCRE costs.
5/22 38/163 3. The timing of the reference period in 2019/20 for the temporary block and top up calculation has resulted in various non recurrent adjustments in this period reducing the value of the initial top up paid to SRFT. The month 8-10 2019/20 reference spend was suppressed due to non recurrent actions taken to deliver the quarter 3 financial position totalling £1.8m and also excludes stakeholder repayments which were paid as an annual amount at year end outside the reference period. M5 also includes a year to date amount of £0.3m to reflect the 8-10 reference period including a PDC Dividend correction to the 19/20 position. The impact of this and other smaller timing differences has the effect of undervaluing the monthly top up payment to SRFT by £3.7m in the year to date. 4. The block and top up model ignores that some commissioner income in the reference period was unrelated to clinical activity and cannot therefore continue to be earned over and above the block contract. The impact of this is to undervalue the initial monthly top up payment required by £5.6m in the year to date. Up to month 4 this was offset by £7.7m per month of additional ASC income which continued to be received via the Salford pooled budget. In month 5 the SRFT in month top up figure received from NHSI/E was reduced by £36.2m to reflect the over payment of ASC income for months 1-5, leaving only £2.3m remaining as a duplicate ovepayment in the year to date position. The net impact of these adjustments has resulted in the overall monthly top up figure being understated by NHSI/E by a total of £3.3m year to date. 5. The value of commercial income received by the Trust outside the block and top up model has fallen by £2.5m in the year to date, with the majority of this being lost car park income and income from providing services to schools, private patients and overseas visitors. 6. New costs year to date of £3.0m which have been incurred by SRFT in 2020/21 which are over and above those included in the reference period and therefore not included in the initial top up. The most significant of these are an increase to depreciation and PDC Dividends and CEA payments made. This is a reduction of £0.3m from M4 due to a PDC Dividend correction reducing the amount payable in the year to date position by £0.4m Cash: The closing cash position for the month is £179.8 million, an increase of £4million compared to month 4: the main driver behind the increase in cash is the growth in payables, moving from £139million at month 4 to £146million at month 4. This cash balance is still significantly above plan and is primarily due to three main factors: Payments in advance from CCG’s, supporting cashflow throughout Covid-19. Timing delays in capital programmes. Reduction in Aged Debt from the GM Provider exercise.
NCA # 274090 09/25/2020 10:33:46
6/22 39/163 1.3 PAT Financial Position The Month 5 position is a deficit of £8.5m and year to date £31.3m. After including the final top up, the adjusted financial positon is break even (actual position is a £89k deficit due to donated asset depreciation which is excluded from the above block / top up model
M1 M2 M3 M4 M5 YTD £m £m £m £m £m £m
Position Post Block & Top Up 0.0 0.0 0.0 0.0 0.0 0.0 Note
COVID-19 Additional cost 3.7 4.8 4.8 4.5 5.3 23.1 1
Mitigating Underspends (3.8) (4.7) (4.2) (3.5) (4.0) (20.2) 2
Reference Period Issues 2.5 2.5 2.5 2.5 2.5 12.5 3
Non Clinical Commissioner Income 0.3 0.2 0.2 0.2 0.2 1.1 4
Loss Of Commercial Income 1.0 0.6 0.8 0.7 0.7 3.8 5
Additional 2020/21 Costs 1.8 1.8 1.8 1.8 3.8 11.0 6
Deficit Pre Final COVID-19 Top Up 5.5 5.2 5.9 6.3 8.5 31.3
The key drivers behind the in month £8.5m difference to the block / top up calculation are:- 1. COVID-19 related expenditure in August of £5.3m. This is made up of £0.4m B&R CO, £2.1m NMCO, £1.6m OCO and £1.2m from Group functions. The biggest areas of COVID-19 spend are the backfill of staff due to sickness / isolation and an expansion of the workforce to support the Trust’s response to the pandemic. The majority of PPE has been supplied and paid for nationally. 2. There has been a £4.0m reduction in the run rate due to the suspension of the Trust’s planned elective programme as part of the Covid-19 response. The majority of the savings are on medical and surgical purchases in theatres and across ward areas linked to the reduction in activity. There has been a reduction in bank and agency spend on nursing and medical staff in non Covid-19 areas also linked to a reduction in clinical activity. 3. The timing of the reference period in 2019/20 for the temporary block and top up calculation has resulted in various non recurrent adjustments in this period reducing the value of the initial top up paid. The month 8-10 2019/20 reference spend was suppressed due to non recurrent actions taken to deliver the quarter 3 financial position totalling £7.5m.The impact of this and other smaller timing differences has the effect of undervaluing the monthly top up payment to PAT by £2.5m. 4. The block and top up model ignores that some commissioner incomeNCA in the # reference 274090 period was received outside of patient care activities and cannot therefore continue09/25/2020 to be earned 10:33:46 over
7/22 40/163 and above the block contract. The impact of this is to further undervalue the initial monthly top up payment required by £0.2m. 5. The value of commercial income received by the Trust outside the block and top up model has fallen by £0.7m. The majority of this is within estates and facilities) lost car park income & catering income) and a reduction in income from CRU (Road traffic accidents) but this loss is being reimbursed through the retrospective top up. 6. New costs which have been incurred in 2020/21 which are over and above those included in the reference period and therefore not included in the initial top up. The most significant area in month 5 is the stakeholder repayment to GMH&SC has been recognised in full at £3.4m in month 5 increasing the run rate for these costs by £2.0m in month. Other additional costs are related to due diligence (FYE impact) and LCO transformation schemes, the impact of the pay awards and inflation above the uplift included in the block and top up payment. Cash: The cash position at the end of June is higher than usual at £85.2m. This is due, in the main, to commissioners making accelerated block contract payments under the temporary financial framework (Circa £53m) to ensure that no provider should require any revenue support funding due to insufficient cash.
1.4 Retrospective Top Up Payments Confirmation has been received that PAT claims for retrospective top up will be paid in full for months 1 to 4 totalling £22.8m with the Trust awaiting confirmation for the month 5 top up of £8.4m For Salford there is £12.9m of retrospective top up payments that are still on hold awaiting validation of which relate to provisions for contractual obligations, the impact of loss of hosted services activity and an adverse PDC variance versus original plan.
NCA # 274090 09/25/2020 10:33:46
8/22 41/163 1. PAT : Summary Dashboard as at 31st August 2020 PAHT DASHBOARD 2020/21 MONTH 5 - AUG 2020
SUMMARY Jun Jul Aug YTD In Mth Actual 20/21 Variance to Plan by Month Contribution Variance - Year to date £34,307k YTD Var YTD Var Plan Act Var Var 40.0 Contribution Variance - In Month £6,859k 38.0 Actual 19/20 £'000 £'000 £'000 £'000 £'000 £'000 36.0 YTD BREAKDOWN 34.0 Clinical Income 20,632 26,937 244,969 276,903 31,935 4,998 32.0 30.0 Divisional Income (3,317) 2,367 41,611 46,797 5,186 2,819 28.0 Income from Activities Var. - Year to Date £37,121k 26.0 High Cost Drugs Income (3,040) (3,518) 14,998 12,437 (2,561) 957
s 24.0
PBR Income (£2,561k) n Total Income from Activities 18,715 25,786 301,578 336,138 34,560 8,774
o 22.0 i l l Pay Expenditure £5,760k i 20.0 Pay 3,304 3,740 (236,729) (230,969) 5,760 2,020
m 18.0
BCLC Var. - Year to Date (£8,218k) £ 16.0 BCLC (6,588) (6,575) 8,218 - (8,218) (1,644) 14.0 PBR Expenditure £2,561k 12.0 High Cost Drugs Expenditure 1,657 1,811 (14,998) (12,437) 2,561 750 10.0 Non Pay Expenditure Var. - Year to Date (£3,646k) 8.0 Non Pay 1,752 157 (77,482) (81,128) (3,646) (3,803) Non EBITDA Var. - Year to Date £3,290k 6.0 Non EBITDA 1,750 2,528 (14,982) (11,692) 3,290 762 4.0 2.0 Total Expenditure 1,874 1,662 (335,973) (336,226) (253) (1,915) - l r r t c v y g n p b 2020/21 BCLC Achieved (Target = £19,724k) £0k n c (2.0) u p a e o a u a e e u J J J O A S F D A N
(4.0) M (6.0) M Surplus/(Deficit) 20,589 27,448 (34,396) (88) 34,307 6,859
Jun Jul Aug YTD Contribution In Month Clinical Income YTD Pennine Acute YTD Var YTD Var Plan Actual Variance Variance Capital expenditure and cash balances 2020/21 POD Plan Actual Variance In Mth Var £'000 £'000 £'000 £'000 £'000 £'000 140.00 90.0 £'000 £'000 £'000 £'000 Bury & Rochdale Co 3,266 3,989 9,644 14,554 4,910 922 Plan (£m) A&E 19,835 15,308 -4,528 -420 120.00 88.0 North Manchester CO 3,960 5,207 2,895 9,460 6,565 1,359 YTD Community 10,122 9,292 -830 -159 100.00 Oldham CO 2,463 2,264 16,226 18,483 2,257 -7 86.0 Critical Care 8,033 7,730 -303 -549 l
a 80.00 Actual(£m h t
Corporate/Support Services 10,900 15,988 -63,160 -42,586 20,574 4,586 i Maternity 20,322 19,633 -689 -248 s a p 84.0 ) YTD a C
PAT (Excl Hosted) Total 20,589 27,448 -34,396 -89 34,307 6,859 C 60.00 Out Patient 31,751 20,640 -11,110 -1,747 82.0 Elective 13,467 4,578 -8,889 -1,198 40.00 Cash Balance Day Case 21,626 8,152 -13,474 -2,014 80.0 Hosted 0 0 0 0 0 0 20.00 (£m) Non Elective 79,850 64,207 -15,643 -2,435 0.00 78.0 Other 32,096 119,534 87,438 13,769 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Education 7,866 7,830 -36 0 Grand Total 20,589 27,448 -34,396 -89 34,307 6,859 Grand Total 244,969 276,903 31,935 4,998
NON-CONTRACTUAL PAY - YTD SPEND - £41,542k BETTER CARE LOWER COST
Monthly Premium Spend 10,000
9,000 WLI 8,000
7,000 Overtime
s 6,000 0
0 Locum 0 '
£ 5,000
Medics n i
d 4,000 Bank n e p
S 3,000 Agency 2,000 1,000 NCA # 274090 0 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 09/25/2020 10:33:46 -1,000
9/22 42/163 2. SRFT : Summary Dashboard as at 31st August 2020
SRFT (EXCLUDING HOSTED) DASHBOARD 2020/21 MONTH 5 - AUG 2020
SUMMARY Jun Jul Aug YTD In Mth Actual 20/21 Variance to Plan by Month Contribution Variance - Year to date (£700k) YTD Var YTD Var Plan Act Var Var 8.0 Contribution Variance - In Month £316k Actual 19/20 £'000 £'000 £'000 £'000 £'000 £'000 7.0 YTD BREAKDOWN Clinical Income 55,969 49,973 260,856 324,916 64,060 14,087 6.0 Divisional Income (3,241) (6,594) 24,449 16,415 (8,034) (1,440) Income from Activities Var. - Year to Date £56,026k 5.0 PBR Income (33,448) (44,881) 57,666 1,681 (55,985) (11,104) s
PBR Income (£55,985k) 4n .0 Total Income from Activities 19,279 (1,503) 342,971 343,012 41 1,543 o i l l Pay Expenditure £925k 3i .0 Pay (5,046) 898 (175,139) (174,214) 925 27 m
BCLC Var. - Year to Date (£15,613k) £ BCLC (9,370) (12,493) 15,613 1 (15,613) (3,120) 2.0 PBR Expenditure £9,058k PBR Expenditure 7,251 8,269 (57,382) (48,324) 9,058 789 1.0 Non Pay Expenditure Var. - Year to Date £4,127k Non Pay (11,355) 3,622 (114,565) (110,437) 4,127 505 - l r r t c v y g
Non EBITDA Var. - Year to Date £762k n Depreciation ------p b n c u p a e o a u a e e u J J J O A S F D A N (1.0) M M Non EBITDA 117 190 (10,856) (10,093) 762 572 2020/21 BCLC Achieved (Target = £37,477k) £0k (2.0) Total Expenditure (18,403) 486 (342,328) (343,069) (741) (1,227) (3.0) Surplus/(Deficit) 876 (1,016) 643 (57) (700) 316
Jun Jul Aug YTD Contribution In Month Clinical Income YTD Salford Royal YTD Var YTD Var Plan Actual Variance Variance Capital expenditure and cash balances 2020/21 POD Plan Actual Variance In Mth Var £'000 £'000 £'000 £'000 £'000 £'000 45.0 200.0 £'000 £'000 £'000 £'000 Healthcare -12,424 6,636 -16,281 -8,791 7,490 855 40.0 180.0 A&E 8,911 9 -8,903 -1,779 ASC & MH 230 438 -1,286 -743 542 105 35.0 160.0 Community 14,929 2,196 -12,733 -2,547 Corporate 14,865 -7,329 37,528 29,736 -7,792 -463 30.0 140.0 Critical Care 8,838 2 -8,837 -1,770
l 120.0
Estates, Facilities & Digital -1,795 -760 -19,318 -20,258 -940 -180 a Dialysis 5,552 1 -5,551 -1,110 h
t 25.0 Plan (£m) i s a p 100.0 a SRFT (Excl Hosted) Total 876 -1,016 643 -57 -700 316 20.0 C Education 6,846 8,219 1,374 275 C Actual (£m) 80.0 Elective 33,518 44 -33,474 -6,717 15.0 Cash Balance 60.0 Non Elective 51,996 146 -51,850 -10,387 10.0 40.0 Hosted -903 951 -707 7 714 -236 Other 94,499 313,844 219,346 45,181 5.0 20.0 Out Patient 35,386 96 -35,290 -7,055 - 0.0 l r r r t c v y g n p b n Reserves 0 0 0 0 c u p a a e o a u a e e u J J J O A S F D A N M M Grand Total -27 -66 -64 -49 14 80 M Grand Total 260,475 324,556 64,082 14,091 381.30 359.56 NON-CONTRACTUAL PAY - YTD SPEND - £3,903k BETTER CARE LOWER COST
Monthly Premium Spend 5,000
4,500 WLI 4,000 Specialling 3,500 Overtime
s Locum 0
0 3,000 0
' Bank £
n
i 2,500 Agency
d n e
p 2,000 S 1,500
1,000
500
0 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 NCA # 274090 09/25/2020 10:33:46
10/22 43/163 Appendices
NCA # 274090 09/25/2020 10:33:46
11/22 44/163 A. PAT Income and Expenditure Position as at 31st August 2020
PAHT Summary Financial Position PAHT Bury & Rochdale CO North Manchester CO Oldham CO Corporate / Support Services
In Month Performance Annual Year to Date Performance Plan Actual Var Plan Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 48,993 55,662 6,669 Clinical Income 587,918 244,969 276,903 31,935 76,933 77,172 239 68,937 70,353 1,416 91,627 91,829 201 7,471 37,549 30,078 3,000 2,250 (750) Clinical Income - PbR Excluded Drugs & Devices 35,995 14,998 12,437 (2,561) 4,362 4,123 (239) 6,122 4,706 (1,416) 3,347 3,145 (202) 1,167 463 (704) 4,998 8,433 3,434 Covid Final Top Up 21,093 21,093 31,249 10,156 0 0 0 0 0 0 0 0 0 21,093 31,249 10,156 1,582 1,575 (7) Education Income 18,979 7,908 7,829 (79) 0 0 0 0 0 0 0 (4) (4) 7,908 7,833 (75) 891 569 (323) Other Patient Income 10,672 4,535 1,973 (2,562) 147 176 30 658 639 (19) 430 362 (67) 3,300 795 (2,505) 1,664 1,414 (250) Divisional Income 18,979 8,075 5,747 (2,329) 521 678 157 541 612 71 258 249 (9) 6,755 4,208 (2,547) 0 0 0 Income - Centrally Held Budgets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 61,128 69,902 8,774 Total Income 693,638 301,578 336,138 34,560 81,963 82,150 187 76,259 76,310 51 95,662 95,580 (81) 47,695 82,097 34,403
(48,000) (46,166) 1,833 Pay (539,015) (235,018) (229,204) 5,814 (51,434) (50,352) 1,082 (60,125) (56,904) 3,220 (65,864) (66,061) (196) (57,596) (55,887) 1,709 1,043 0 (1,043) Pay - Unachieved BCLC Targets 12,510 5,213 0 (5,213) 0 0 0 0 0 0 0 0 0 5,213 0 (5,213) (468) (282) 186 Pay - Centrally Held Budgets (4,987) (1,711) (1,765) (54) 0 0 0 (442) (442) (0) 0 0 0 (1,269) (1,323) (54) (47,425) (46,448) 977 Total Pay (531,493) (231,516) (230,969) 547 (51,434) (50,352) 1,082 (60,566) (57,346) 3,220 (65,864) (66,061) (196) (53,652) (57,210) (3,558) (15,092) (18,898) (3,806) Non Pay (179,457) (77,024) (80,456) (3,432) (16,188) (13,282) 2,906 (6,379) (4,798) 1,581 (9,400) (7,892) 1,509 (45,056) (54,484) (9,428) (3,000) (2,250) 750 Non Pay - PbR Excluded Drugs & Devices (35,995) (14,998) (12,437) 2,561 (4,362) (4,123) 239 (6,122) (4,706) 1,416 (3,347) (3,145) 202 (1,167) (463) 704 601 0 (601) Non Pay - Unachieved BCLC Targets 7,214 3,006 0 (3,006) 0 0 0 0 0 0 0 0 0 3,006 0 (3,006) (86) (83) 3 Non Pay - Centrally Held Budgets (2,429) (459) (672) (213) (336) 161 497 (296) 0 296 (824) 0 824 997 (834) (1,831) (17,577) (21,231) (3,654) Total Non Pay (210,667) (89,475) (93,565) (4,091) (20,885) (17,243) 3,642 (12,798) (9,504) 3,294 (13,572) (11,037) 2,535 (42,220) (55,781) (13,561)
(3,874) 2,223 6,097 EBITDA (48,522) (19,413) 11,603 31,017 9,644 14,554 4,910 2,895 9,460 6,565 16,226 18,483 2,257 (48,178) (30,894) 17,284
(2,996) (2,234) 762 Non EBITDA (60,157) (14,982) (11,692) 3,290 0 0 0 0 0 0 0 0 0 (14,982) (11,692) 3,290 0 0 0 Non EBITDA - Centrally Held Budgets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
(6,871) (12) 6,859 Cumulative surplus/(deficit) (108,679) (34,396) (88) 34,307 9,644 14,554 4,910 2,895 9,460 6,565 16,226 18,483 2,257 (63,160) (42,586) 20,575
20 12 (9) Technical Adjustments (Donated Assets & 24,444 102 89 (13) 0 0 0 0 0 0 0 0 0 102 89 (13) Impairments) (6,850) 0 6,850 2020/2021 Control Total Inc PSF (84,2350) (34,294) 0 34,294 9,644 14,554 4,910 2,895 9,460 6,565 16,226 18,483 2,257 (63,059) (42,497) 20,561
NCA # 274090 09/25/2020 10:33:46
12/22 45/163 B. PAT Income and Expenditure Run Rate as at 31st August 2020
Apr FY20 May FY20 Jun FY20 July FY20 Aug FY20 Sep FY20 Oct FY20 Nov FY20 Dec FY20 Jan FY21 Feb FY21 Mar FY21 £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Clinical Income (Incl PbR Drugs) 57,954 57,814 57,842 57,819 57,912 Covid Final Top Up 6,255 8,433 Education Income 1,577 1,568 1,535 1,574 1,575 Other Income 7,101 6,691 7,276 1,231 1,983 Pay (45,117) (46,470) (47,592) (45,264) (46,634) Non Pay (15,863) (15,381) (13,512) (16,273) (18,985) PbR Drugs (2,471) (2,360) (2,510) (2,845) (2,250) Centrally Held Budgets (652) 386 (633) (297) 190 Non EBITDA (2,548) (2,267) (2,425) (2,218) (2,234) Net Impairments 0 0 0 0 0 PAT Reported Actual Surplus/(Deficit) (19) (19) (20) (19) (12) 0 0 0 0 0 0 0
Adjustments to determine underlying position
I&E adjustments NR AOB Block Income (53,307) (53,307) (53,307) (53,307) (53,307) NR AOB Top-Up Income (4,049) (4,049) (4,049) (4,049) (4,049) NR AOB Retrospective Top-Up Income (5,526) (5,246) (5,826) (6,255) (8,433) NR Clinical Income under plan 56,911 57,638 53,264 51,529 51,437 NR Divisional Income (over) / under plan (1,403) (893) (972) 1,152 579 NR Covid spend 3,664 4,784 4,785 4,508 5,225 NR Pay under spend (2,543) (3,477) (2,491) (2,615) (2,202) NR Non-Pay (under) / over spend (1,942) (3,364) 523 1,171 2,860 NR Financing costs under spend (449) (730) (571) (778) (762)
Revised Underlying Actual Surplus/(Deficit) (8,663) (8,663) (8,663) (8,663) (8,663) 0 0 0 0 0 0 0
2020/21 Average normalised run rate deficit (8,663)
NCA # 274090 09/25/2020 10:33:46
13/22 46/163 C. PAT Balance Sheet as at 31st August 2020
August 2020 Prior month Movement From prior Plan Actual Actual From plan month Consolidated Consolidated Consolidated Consolidated Consolidated £000 £000 £000 £000 £000 £000 £000 £000 ASSETS Assets Non-Current Intangible Assets 3,579 6,961 7,163 3,382 (203) Property Plant and Equipment 324,353 292,521 292,557 (31,832) (37) On Balance PFI Assets 0 0 0 0 0 Investments in Associates and Joint Ventures 0 0 0 0 0 327,932 299,481 299,720 (28,451) (239)
Trade and Other Receivables Non Current Non NHS Trade Receivables 0 2,053 2,327 2,053 (273) Accrued Pension Contribution 3,823 1,375 1,375 (2,448) 3,823 3,428 3,701 (395) (273)
Assets Non-Current - Total 331,755 302,909 303,422 (28,846) (513)
Assets Current Inventories 6,093 7,464 7,542 1,371 (77)
Trade and Other Receivables NHS Trade Receivables 21,995 28,787 25,001 6,792 3,786 Non NHS Trade Receivables 20,177 19,499 15,745 (678) 3,754 Trade and Other Receivables - Total 42,172 48,286 40,746 6,114 7,540
Prepayments Current 4,005 9,925 8,073 5,920 1,852
Cash and Cash Equivalent Cash 3,000 85,153 83,910 82,153 1,243 Current Asset Investments 0 0 0 0 Cash and Cash Equivalent - Total 3,000 85,153 83,910 82,153 1,243
Assets Current - Total 55,270 150,828 140,271 95,558 10,557
ASSETS - TOTAL 387,025 453,738 443,693 66,713 10,044
LIABILITIES Liabilities Current Loans Current FTFF (4,540) (164,553) (165,193) (160,013) 641 Deferred Income (3,800) (7,811) (7,400) (4,011) (411) Provisions (870) (3,586) (3,586) (2,716) 0
Trade and Other Payables Current Trade Creditors (57,320) (77,412) (72,597) (20,092) (4,815) Other Creditors 0 0 0 0 0 Capital Creditors (7,000) (6,862) (6,920) 138 58 Trade and Other Payables - Total (64,320) (84,274) (79,517) (19,954) (4,757)
Other Financial Liabilities Current Payments on Account 0 (63,678) (57,854) (63,678) (5,824) PDC Dividend 0 (1,234) (1,488) (1,234) 254 Other Financial Liabilities Current - Total 0 (64,913) (59,343) (64,913) (5,570)
Liabilities Current - Total (73,530) (325,136) (315,039) (251,606) (10,096)
NET ASSETS EMPLOYED 313,495 128,602 128,654 (184,893) (52)
Liabilities Non-Current Loans Non Current FTFF (88,644) (50,852) (50,852) 37,792 0 Provisions (7,750) (11,834) (11,875) (4,084) 41
TOTAL ASSETS EMPLOYED 217,101 65,916 65,927 (151,185) (12)
TAX PAYERS AND OTHER EQUITY Public Dividend Capital 388,854 218,637 218,637 (170,217) 0 Accumulated Losses/Retained Income (247,080) (223,314) (223,302) 23,766 (12) Revaluation Reserve 75,327 70,592 70,592 (4,735) 0 TAX PAYERS AND OTHER EQUITY - TOTAL 217,101 65,916 65,927 (151,185) (12) NCA # 274090 09/25/2020 10:33:46
14/22 47/163 D. PAT Cash flow as at 31st August 2020
Cashflow from 2020/21 Actual Variance Annual Plan cashflow from revised Annual Plan Year to date plan plan £000s £000s £000s £000s
Operating cashflows before movement in working capital (47,043) (15,688) 11,603 27,291 Increase/(decrease) in working capital 17,010 13,632 57,717 44,085 Cashflow from operations (30,033) (2,056) 69,321 71,377
Capital expenditure (158,879) (22,146) (15,855) 6,291 Increase/(decrease) in capital creditors - - - - Interest receivable 199 68 13 (55) Cashflow before financing (158,680) (22,078) (15,843) 6,235 PDC received/ Repaid 256,205 162,057 42 (162,015) Repayment of loan (63,350) (140,346) - 140,346 Repayment of PFI principal - - - - Interest paid - PFI finance lease - - - - Interest paid - FTFF loan and other (3,000) (1,000) (783) 217 Other financing cashflows (1,042) 3,423 1 (3,422) Financing cashflow 188,813 24,134 (739) (24,873) Net cash (outflow) / inflow 100 - 52,738 52,738
Year to date Year to date Reconciliation of cash movements Annual Plan plan Act Variance £000s £000s £000s £000s Opening cash balance as at 1st April 2020 3,000 3,000 32,390 29,390 Closing cash balance 3,100 3,000 85,129 82,129 Net cash movement 100 - 52,738 52,738
NCA # 274090 09/25/2020 10:33:46
15/22 48/163 E. PAT Capital Expenditure as at 31st August 2020
Submitted Proposed Actual Planned funding Cmaeptihtaold scheme plan Adjust plan 31 Aug 20 £000s £000s £000s £000s PDC MFT: HIP2 NMGH 21,100 21,100 - GM Healthier Together ROH 16,592 16,592 - IT GDE 2,500 2,500 775 NEEF 2,251 2,251 Critical Infrastructure Risks (CIR) 14,333 14,333 UEC MOUs COVID recovery 1,921 1,921 PDC Total 42,443 16,254 58,697 775 Internally Equipment/other schemes: Funded Lifecycling/other unallocated 8,059 - 1,753 6,306 Estates/other schemes 640 640 1,415 Equipment 400 400 195 Intermediate Care NMGH 400 400 685 CO Allocations 600 600 62 NMGH ward moves 40 40 40 GDE Fast Follower 116 116 116 GM Healthier Together ROH 346 346 341 Sub Total Equipment/other schemes (NHSEI return) 10,601 - 1,753 8,848 2,854 Trafford Orthopaedic schemes 5,995 - 1,221 4,774 1,335 Stabilising Technology Infrastructure 2,300 1,140 3,440 3,440 UEC ROH (2019-20 scheme) 1,980 - 65 1,915 61 Energy schemes (NMGH/ROH) internally funded 427 351 778 778 Internally Funded Total 21,303 - 1,548 19,755 8,468 Loans (Interim) - approved IT urgent remediation 3,000 3,000 3,000 Loans (Interim)- approved Total 3,000 - 3,000 3,000 Loans other (e.g. Salix) Energy schemes (NMGH/ROH) SALIX funded 3,423 3,423 108 Loans other (e.g. Salix) Total 3,423 - 3,423 108 Loans (Interim) ROH ward refurbs/ED/Wave 4 extra 21,398 - 21,398 - - to be approvedIT due diligence 17,845 - 5,845 12,000 1,580 Equipment 13,300 - 6,884 6,416 Estates/Facilities (aggregated no item > del limit) 13,100 - 13,100 - IT stabilisation (disaggregation) 8,700 4,500 13,200 IT preparation for acquisition 7,200 - 7,200 - EPR 5,300 - 5,300 - Estates 3,200 - 3,200 - Loans (Interim)- to be approved Total 90,043 - 58,427 31,616 1,580 Grand Total (excluding Covid) 160,212 - 43,721 116,491 13,931
PDC COVID schemes NCA4 ,3#9 82740904,398 1,925 09/25/2020 10:33:46 Grand Total (Including Covid) 160,212 - 39,323 120,889 15,856 * Latest plan agreed with GM submitted to NHSI 27 July 2020 plus UEC MOUs £1.921m
16/22 49/163 During the month PAT spent a further £1.5m on capital taking the total YTD spend to £15.9m, IT (excluding GDE) is the largest contributor of this and accounts for £8m of the YTD spend. Covid Schemes saw minimal increase in the month with £160k spent taking to a total of £1.9m, the annual plan is set at £4.4m
There have been changes to the MFT HIP2 NMGH plan which has reduced to c£7m for 2020-21, from an initial proposed plan of £21,100. There have also been changes to the accounting of this scheme which will now be accounted for in MFTs books.
NCA # 274090 09/25/2020 10:33:46
17/22 50/163 G. SRFT Income and Expenditure Position as at 31st August 2020
SRFT SRFT Salford CO Group Functions Bury & Rochdale CO Oldham CO Hosted Services
In Month Performance Year to Date Performance Summary Financial Position Annual Plan Actual Var Plan Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var Plan Actual Var £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000
53,330 33,304 (20,026) Clinical Income 646,101 283,493 311,641 28,148 216,795 217,778 983 36,205 64,324 28,119 18,404 17,464 (940) 12,088 12,088 (0) (14) (14) 11,533 430 (11,104) Clinical Income - PbR Excluded Drugs & Devices 138,398 57,666 1,681 (55,985) 57,461 46,741 (10,720) 206 (45,060) (45,265) 1,046 34,706 33,660 Covid Final Top Up 1,046 1,046 34,652 33,606 1,046 34,652 33,606 1,445 1,734 288 Education Income 17,345 7,227 8,666 1,439 1,856 1,786 (70) 5,371 6,793 1,422 88 88 433 (141) (574) Other Patient Income 5,194 2,164 925 (1,239) 326 45 (281) 1,838 880 (958) 6,213 5,248 (965) Divisional Income 71,594 31,472 24,261 (7,211) 3,842 3,427 (415) 7,877 2,142 (5,735) 1,875 1,913 38 442 409 (33) 17,437 16,371 (1,066) (83) (167) (83) Income - Centrally Held Budgets (1,000) (417) (833) (417) (417) (833) (417) 73,917 75,113 1,196 Total Income 878,677 382,651 380,993 (1,658) 280,280 269,776 (10,504) 52,125 62,897 10,772 20,279 19,377 (902) 12,530 12,497 (33) 17,437 16,445 (992)
(39,837) (39,651) 186 Pay (469,628) (200,897) (199,616) 1,281 (130,488) (128,826) 1,662 (34,566) (35,503) (936) (14,909) (14,573) 336 (9,695) (9,311) 384 (11,239) (11,404) (165) 1,703 (1,703) Pay - Unachieved BCLC Targets 20,405 8,513 (8,513) 8,513 (8,513) (772) (772) (0) Pay - Centrally Held Budgets (9,210) (3,808) (3,808) (0) (3,808) (3,808) (0) (38,905) (40,422) (1,517) Total Pay (458,433) (196,192) (203,424) (7,232) (130,488) (128,826) 1,662 (29,861) (39,311) (9,450) (14,909) (14,573) 336 (9,695) (9,311) 384 (11,239) (11,404) (165)
(21,981) (21,697) 284 Non Pay (263,849) (121,279) (115,589) 5,690 (78,413) (71,408) 7,005 (27,755) (31,086) (3,330) (8,069) (6,937) 1,132 (843) (699) 143 (6,198) (5,458) 740 (11,476) (10,688) 789 Non Pay - PbR Excluded Drugs & Devices (137,717) (57,382) (48,324) 9,058 (57,177) (48,196) 8,981 (206) (129) 77 (0) (0) 1,420 (1,420) Non Pay - Unachieved BCLC Targets 17,038 7,099 (7,099) 7,099 (7,099) (1,294) (1,233) 61 Depreciation (15,526) (6,469) (6,192) 277 (6,469) (6,192) 277 (821) (731) 90 Non Pay - Centrally Held Budgets (9,852) (4,105) (3,682) 423 (4,105) (3,682) 423 (34,152) (34,348) (196) Total Non Pay (409,906) (182,136) (173,788) 8,348 (135,590) (119,604) 15,986 (31,436) (41,089) (9,653) (8,069) (6,937) 1,132 (843) (699) 143 (6,198) (5,458) 740
859 342 (517) EBITDA 10,338 4,323 3,781 (542) 14,202 21,346 7,144 (9,172) (17,502) (8,330) (2,699) (2,133) 566 1,992 2,487 495 (417) (417)
Pence in the £ adjustment 859 342 (517) Revised EBITDA 10,338 4,323 3,781 (542) 14,202 21,346 7,144 (9,172) (17,502) (8,330) (2,699) (2,133) 566 1,992 2,487 495 (417) (417)
(877) (366) 511 Non EBITDA (10,528) (4,387) (3,901) 485 (4,387) (3,901) 485 Non EBITDA - Centrally Held Budgets
(18) (24) (6) Cumulative surplus/(deficit) (190) (64) (120) (57) 14,202 21,346 7,144 (13,559) (21,403) (7,845) (2,699) (2,133) 566 1,992 2,487 495 (417) (417)
18 24 6 Technical Adjustments (Donated Assets & 190 64 120 57 64 120 57 Impairments) 0 (0) (0) 2020/2021 Control Total Inc PSF 0 0 0 0 14,202 21,346 7,144 (13,495) (21,283) (7,788) (2,699) (2,133) 566 1,992 2,487 495 (417) (417)
(1,391) 1,391 Provider Sustainability Funding (16,686) (6,953) 6,953 NCA # 274090(6,953) 6,953 Financial Recovery Fund 09/25/2020 10:33:46 Marginal Rate Emergancy Tariff (MRET) (1,391) (0) 1,390 2020/2021 Control Total Exc PSF (16,686) (6,953) 0 6,953 14,202 21,346 7,144 (20,448) (21,283) (835) (2,699) (2,133) 566 1,992 2,487 495 (417) (417)
18/22 51/163 H. SRFT Income and Expenditure Run Rate as at 31st August 2020
Apr 20 May 20 Jun 20 Jul 20 Aug 20 Sep 20 Oct 20 Nov 20 Dec 20 Jan 21 Feb 21 Mar 20 £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s £000s Clinical Income (Incl PbR Drugs) 62,465 77,540 70,163 69,420 33,733 Covid Final Top Up 7,925 (4,278) (2,370) (1,331) 34,706 Education Income 1,718 1,659 1,823 1,733 1,734 Other Income 5,119 4,829 5,845 4,286 5,107 Pay (40,467) (40,376) (39,807) (39,315) (39,651) Non Pay (22,859) (26,829) (23,618) (20,586) (21,697) PbR Drugs (10,141) (9,144) (7,893) (10,458) (10,688) Centrally Held Budgets (1,676) (1,296) (2,006) (1,676) (1,669) Non EBITDA (2,106) (2,130) (2,161) (2,097) (1,599) Net Impairments 0 0 0 0 0 SRFT Reported Actual Surplus/(Deficit) (23) (25) (24) (24) (24)
Adjustments to determine underlying position
I&E adjustments NR AOB Block Income (50,075) (50,075) (50,075) (50,075) (50,075) NR AOB Top-Up Income (10,256) (10,256) (10,256) (10,256) (10,256) NR AOB Retrospective Top-Up Income (7,925) 4,278 2,370 1,330 (34,706) NR Clinical Income under plan 61,326 46,023 53,537 52,213 89,558 NR Divisional Income under plan (Commercial) 341 2,112 (60) 2,874 1,182 NR Covid spend 5,476 11,331 5,420 2,693 2,949 NR Pay under spend (69) (523) (237) (375) (241) NR Non-Pay under spend (2,012) (6,131) (3,949) (1,462) (1,537) NR Hosted deficit 143 169 145 16 583 NR Financing costs under spend (65) (42) (10) (74) (572)
Revised Underlying Actual Surplus/(Deficit) (3,139) (3,139) (3,139) (3,139) (3,139) 0 0 0 0 0 0 0
NCA # 274090 09/25/2020 10:33:46
19/22 52/163 I. SRFT Balance Sheet as at 31st August 2020
August 2020 Prior month Movement From prior Plan Actual Actual From plan month Consolidated Trust excluding Hosted Hosted Consolidated Consolidated Consolidated Consolidated £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 ASSETS Assets Non-Current Intangible Assets 15,727 8,629 0 8,629 8,759 (7,098) (130) Property Plant and Equipment 155,743 152,918 0 152,918 153,457 (2,825) (539) On Balance PFI Assets 88,467 90,253 0 90,253 90,431 1,786 (178) Investments in Associates and Joint Ventures 0 0 0 0 0 0 0 259,937 251,800 0 251,800 252,647 (8,137) (847)
Trade and Other Receivables Non Current PFI Finance Lease Prepayment 0 0 Non NHS Trade Receivables 4,455 4,523 0 4,523 4,127 68 397 Accrued Pension Contribution 0 1,629 0 1,629 1,629 1,629 4,455 6,152 0 6,152 5,756 1,697 397
Assets Non-Current - Total 264,392 257,952 0 257,952 258,403 (6,440) (451)
Assets Current Inventories 4,729 5,149 0 5,149 4,675 420 474
Trade and Other Receivables NHS Trade Receivables 30,935 34,929 5,768 40,697 34,315 9,761 6,382 Non NHS Trade Receivables 10,533 13,957 3,492 17,449 17,617 6,916 (168) Other Receivables Current 0 0 0 0 0 0 0 BCLC accrued income 0 0 0 0 0 0 0 Incomplete spells 1,125 1,125 0 1,125 1,125 0 0 Provision for Bad Debt 0 0 0 0 0 0 0 Trade and Other Receivables - Total 42,593 50,011 9,260 59,271 53,057 16,678 6,214
Prepayments Current 4,000 13,578 0 13,578 15,994 9,578 (2,416) Prepayment - Loan Interest 0 0 0 0 0 0 0 Prepayments Current - PFI 4,471 4,513 0 4,513 4,471 42 42
Cash and Cash Equivalent Cash 28,892 164,768 15,063 179,831 175,782 150,939 4,049 Current Asset Investments 0 0 0 0 Cash and Cash Equivalent - Total 28,892 164,768 15,063 179,831 175,782 150,939 4,049
Assets Current - Total 84,685 238,019 24,323 262,342 253,979 177,656 8,363
ASSETS - TOTAL 349,078 495,972 24,323 520,294 512,382 171,217 7,913
LIABILITIES Liabilities Current Loans Current FTFF (579) (606) 0 (606) (588) (27) (18) Deferred Income (6,410) (11,012) (4,637) (15,649) (13,737) (9,239) (1,912) Deferred Income from non-NHS 0 0 0 0 0 0 Deferred Government Grant Income 0 0 0 0 0 0 PFI creditor repayment liability (3,850) (3,907) 0 (3,907) (3,907) (57) 0 Loan Interest Creditor 0 0 0 0 0 0 0 Provisions (5,413) (27,065) 0 (27,065) (27,080) (21,652) 15
Trade and Other Payables Current Trade Creditors (13,423) (139,174) (6,540) (145,714) (138,975) (132,291) (6,739) Other Creditors 0 0 0 0 0 0 0 Capital Creditors (5,104) (902) 0 (902) (2,504) 4,202 1,602 Trade and Other Payables - Total (18,527) (140,076) (6,540) (146,616) (141,479) (128,089) (5,137)
Other Financial Liabilities Current Accruals 0 0 0 0 0 0 0 0 Reserves accruals (6,651) (8,237) 0 0 (8,237) (6,651) (1,586) (1,586) Payments on Account (55,320) (53,535) 0 0 (53,535) (55,320) 1,785 1,785 PDC Dividend (940) (642) 0 0 (642) (940) 298 298 Other Financial Liabilities Current - Total (62,911) (62,414) 0 (62,414) (62,911) 497 497
Liabilities Current - Total (97,690) (245,080) (11,177) (256,257) (249,702) (158,568) (6,555)
NET ASSETS EMPLOYED 251,388 250,892 13,145 264,037 262,679 12,649 1,358
Liabilities Non-Current Loans Non Current FTFF (6,416) (6,416) 0 (6,416) (6,416) 0 0 Deferred Income - non current (4,167) 0 (4,059) (4,059) (2,341) 108 (1,718) Other creditors (60) 0 0 0 0 60 0 PFI Leases Non Current (89,989) (89,436) 0 (89,436) (89,772) 553 336 Provisions (4,740) (6,936) 0 (6,936) (6,936) (2,197) 0 Pension (Non Current Liability) (18,316) (13,876) 0 (13,876) (13,876) 4,440 0
TOTAL ASSETS EMPLOYED 127,700 134,227 9,087 143,314 143,338 15,614 (24)
TAX PAYERS AND OTHER EQUITY NCA # 274090 Public Dividend Capital 142,427 136,637 0 136,637 09/25/2020136,637 (5,790) 10:33:460 Accumulated Losses/Retained Income (58,306) (52,147) 9,087 (43,060) (43,036) 15,246 (24) Revaluation Reserve 43,579 49,737 0 49,737 49,737 6,158 0 TAX PAYERS AND OTHER EQUITY - TOTAL 127,700 134,227 9,087 143,314 143,338 15,614 (24)
20/22 53/163 J. SRFT Cash flow as at 31st August 2020
Cashflow from 2020/21 Annual Plan Actual Variance from cashflow revised plan Annual Plan Year to date plan £000s £000s £000s £000s
Operating cashflows before movement in working capital 37,404 11,214 9,973 (1,241) Increase/(decrease) in working capital (30,398) (28,613) 97,437 126,050 Cashflow from operations 7,006 (17,399) 107,410 124,809
Capital expenditure (51,243) (13,732) (5,366) 8,366 Increase/(decrease) in capital creditors - - - - Interest receivable 139 48 21 (27) Cashflow before financing (51,104) (13,684) (5,345) 8,339 PDC received/ Repaid 26,778 6,734 736 (5,998) Repayment of loan (512) - - - Repayment of PFI principal (3,480) (1,160) (1,659) (499) Interest paid - PFI finance lease (7,879) (2,624) (3,167) (543) Interest paid - FTFF loan and other (190) - - - Other financing cashflows (13,362) (3,556) - 3,556 Financing cashflow 1,355 (606) (4,090) (3,484) Net cash (outflow) / inflow (42,743) (31,689) 97,976 129,665
Year to date plan Year to date Reconciliation of cash movements Annual Plan Act Variance £000s £000s £000s £000s Opening cash balance as at 1st April 2020 60,581 60,581 81,855 21,274 Closing cash balance 17,838 28,892 179,830 150,938 Net cash movement (42,743) (31,689) 97,976 129,665
NCA # 274090 09/25/2020 10:33:46
21/22 54/163 K. SRFT Capital Expenditure as at 31st August 2020
Planned Actual to Submitted Proposed funding Capital scheme Adjust 31st Aug plan plan method 2020 £000s £000s £000s £000s PDC Acute Receiving Centre (MT) 14,981 - 8,949 6,032 266 Acute Receiving Centre (HT) 7,490 - 4,474 3,016 - Local Health Care Record 2,500 2,500 1,426
Global Digital Excellence 1,045 1,045 90
LED Lighting 762 762 412 Critical Infrastructure 5,339 5,339 678 PDC Total 26,778 - 8,084 18,694 2,872 Internally Routine equipment replacement 7,000 -2,651 4,349 370 Funded Routine building maintenance 5,692 -5,464 228 -
Equipment slippage 3,156 - 3,156 32
Routine IT replacement 2,251 3,125 5,376 274 LHCRE Slippage 1,563 - 1,335 228 - PACS 1,200 1,200 58 GM Digital Slippage 1,172 -499 673 -
Telephony 1,000 600 1,600 -
Group contingency 400 - 400 - - Summerfield House 240 240 - GDE Slippage 219 -219 - - Care Org Contingency 100 -100 - - Major Trauma/ Healthier together - - - - Internally Funded Total 23,993 -6,943 17,050 734 Grand Total (excluding Covid) 50,771 - 15,027 35,744 3,606 PDC Covid schemes 2,796 2,796 1,551 Grand Total (Including Covid) 50,771 - 12,231 38,540 5,157
In the month SRFT increased its capital spend by a net £500k, moving from a month 4 YTD position of £4.7million to £5.2million at month 5. Covid capital schemes saw a net decrease, moving from £1,966k reported at month 4 to £1,551K at month 5, a decrease of £415k. This was due to a receipting issue which saw £500k worth of incorrect GRNI accruals entered into the position at M4; this has now been rectified in M5.
Internally funded schemes now stand at £734k YTD and have seen an increase of £120k in-month, with the largest contributor being the PACS capital scheme incurring £58k of spend.
PDC funded schemes now stand at £2,872k an increase of £700k in-month. The £700k is primarily driven from: 1. Critical Infrastructure scheme, increasing by £175k. 2. Local Health Care Record lighting scheme, increasing by £300k, 3. Global Digital Excellence commencing and incurring £90k of spend. NCA # 274090 09/25/2020 10:33:46
22/22 55/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Infection Prevention and Control Report
Meeting Group Board (Committees in Common) Author (s) Linda Swanson, Director of Nursing Infection Control
Presented by Chris Brookes, Executive Medical Director
Date 28th September 2020
Executive This paper describes the comprehensive suite of measures adopted by the Summary NCA to protect patients and staff from COV19 infection.
It details how staff engagement with respect to these measures is being supported via an NCA collaborative and how compliance is to be assured utilising Leadership reality rounding. Specific questions to inform these rounds have been agreed, triangulating with the CQC Board Assurance Framework .
Commentary is provided around other Hospital Acquired Infections with particular focus on C difficile. This narrative both recognises and reaffirms the critical importance of robust antibiotic stewardship as a key factor in minimising this infection. Annual Plan Clinical and Operational Excellence – doing things right Objective 3.1 We will keep our patient and service users safe by achieving zero hospital acquired Covid cases for patients and staff
Associated Risks 3.1.1IF we do not maintain safe and reliable infection prevention and control THEN patients and staff may come to harm
Recommendations The Group Board is asked to note the contents of this paper and support the recommendations to: affirm the suite of measures described in the paper as those necessary to protect patients and staff from COV19 infection; assure the reliable application of these measures via Leadership reality rounding thereby confirming compliance with the CQC COV19 BAF; and note the focus on reduction of CDI utilising strict application of antibiotic stewardship measures and assuring these via robust audit.
Equality Does this paper relate to a matter where equality issues may arise? Y/N Freedom of This document does not contain confidential information and can be made Information available to the public.
NCA # 274090 09/25/2020 10:33:46
1/1 56/163
Northern Care Alliance IPC Assurance Report
September 2020 Group Associate Director Infection Control
NCA # 274090 09/25/2020 10:33:46
1/18 57/163 INTRODUCTION
This paper seeks to provide assurance in the reliability of the COVID-19 Infection Prevention and Control (IPC) measures introduced as part of the Northern Care Alliance response to the COVID- 19 pandemic declared by the World Health Organisation (WHO) in March 2020.
BACKGROUND COVID-19 VIROLOGY AND TRANSMISSION POTENTIAL Coronaviruses are a large family of viruses with some causing less severe disease, such as the common cold, and others causing more severe disease, such as Middle East respiratory syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) coronaviruses. COVID-19 is a new (novel) coronavirus first detected in China in December 2019.
COVID-19 is a highly transmissible respiratory infection, primarily transmitted between people through respiratory droplets and contact routes. Airborne transmission is also possible where aerosols may be generated (e.g by procedures or support treatments).
Human-to-human transmission is currently occurring extensively across the UK, and there has been an exponential rise in cases across the Northwest and Northeast. There is no one element that will reduce transmission of COVID-19-instead management of the virus relies upon a suite of IPC precautions required for both suspected and confirmed cases. This suite of measures form the pillars of IPC, which, implemented robustly and reliably have been demonstrated to reduce nosocomial transmission of COVID-19. It is also imperative to have systems and processes in place within healthcare (regardless of setting) to enable prompt identification, assessment and management of cases, and to respond immediately to any identified cases, increasing incidents or outbreaks, providing transparency on performance and supporting a focus on continuous improvement.
COVID-19 IPC Measures
No single IPC measure will work in isolation. Controlling and preventing COVID-19 requires a bundle prevention and control measures in place consistently and reliably in order to be effective. These measures include:
- early identification of possible cases
-management of suspected/confirmed patients,
-patient placement,
-bio-security measures,
- the use of standard infection control precautions such as hand hygiene, PPE, social distancing, environmental and equipment decontamination, reporting of nosocomial infections and management and prevention of outbreaks.
1. Early Identification and Management of Suspected/Confirmed Patients
In early May 2020 admission screening for COVID-19 was introduced for all inpatient admissions. Patient placement was supported with an inpatient management policy aimed at early identification NCA # 274090 and management of inpatients. During the early phases of the pandemic patient care areas were 09/25/2020 10:33:46 zoned (green, yellow, blue) to ensure segregation of patients according to their COVID-19 status.
2/18 58/163 This approach was reviewed and a new policy introduced across the NCA in September in line with national guidance to support the safe remobilisation of healthcare services.
This replaces zoning and focuses on the management and placement of patients based upon patient risk pathways (high, medium and low risk), and is part of a crucial range of strategies aimed at ensuring a safe and gradual return of essential services.
Compliance with COVID-19 screening across the NCA is audited on a monthly basis by the audit department as part of our BAF. The results of these audits are shared with the senior leadership team and used to inform reality rounding for each care organisation.
2. Bio-Security
Bio-security measures are key to controlling COVID-19. Segregation of possible/confirmed inpatients, reduction in opportunities for crowding, and maximising opportunities for social distancing are all measures which will help to limit the potential for transmission.
In early May 2020 bio-security measures were introduced to restrict access and egress to our sites. This included separately designated staff and patient/access into buildings, the use of security staff at entrances, hand hygiene check points, provision of masks, symptom check signage, directional signage, social distancing signage and the implementation of zoning of clinical spaces to segregate patients who were positive, suspected, or negative for COVID-19.
All entrances to sites across the NCA continue to be manned by security staff to reduce potential for crowding, limit visitors, and ensure that all visitors comply with hand hygiene and the wearing of face masks prior to entering our sites. In addition to security IPC Safety Officers are on hand to provide advice and support to staff and visitors in the necessary bio-security measures, which include how to wear your mask, ensuring directional signage is followed, and that social distancing takes place.
Directional signage is in place throughout public areas such as corridors. Social distancing signage is in place in both public and staff areas. Each clinical and non-clinical area within the organisation has had to complete an environmental COVID-19 secure risk assessment to ensure social distancing and environmental cleaning is in place reliably within the work place. This is in addition to the individual staff COVID-19 risk assessments which have completed and held centrally within the organisation.
3. Standard Infection Control Precautions and Transmission Based Precautions
In addition to bio-security, standard infection control precautions (SICP’s) with the addition of transmission based precautions (TBP’s) are required to reduce transmission of COVID-19. SICP’s include hand hygiene, use of PPE, respiratory and cough hygiene, placement of patients (assessing for risk of infection, isolation), and safe management of the care environment/equipment/waste etc. TBP’s include droplet, contact and airborne precautions.
Hand Hygiene
COVID-19 is de-activated by alcohol hand rub. Hand hygiene is the singleNCA most # effective274090 IPC measure in preventing spread of infection, and combined with other precautions09/25/2020 (such as 10:33:46 respiratory) forms a crucial part of an effective IPC toolkit.
3/18 59/163 Hand hygiene check points and gel stations were increased throughout the organisation to include all entrances, ward entrances, and non-clinical spaces such as offices etc. Staff and visitors are prompted upon entrance and exit to clean their hands, and education is provided by IPC safety officers and the IPC team to visitors/staff on this. Hand hygiene compliance is audited on a weekly basis by all clinical areas, and is included as part of senior leadership reality rounding and NAAS inspections.
Use of PPE
PPE is used to protect the wearer from exposure to either a risk of contact with body fluids or risk of exposure to potential/confirmed infection. They may also be used to protect vulnerable patients from exposure to others.
The level of PPE required for contact with known/suspected COVID-19 patients is dictated by national guidance. As emerging evidence on COVID-19 became available PPE requirements have been adjusted accordingly.
A fluid repellent surgical face mask (FRSM/T11R) is required whenever entering a clinical setting or coming within 2m of a patient, with the addition of other PPE (gloves, apron, eye protection) when coming within 2m of the patient. In procedures/areas where aerosol generating procedures (AGP’s) are performed a filtering face piece (FFP3) mask and full length gown is also required. In addition to reduce the likelihood of asymptomatic accidental transmission of COVID-19 the NCA implemented the wearing of a T1 face mask for all staff/visitors within healthcare buildings (whenever not in patient facing level of PPE), including their use in all non-clinical settings (offices etc) for all staff.
In September 2020 this was expanded to include the wearing of a T1 mask for all inpatients who were able to tolerate it.
Education and advice for staff and visitors on the wearing of masks has been supported by the IPC Safety Officers, the IPC teams, and a robust communication strategy.
Social distancing
The distance to be maintained between persons is based upon the transmission potential of respiratory droplets, with most falling <2m from the infection source. Although there has been much debate on whether social distancing should be 1m or 2m , due to the available science, subsequently endorsed by newly published national guidance, 2m social distancing requirements were maintained within the NCA at all times.
To support this an audit and measurement of all inpatient bed spaces was undertaken by the estates and IPC teams, ensuring a minimum of 2m between beds paces..
2m social distancing signage is in place throughout our sites, in corridors, waiting areas, shops, restaurants, offices and ward rest areas.
Social distancing is included as a key indicator in reality rounding, NAAS inspections, and the IPC collaborative.
Environmental Decontamination NCA # 274090 09/25/2020 10:33:46 COVID-19 fomites can survive for 3-5 days within the environment (dependant on surface, heat and humidity). Critical to the control of COVID-19 is effective and regular environmental
4/18 60/163 decontamination. National guidance recommends a frequency of at least once daily, with increased frequency in COVID-19 care areas, single rooms, cohort areas and clinical rooms (including rooms where PPE is removed) of at least twice daily, using a combined detergent/disinfectant solution at a dilution of 1,000 ppm chlorine.
The NCA have twice daily cleaning as a standard and have increased this to 4 x daily cleans of high touch points within COVID-19 care areas, single rooms, cohort areas and clinical rooms (including rooms where PPE is removed). Specialist cleaning advice (e.g following an aerosol generating procedure (AGP), car cleaning within the community setting) is in line with national guidance and is included in NCA COVID-19 policies.
In addition to national cleaning requirements the NCA have introduced a new cleaning technology – UV light- to provide additional decontamination following routine cleaning. This technology provides high level decontamination and can be deployed rapidly to areas where there may be increased incidence of infection, and is also deployed on a rolling programme of pro-active preventative cleaning (e.g in theatres/public conveniences etc). Cleaning standards are on a rolling programme of auditing, with results fed back through CO IPCC’s.
4. IPC collaborative
The NCA IPC Nosocomial Infection Collaborative is a Quality Improvement Project which is designed to improve reliability with respect to the suite of infection control issues necessary to eliminate nosocomial transmission.
The COVID 19 Nosocomial Infection Collaborative has been designed to unite the organisations in a shared purpose to achieve no nosocomial COVID 19 infections across all our sites and to ensure staff fully understand the rationale behind the required IPC measures and do their utmost to avoid transmissions in all aspects of their daily routines including both patient facing and not patient facing roles and across both acute and community settings.
The aims of the collaborative are: To minimise Nosocomial COVID infections To achieve 100 days at each NCA site without a nosocomial infections
The project structure is developed based upon the IHI Breakthrough Series (BTS) Collaborative. Due to COVID we have not be able to use face to face meetings so the collaborative has been designed as a high intensity virtual programme which uses the BTS principles.
Progress to date:
The pace and change of the collaborative has been rapid, key milestones are as follows: • Expert faculty set up established. • Collaborative Launch event – 28/7/2020 – Scene setting, challenges, QI methodology, ask for PDSAs • Potential 116 teams across all 4 care organisations participating – heard back from 80 regarding their PDSAs • All teams have now been asked to focus their PDSA’s within one of the following 5 themes to inform a potential change package; o Environment o Hygiene and Cleanliness o PPE o Health and Safety NCA # 274090 09/25/2020 10:33:46 o Visiting • Local steering groups have been set up monthly at each care organisation
5/18 61/163 Measurement Plan:
A proposed measurement plan is as follows, process measures remain to be agreed.
Outcome Process Balancing Qualitative • Number of • 7/7 screening • C-difficile • Attitude survey – Nosocomial numbers - • Falls a sense check infections – audited • Side room – with staff already • Swabbing RAG rating regarding sourced discharge to compliance knowledge of • Days care home • Potential bed importance/nece between numbers – manager flow ssity of Nosocomial audited audit – to be PPE/emotional Infections – • Other scoped needs – link with already potential • Staff people team sourced process sickness- measures to stress/anxiety be discussed with IPC officers and scoped • Number of staff COVID infections – already sourced • Acid test – staff knowledge of correct PPE
Current activity:
All participating teams have completed the planning and are in the action period, undertaking their PDSAs Reality rounding is taking place by organisational leaders at each CO
Next steps:
A second collaborative event took place on 10/9/2020. The challenge to the participating teams is to ensure reliability of IPC practices and processes.
5. Reality rounding
The need for reliability in practices and processed in IPC is fundamental to reducing nosocomial transmission of COVID-19 and to ensuring a safe re-mobilisation of services. The NCA recognised that the national guidance in response to a rapidly developing situation interpretationNCA # 274090 of policies and procedures relating to IPC became increasingly challenging for the workforce.09/25/2020 As a result 10:33:46 the care organisations developed IPC reality rounding. The purpose of reality rounding is to
6/18 62/163 Demonstrate leadership attention to a specific issue Demonstrate leadership support Help leadership to understand barriers and obstacles in care settings to delivering policies and procedures as intended
Each care organisation undertakes reality rounding either daily or weekly. The reality rounding tool used has been developed to include some key elements in maintaining COVID security, such as hand hygiene, use of masks, patient placement etc.
Reality Rounding Feedback
Each care organisation was asked to feedback on IPC reality rounding undertaken and to describe the schedule or programme of future reality rounds. Emerging themes from reality rounding are:
Challenges with social distancing in staff rest areas Compliance of staff with social distancing in rest areas Wearing of correct masks between the clinical and non clinical areas Wearing of uniform travelling to and from work Constantly changing environment and need to work differently
The positive benefits of reality rounding reported by staff included feeling supported by the senior leadership teams, feeling able to get support to resolve issues and getting additional IPC support.
Next Steps
The reality rounding tool has been re-designed to specifically include the national IPC checklist A suggested reality rounding programme will be developed Thematic reporting is undertaken from the rounds to enable each CO-reporting via the CO Clinical Effectiveness committees to understand emerging themes and develop action plans to address
6. Outbreaks and Nosocomial Infections
Nosocomial infection of COVID-19 is an important indicator on reliability of IPC measures. To determine the likelihood of onset COVID-19 is classed as:
Community -Onset (CO)- First positive specimen within 48 hours Hospital-Onset Indeterminate Healthcare-Associated (HO-iHA) – First positive specimen date 3-7 days after admission to trust Hospital-Onset Probable Healthcare-Associated (HO-pHA) – First positive specimen date 8-14 days after admission to trust Hospital-Onset Definite Healthcare-Associated (HO-dHA) – First positive specimen date 15 or more days after admission to trust.
For the purposes of outbreak identification the following categories are used.
1. Healthcare-Onset Probable Healthcare-Associated (HO-pHA) – First positive specimen date 8-14 days after admission to trust NCA # 274090 09/25/2020 10:33:46 2. Healthcare-Onset Definite Healthcare-Associated (HO-dHA) – First positive specimen date 15 or more days after admission to trust.
7/18 63/163 Each case falling within these categories undergoes a rapid Root Cause Analysis to establish how the infection has occurred, whether there are any other linked cases that might indicate ongoing transmission, and to establish and share rapid learning.
An outbreak of COVID-19 is defined as two or more cases occurring within the same ward/ environment within 14 days of each other. The NCA has a robust outbreak control policy which directly aligns with national recommendations for identification and management of outbreaks. An out break is considered closed when a 28 day period has elapsed with no further positive cases identified. Themes from outbreaks have been used to inform the 5 pillars of the IPC Collaborative programme of PDSA’s. Since April 2020 the following outbreaks have been identified.
For completeness, the following charts detail all NCA outbreaks (ie not just those where COV19 is the microorganism involved)
The Royal Oldham Hospital
No. 0f No. of Key themes patients staff Cross Date identified OB/PI Date War Organis affecte affecte Transmission PII/Outbrea I commenced d m d d ? Y/N Ribotyped k Closed OB 14/03/20 G2 Covid -19 5 0 Y N/a 24/03/20 Delay in swabbing PII 29/04/20 F7 C.Difficile 2 0 y Yes both 28/05/20 Missed 602 opportunities to obtain sample, Non completion of BSC. 15/05/20 F9 Covid -19 4 2 Y N/a 25/05/20 OB OB 22/5/20 F10 Covid -19 6 0 Y N/a 29/05/20 Multiple patient moves OB 13/08/20 F11 Covid -19 2 2 Y N/a 28/08/20 Staff PPE breaches, lack of social distancing in none clinical areas. Outlier on Haematolog y ward. OB 04/09/20 T4 CPE 2 0 ? N 17/09/20
The Bury and Rochdale Care Organisation
Key themes No. 0f identified patien No. of Date ts staff Cross PII/Outbr OB/ Date affect affect Transmissi Ribotyp eak PII commenced Ward Organism ed ed on? Y/N ed Closed
17/03/20 WIMCU (RI) COVID 5 0 Yes No 14/04/20
OB Lack of NCA # 274090social 09/25/2020 10:33:46distancing
Inadequate
8/18 64/163 use of PPE
No strategy for zoning in use
OB 01/05/20 Apollo (FGH) Acinetobacter 9 0 Yes Yes 01/07/20 Inappropriat baumannii e use of PPE
Lack of HH
OB 12/05/20 Ward 21 (FGH) COVID 9 0 Yes No 15/06/20 Lack of social distancing
Inadequate use of PPE
No strategy for zoning in use
OB 24/05/20 AHP (Physio COVID 0 11 Yes No 01/07/20 Lack of and OT) social distancing
Inappropriat e accommoda tion for the number of staff in the building
OB 04/06/20 Endoscopy COVID 0 7 Yes No 01/07/20 Lack of (FGH) social distancing
Inadequate use of PPE
12/06/20 CAU (RI) COVID 4 1 Yes No 01/07/20 Lack of social OB distancing
Inadequate use of PPE
19/08/20 Ward 21 FGH COVID 4 0 Yes No 07/09/20 Lack of social OB distancing
Inappropriat e patient placement
OB 21/08/20 ITU FGH COVID 1 2 Yes No 07/09/20 Lack of social distancing
Inadequate use of PPE NCA # 274090 09/25/2020 10:33:46Inappropriat e patient placement
9/18 65/163 The Salford Care Organisation
No. of Cross Date No. of staff OB/PII Date Ward Organism patients Transmission? Ribotyped PII/Outbreak Lost bed days affected affected Y/N Closed
OB 17/04/2020 CCU VRE 7 0 Y N 0 OB 25/04/2020 CCU S. Marcesens 5 0 Y N 23/05/2020 0 OB 19/05/2020 B7 COVID 3 Y N OB 20/05/2020 CCU COVID 0 3 Y N 03/06/2020 0 PII 22/05/2020 L4 CDIFF 2 0 y 0 OB 27/05/2020 H3 COVID 7 8 y N OB 01/06/2020 H5 COVID 0 4 y N OB 28/08/2020 HG COVID 0 2 N OB 30/08/2020 BH COVID 0 2 N OB 16/09/2020 MAPLES COVID 3 0 Y N patient visited family in their home. Family positive
Nosocomial Infections
Key considerations when reviewing the data below are that COVID-19 prevalence amongst the population was low post the first wave. This is now increasing exponentially. The use of zoning was introduced in early May 2020. The use of face masks for all staff whenever not clinical was introduced in early June 2020.
NCA Weekly Data
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12/18 68/163 Days Between Infections (aim 100 days)
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14/18 70/163 Other Nosocomial Infections
During the pandemic there were increased gram negative infections noted nationally within critical care settings. It is thought that increased prescribing of broad spectrum antimicrobials may be a contributing factor. In the early phase of the pandemic the NCA experienced an outbreak of Acinetobacter baumannii within the FFGH CCU affecting 9 patients. Learning identified sessional use of PPE as a potential transmission factor and practices within the CCU’s were adjusted due to this.
Clostridium difficile infection (CDI) has also increased nationally during the pandemic. Each year NHSI/E set objectives for trusts CDI rate and number of cases. This has not been set for 2020 to date, however when comparing our performance in terms of number of cases 2020 is displaying an upward trend. Due to this the NCA uses CDI as a balancing measure within the IPC collaborative, and as a result of this increase have also formed a CDI Review Group which meets monthly and is attended by the senior leadership team from within each CO. Actions from this group have included education on early de-escalation of antimicrobials, targeted antimicrobial stewardship ward rounds, a Take 5 staff education communication and collaborative learning across the CO’s. The group will continue to meet to review emerging themes and necessary actions for a further 3 months. NCA # 274090 In 2019-20, the performance of Salford Royal with respect to CDI was recognised09/25/2020 as a statistically 10:33:46 significantly good performer in comparison with other organisations-NW chart, reproduced below. Recent performance has been more challenging yet has been recognised by the Care
15/18 71/163 Organisation leadership, with particular focus and leadership attention directed towards antibiotic stewardship. A comprehensive audit policy to assure reliability with this was presented to GRAC in September 2020.
The NCA has robust policies for the early identification and management of infection within patients. These include screening for other alert organisms upon admission such as MRSA and CPE. Infection surveillance continues for all other alert organisms and is reported monthly to each CO and to PHE.
NCA # 274090 09/25/2020 10:33:46
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17/18 73/163 MRSA Bacteraemia
During this time there has been 1 case of nosocomial MRSA bacteraemia in the Salford CO in June 2020. The likely source of the infection was chronic leg and foot ulcers.
Data source PHE September 2020
The committee is asked to note the contents of this paper and support the recommendations-
1) Affirm the suite of measures described in the paper as those necessary to protect patients and staff from COV19 infection. 2) Assure the reliable application of these measures via Leadership reality rounding thereby confirming compliance with the CQC COV19 BAF. 3) Note the focus on reduction of CDI utilising strict application of antibiotic stewardship measures and assuring these via robust audit.
NCA # 274090 09/25/2020 10:33:46
18/18 74/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Harm Reduction, Safety Improvement
Meeting Group Board (Committees in Common) Sara Barton, Clinical Lead for QI and Acute Physician Author (s) Siobhan Moran, Director of Quality Improvement Libby McManus, Chief Nursing Officer Presented by Elaine Inglesby-Burke, Chief Nursing Officer Date 28 September 2020 Executive In response to the harm paper presented to Board in July 2020, the NCA has Summary proposed a change in the QI Strategy, on an interim basis, to focus on the current challenges the organisation is experiencing. This paper outlines the proposal which focuses on using our QPID resource for four programmes as well as a proposal for the measuring and monitoring of the safety and quality component of these four programmes in the QI Dashboard.
Harm and Mortality Programme Surgical Programme Urgent and Emergency Care Programme System Wide Outpatients Programme
Annual Plan We will identify and act on new safety and inequality issues associated with Objective Covid ways of working Associated Risks 3.3.2 IF we fail to develop and deliver an NCA Quality Improvement Strategy THEN we may not secure the appropriate improvement capability and capacity and fail to improve safe, reliable and compassionate care
Recommendations The Group Board is asked to:
Approve QPID focus on: o Harm and Mortality Programme o Surgical Programme o Urgent and Emergency Care Programme o System Wide Outpatients Programme Board to approve measuring and monitoring proposal Board to approve how they receive updates – a reformed QI Dashboard aligned to the programmes above, quarterly Board to approve the governance of the QI strategy to be owned by the Executive Quality Committee and report to GRAC/Executive Management Committee and the subgroups proposed in item 5.0. Board to approve the timeline for re-considering the interim QI strategy in Jan-Mar 2022
Equality Does this paper relate to a matter where equality issues may arise? Y Freedom of This document does not contain confidential information and can be Information made available to the public. NCA # 274090 X Please ‘cross’ one of 09/25/2020 10:33:46 the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
1/15 75/163 Introduction
During the initial surge of COVID-19 the organisation, as well as the QPID team, were focused on rapid pathway, structural and staffing changes in order to deal with the nationally predicted numbers of patients. The organisation has changed immeasurably in the subsequent months, perhaps permanently. Was hasn’t changed is the organisation’s focus on quality and safety.
Salford Royal and subsequently the Northern Care Alliance (SRFT) built its reputation on its high profile campaign to reduce harm and mortality. For the last 12 years it has been a fundamental part of the organisation. When Salford Royal became part of the Northern Care Alliance the experience relating to improvement and harm reduction was shared and results replicated across the new Group. We know that the QI approach and the harm and mortality subject areas are cited by our staff as a reason to come and work at the NCA.
In the most recent Pennine Acute CQC report it was stated repeatedly that “all staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them” this kind of recognition may not have occurred without the quality improvement work on harm and mortality.
Now, in these intensely challenging times, we need to continue our commitment to quality and safety and rely on our tried and tested QI methods.
1.0 Purpose of the Paper
In May 2020, the Board approved an interim QI Strategy and then in July 2020, the Board were presented with a retrospective review of a variety of patient interactions and data sources with the specific aim of identifying learning and potential new/different harms occurring as a result of the necessary rapid changes taking place due to COVID- 19. This paper outlines an interim QI Strategy Workplan that aims to address the findings of that review.
2.0 QPID Strategy
In 2019, a new QPID Strategy covering the whole of the NCA was launched (see Appendix 1). It became clear after the initial COVID-19 surge that the organisations QPID strategy would need to change to address the changing landscape of safety and quality in the organisation and the need for a productivity driven recovery of previous activity levels. Another review of the strategy is recommended in 12-18 months.
Interim QPID Strategy A case-note review took place in June/July 2020, results previously presented to Board in July 2020, which aimed to ascertain how the quality and safety landscape had changed since the initial COVID-19 surge and thus inform an interim QPID Strategy. As predicted, the picture of quality and safety across the organisation is vastly different with new harms emerging, such as hospital acquired COVID-19, and others reconfiguring our view of priorities, such as patients waiting for treatment.
To address these changes in priority, an Interim QPID Strategy was proposed and approved by the Executive Quality Committee. This includes the quality, safety and productivity components of three of the strategic transformation programmes and an additional harm/mortality programme. The strategic transformation programmes will look to improve all aspects of quality in their areas as defined by the Institute of Medicine definition of quality (Safe, Effective, Patient Centred, Timely, Efficiency/Cost, Equitable), focusing initially on those aspects which have been greatly affected by COVID-19 (waiting lists, etc.) NCA # 274090 The Strategic Transformation Programmes are set up to align with areas of care delivery and are overseen by the 09/25/2020 10:33:46 Executive Management Committee/GRAC. They are:
1. System Wide Outpatients Programme 2. Urgent, Emergency, and Community Care Programme 3. Surgical Programme
2/15 76/163 There are some harms, however, that emerged during the case-note review that don’t align specifically with a single area of delivery, or span all strategic transformation programmes (such as nutrition and hydration). The highest priority of these have been selected to be projects in a harm reduction programme which is being run in addition to the three strategic programmes.
The Harm Programme includes the following projects:
Infection prevention and control collaborative Equity of care Diabetes Nutrition and Hydration – acute Delirium (specifically arising as a result of COVID disease process and also issues arising as a result of changes made to ward and skill mix) Community: Deconditioning, frailty and nutrition and hydration
[Note: there are three additional strategic transformation programmes running which aren’t covered by the QPID interim strategy as they are either not QI programmes or are funded and resourced separately. They areDigital Control Centre, and Rapid Diagnostic Centres.]
2.1 Strategic Transformation Programmes
Each of the strategic transformation programmes will focus on reinstating activity safely with new pathways, where necessary, and address safety and experience in those new pathways as well as a longer term view to transform delivery of care in each area. Programme teams from QPID have been assigned and improvement projects commenced using NCA QI methods.
NCA # 274090 09/25/2020 10:33:46
3/15 77/163 Strategic Programme Productivity Aims Measures of the Safety and Quality Components System Wide Outpatients Safely achieve 100% of 2019 outpatient activity levels Evidence of equity of services for patients unable to access Programme 60% of care delivered non-face-to-face digital pathways 100% of clinically urgent patients are seen first Patient satisfaction with virtual appointment 100% patients receive updated communication Patient satisfaction with communication while waiting All outpatient departments are 100% compliant with Staff satisfaction with virtual appointment current PPE and IPC guidance % of patients discharged after first appointment Improve digital maturity scale of outpatient pathways Harm to patients as a consequence of waiting (stratified by potential, minor, moderate, major) Outpatient department reliability to IPC guidance Urgent, Emergency, and Reduction in crowding: Reduce attendances by 1/3 Crowding: A&E attendance rates Community Care 80% maximum occupancy in acute setting Total bed occupancy Programme Improvement in timely discharge Number of ward transfers Aims achieved by: Discharge o Pre-ED streaming o Number of patients with delayed discharge o Redesigned community pathways o Audit of appropriate communication on discharge o Virtual hospital o Audit of appropriate community pathway in place on o Improved board/ward rounds discharge o Discharge to assess Readmissions Reliability of Society for Acute Medicine standard time to senior decision maker Appropriate and timely specialty input Surgical Programme o Reduction in waiting list growth o Patient satisfaction with communication while waiting o Improved surveillance of patients who have delayed o % of theatres open surgical treatment o Reliability to IPC measures o Improved theatre efficiency o Harm to patients as a consequence of waiting (stratified by o 0 hospital acquired infections for surgical patients potential, minor, moderate, major) o Reduction of on the day cancellations o Patients admitted acutely for management of elective condition on waiting list (rate) o Number of cancer resections with clear margins (marker of curative treatment; Number of patients thought curative who weren’t (potential markers of late intervention/ NCA # 274090presentation) 09/25/2020 10:33:46
4/15 78/163 2.2 Harm Programme
The harm programme is made up of several projects as well as a surveillance system including a patient safety faculty.
o Infection prevention and control collaborative o Diabetes o Equity of care o Nutrition and Hydration o Community: Deconditioning, frailty o Delirium (specifically arising as a result of COVID disease process and also issues arising as a result of changes made to ward and skill mix) o Surveillance system (including patient safety faculty and mortality surveillance)
2.2.1 Infection Prevention and Control Collaborative
Aim: 0 nosocomial transmissions of Covid-19
Progress: Learning Session 2 complete Senior leader reality rounding underway Draft change package testing
Measures:
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5/15 79/163 2.2.2 Diabetes project
Aim: 95% reliability to diabetic monitoring policy (inpatient) Reduction in insulin administration incidents and related harm (community)
Progress:
Planning group and programme structure in place Microsystems coaching for key focus areas in the acute and community setting NCA # 274090 09/25/2020 10:33:46 Measures:
Outcomes for diabetic patients who also have COVID-19 Reliability to diabetic monitoring policy
6/15 80/163 Number of incidents and harm related to insulin administration in the community Diabetic patients satisfaction with virtual and technology based monitoring
2.2.3 Equity of Care
Aim: Seek out, analyse and eradicate inequities in access to care across the NCA
Progress: Planning group and programme structure in place Case note review faculty established Patient stories being gathered Scoping of possible measures
Measures: DATIX reports where language barrier/ communication is a factor Delays in access to treatment stratified by ethnicity
2.2.4 Nutrition and Hydration NCA # 274090 Aim 09/25/2020 10:33:46
7/15 81/163 Measures: Dietician waiting list growth/decrease Harm incidents reported related to nutrition and hydration Reliable care planning
2.2.5 Frailty and Deconditioning (community):
Aim: To reduce the number of patients known to us experiencing significant deconditioning
Driver Diagram:
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Progress: Frailty review through Learning from Deaths process
8/15 82/163 Bury has joined National Frailty Network
Measures: Patients who report a decrease in physical activity/ ability/ independence while under our care due to a wait for therapy or suboptimal therapy input. This can include a failure to refer for therapy.
2.2.6 Delirium
Aim: reduction in the incidence of inpatient delirium by 50%
Driver Diagram:
Progress: SCO has significant work around delirium identification and management to build on around 4AT and electronic tools, aim to spread the learning across group
Measures: Patients with diagnosis of delirium during an inpatient stay Patients receiving sedative medications “specialling rates” for providing one to one care for delirious patients
3.2.6 Surveillance system: NCA # 274090 Surveillance systems to capture and deal with arising issues in quality of care exist in current governance systems, 09/25/2020 10:33:46 risk registers, incident reporting and mortality review processes. Given the rapidly changing nature of our care pathways at the moment, agilely monitoring our systems for emerging issues will be necessary. To that end, two groups have formed. The first, is a Clinical Advisory Group meeting weekly to rapidly review new national guidance in regards to COVID-19 and its consequences and issue advice to Care Organisations. The second, is a newly formed patient safety faculty, meeting weekly, to act in a clinical advisory capacity for EQP on emerging quality issues.
9/15 83/163 Specific clinically led review groups will form and disperse based on arising need (ex. 104 day cancer waits surveillance group).
3.0 Dashboards and Monitoring Each programme and project indicated in this paper will have its own suite of measures as indicated in the above. A programme/project update will be presented to the Executive Management Committee on a rotating schedule and a full programme update will be presented to Board on a Quarterly basis. The Safety and Quality measures of each programme will be overseen by EQP.
In line with this proposal, the QI dashboard will be reformed to align with this set of selected programmes and measure them using the IOMs dimensions of quality: Safe, Effective, Patient Centred, Timely , Efficiency/Cost, Equitable
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10/15 84/163 Board QI Dashboard Proposal
Domain Safe Effective Patient Centred Timely Efficiency/Cost Equitable Harm and Related incidents of harm AKI occurrence or Inpatient delirium Time in glucose Waiting for Stratify measures by Mortality (nutrition, hydration, progression while frequency and use of range for transfer to ethnicity diabetes, delirium, inpatient sedatives inpatient specialist service frailty) Readmissions Deconditioning: Outliers: Patients Appropriate therapy Patients reporting a in unsuitable input decrease in activity as an inpatient setting due to COVID-19 zoning
Surgical Harm to patients as a % of theatres open Patient satisfaction with Waiting list % of theatres open Stratify measures by Programme consequence of waiting Patients admitted communication while growth/decrease ethnicity (stratified by potential, acutely for waiting o Reduction in minor, moderate, major) management of waiting list Reliability to IPC elective condition on growth measures waiting list o Reduction of on Number of cancer the day resections with clear cancellations margins
Urgent and Reliability of Society for Audit of appropriate Number of ward Number of Total bed occupancy Stratify measures by Emergency Acute Medicine standard community pathway transfers patients with ethnicity Care time to senior decision in place on discharge Audit of appropriate delayed Programme maker Readmissions communication on discharge Appropriate and timely discharge specialty input Crowding: A&E attendance rates System Wide Harm to patients as a Staff satisfaction with Patient satisfaction Waiting list Activity levels Evidence of Outpatients consequence of waiting virtual appointment with virtual growth/decrease compared to equity of Programme (stratified by potential, % of patients appointmentNCA # 274090 2019 services for minor, moderate, major) discharged after first Patient09/25/2020 satisfaction 10:33:46 % of patients unable Outpatient department appointment with communication appointment to access digital reliability to IPC guidance while waiting done virtually pathway % of clinically urgent Stratify patients seen in measures by
11/15 85/163 appropriate timeframe ethnicity
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12/15 86/163 4.0 Governance The Executive Quality Committee, as a sub-committee of GRAC/Executive Management Committee, will take responsibility for monitoring the progress of this interim QI Strategy and more specifically the safety and quality measures and will report to Board quarterly.
Executive Managem ent Committe e Executive Strategic Quality Programme Committee Board
Harm System Wide Clinical CO Quality Safety Programmes Outpatients Advisory Faculty – Committees Programme Board Group – Cross Cross CO clinical CO clinical advice advice on Equity of on emerging emerging quality Urgent/Non- CO Care COVID guidance and safety issues elective/Community Care Mortality Programme Board Review Acute Groups Delirium Surgical Programme Board CO Safety Diabetes Summits Rapid Diagnostic Acute - Nutrition Centres and Hydration Control Centre Programme Community – Frailty, Board Nutrition/hydration, deconditioning Digital Programme Board
4.1 Emerging Priorities Inevitably, new or different priorities may emerge that take precedence over the areas of work stated in the interim QI strategy. As potential new priorities emerge, the responsibility for triage will lay with the EQC/EMC/Strategic Programmes Board. Those boards and committees may decide how an emerging priority is dealt with including whether or not it should proceed to scoping and creation of a Project Initiation. If the scoping leads to a recommendation of a substantial change in priority or resource, a Business Case and return on investment assessment shall be presented to the Executive Management Committee for approval. If such a substantial change in priority or resource were to occur impacting on the agreed interim QI strategy, recommendations will be reported to Board.
5.0 Recommendations 5.1 Board to approve focus of interim QI strategy: 5.1.1 Harm and Mortality Programme 5.1.2 Safety and Quality Components of: Surgical Programme NCA # 274090 Urgent and Emergency Care Programme 09/25/2020 10:33:46 System Wide Outpatients Programme 5.2 Board to approve measuring and monitoring proposal 5.3 Board to approve how they receive updates – a quarterly reformed QI Dashboard
13/15 87/163 5.4 Board to approve the governance of the strategy will be owned by the Executive Quality Committee and the subgroups proposed in item 5.0. 5.5 Board to approve the timeline for re-considering the interim QI strategy in Jan-Mar 2022
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14/15 88/163 Appendix 1: 2019 QI Strategy
Aim 1: Value patients’ and service users’ time as the most important currency in health and social care Aim 2: Provide the best employee experience to enable the best patient and service user experience Aim 3: Improve quality of life by delivering care closer to home, in our communities Aim 4: No preventable deaths Aim 5: Deliver safe and reliable care for every patient and service user, every time
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15/15 89/163 Northern Care Alliance NHS Group : Learning from Deaths Dashboard - June 2020-21
Summary of the total number of deaths, total number of deaths with a Care Quality Review(CQR) and the total number of case record reviews using Structured Judgement Review (SJR) methodology
Time Series: Start date 2017-18 Q1 End date 2020-21 Q1 Total Number of Deaths, Deaths Reviewed and Potentially Preventable Deaths
1400 Mortality over time, total deaths reviewed and SJR's 1365 1376 1296 Total deaths Total number of deaths with a care quality Total number of deaths reviewed using SJR 1236 1270 Total number of deaths 1200 1176 review methodology 1133 1000 1001 1024 963 Care quality reviews 919 918 This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter 877 completed 800 1376 1270 453 402 17 29 558 600 515 514 547 SJR's completed This Year Last Year This Year Last Year This Year Last Year 455 453 453 453 426 402 364 370 1376 4433 453 1613 17 172 400 305
200 This Quarter Last Quarter This Year Last Year 55 86 78 64 73 Total number of deaths considered to have 0 33 32 35 35 29 17 been potentially preventable 2 2 2 10 Q1 2017-18 Q2 Q3 Q4 Q1 2018-19 Q2 Q3 Q4 Q1 2019-20 Q2 Q3 Q4 Q1 2021-22
Summary of total number of learning disability deaths and total number reviewed under the LeDeR & SJR methodology
Time Series: Start date 2017-18 Q1 End date 2020-21 Q1 Total Number of Deaths, Deaths Reviewed and Deaths with 'Very Poor' and/or 'Poor' Overall Care Mortality over time, total deaths reviewed and 'Very Poor' or 'Poor Care identified in 'Overall Care' 25 Total deaths SJR's completed 20 21 Total Deaths reviewed through LeDeR & SJR 'Very Poor' or 'Poor Care' identified in 'Overall Care' Poor and/or Very Poor Total Number of Deaths in scope 17 methodology phase 15 16 13 12 11 10 10 This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter 9 9 9 9 8 6 6 21 9 9 4 0 0 5 5 4 4 3 This Year Last Year This Year Last Year This Year Last Year 2 0 1 21 42 9 33 0 0 Q1 2017-18 Q2 Q3 Q4 Q1 2018-19 Q2 Q3 Q4 Q1 2019-20 Q2 Q3 Q4 Q1 2021-22
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1/1 90/163 Appendix 1 Fairfield and Rochdale Action plan
Action Ref No.
Action ref. no. Action required Lead Person (Name and Job Title) Target Date for Completion
1. Review of incidents, claims, Never Events, NCA Head of Legal and Risk Management Completed complaints and inquests to thematically review and horizon scan trends emerging.
2. Re-establish departmental M&M Meetings across the NCA Professional Standards Manager KPI 75% 1st November care organisation with high Consultant attendance 2020 following COVID-19 pandemic. 85% stretch target Expand membership to include Ward Managers, Clinical Mortality Lead Nurses, Advanced Health Practitioners, Junior KPI 95% 1st March 2021 Doctors and Clinical Coding Rep.
Fairfield and Rochdale 3. Ensure each service at the care organisation is Medical Director KPI 75%1st November represented at the Mortality Oversight Group by an 2020 accountable leader. NCA Head of Legal and Risk Management
NCA Professional Standards Manager KPI 90% 1st March 2021 Clinical Director for M&M Learning for North East Sector
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1/5 91/163 Appendix 1 Fairfield Action plan
4. Revisions to Terms of Reference and implementation Fairfield and Rochdale 30 September 2020 of an annual work programme schedule for the Medical Director Mortality Oversight Group. NCA Head of Legal and Risk Management
NCA Professional Standards Manager
Clinical Director for M&M Learning for North East Sector 30 September 2020 5. Discussions to take place with the Responsible Director of Patient Safety and Professional Officer and Director of Patient Safety and Standards Professional Standards; regarding a proposal to implement into the Consultant appraisal and revalidation process evidence of change/or learning to clinical practice following M&M meetings
6. Clinical Director for M&M Learning for the North East Clinical Director for M&M Learning for North 1st November 2020 Sector to provide direct support to A&E M&M, with a East Sector view to producing clinical change and measurable learning outputs.
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2/5 92/163 Appendix 1 Fairfield Action plan
7. HSMR CUSUM 1 Alert ‘coma, stupor and brain Clinical M&M Lead for A&E Fairfield damage’. 1st November 2020
On-going monitoring at the Mortality Oversight Group to establish if this is an isolated alert or on-going problem given the extremely small numbers; Drive adoption of NCA Policy on ‘Management of out of hospital cardiac arrest patients following return of spontaneous circulation in A&E and ICU’ via the A&E M&M and supported by the Clinical Director for the NES (see action 6)
8. ICU to establish a clinical microsystem as a means to Advanced Critical Care Practitioner and 1st November 2020 implement changes to practice from Learning from ICU Clinical M&M Lead Deaths. Clinical Director for M&M Learning for North East Sector
Clinical Director for Quality Improvement for the NCA
9. HSMR and SHMI outlying basket ‘pneumonia’. Clinical Mortality Lead Baseline compliance to be Project work underway; Test of change to introduce established by 1st on A&E, AMU and ICU a designated chest trolley November 2020 and KPIs and pathways sticker at ward level to improve care introduced. service delivery.
10. Clinical Coding Lead to attend AMU Teaching Clinical Mortality Lead 31st October 2020 Programme and Physicians Directorate Meeting to NCA # 274090 deliver training in relation to importance of clinical 09/25/2020Clinical Coding Lead 10:33:46 documentation from a coding perspective.
3/5 93/163 Appendix 1 Fairfield Action plan
Clinical Mortality Lead 11. Mortality to be added as standing agenda item to the 31st October 2020 Physicians Directorate Meeting to increase awareness.
12. HSMR and SHMI outlying basket ‘sepsis’. NCA Head for Clinical Coding and Data 1st November 2020 Clinical review of ‘sepsis’ to investigate root Standards Assurance causes of decreased coded activity in the North East Sector to inform further Sepsis Lead improvement work; and Triangulate coding review findings and link Dr David Palmer in with the Sepsis Lead to plan improvement Clinical Director for M&M Learning for North work. East Sector
13. Link in with on-going work to spread best practice in Clinical Mortality Lead 1st November 2020 relation to admissions paperwork at the Oldham Care Organisation. Clinical Mortality Lead
14. Review into frailty services to be carried out in Clinical Mortality Lead 1st November 2020 partnership with the Acute Frailty Network. this will result in a programme of improvement work (planning meeting to take place on 16 September 2020, preliminary findings expected in November Clinical Mortality Lead 2020).
15. Progress work on transitional care for patients with Clinical Mortality Lead 31st October 2020 learning disability by establishing a working group with appropriate representation from the Women and NCA Lead Learning Disability and Autism Children’s Division from across the NCA. Nurse
NCA Head of Legal and Risk Management NCA # 274090 09/25/2020 10:33:46
4/5 94/163 Appendix 1 Fairfield Action plan
16. Comparative review of staff to patient ratios for Medical Director 1st March 2021 relevant specialties between the care organisations (including locum, consultants, junior doctors and Associate Director of Workforce nurses). Clinical Director for M&M Learning for North East Sector
17. Increase the number of Consultants trained in SJR NCA Professional Standards Manager 1st December 2020 methodology by holding monthly virtual training sessions across the NCA.
18. Use ‘lens of profound knowledge’ to fundamentally Assistant Director of Quality Improvement 1st November 2020 understand Learning from Death systems to strategically plan how Fairfield evolves into a Clinical Director for M&M Learning for North ‘Learning Organisation’. East Sector
Associate Director of Quality Improvement
NCA Professional Standards Manager
19. Identify an AKI Lead for Fairfield to develop the hub Clinical Director for M&M Learning for North 1st November 2020 and spoke model for nephrology services in East Sector collaboration with Salford Care Organisation (including an evaluation of the effectiveness of the Renalpass referral system and adoption of AKI bundle)
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5/5 95/163 Northern Care Alliance NHS Group : Learning from Deaths Dashboard - June 2020-21
Summary of the total number of deaths, total number of deaths with a Care Quality Review(CQR) and the total number of case record reviews using Structured Judgement Review (SJR) methodology
Time Series: Start date 2017-18 Q1 End date 2020-21 Q1 Total Number of Deaths, Deaths Reviewed and Potentially Preventable Deaths
1400 Mortality over time, total deaths reviewed and SJR's 1365 1376 1296 Total deaths Total number of deaths with a care quality Total number of deaths reviewed using SJR 1236 1270 Total number of deaths 1200 1176 review methodology 1133 1000 1001 1024 963 Care quality reviews 919 918 This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter 877 completed 800 1376 1270 453 402 17 29 558 600 515 514 547 SJR's completed This Year Last Year This Year Last Year This Year Last Year 455 453 453 453 426 402 364 370 1376 4433 453 1613 17 172 400 305
200 This Quarter Last Quarter This Year Last Year 55 86 78 64 73 Total number of deaths considered to have 0 33 32 35 35 29 17 been potentially preventable 2 2 2 10 Q1 2017-18 Q2 Q3 Q4 Q1 2018-19 Q2 Q3 Q4 Q1 2019-20 Q2 Q3 Q4 Q1 2021-22
Summary of total number of learning disability deaths and total number reviewed under the LeDeR & SJR methodology
Time Series: Start date 2017-18 Q1 End date 2020-21 Q1 Total Number of Deaths, Deaths Reviewed and Deaths with 'Very Poor' and/or 'Poor' Overall Care Mortality over time, total deaths reviewed and 'Very Poor' or 'Poor Care identified in 'Overall Care' 25 Total deaths SJR's completed 20 21 Total Deaths reviewed through LeDeR & SJR 'Very Poor' or 'Poor Care' identified in 'Overall Care' Poor and/or Very Poor Total Number of Deaths in scope 17 methodology phase 15 16 13 12 11 10 10 This Quarter Last Quarter This Quarter Last Quarter This Quarter Last Quarter 9 9 9 9 8 6 6 21 9 9 4 0 0 5 5 4 4 3 This Year Last Year This Year Last Year This Year Last Year 2 0 1 21 42 9 33 0 0 Q1 2017-18 Q2 Q3 Q4 Q1 2018-19 Q2 Q3 Q4 Q1 2019-20 Q2 Q3 Q4 Q1 2021-22
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1/1 96/163 Appendix 3 Glossary of Key Terms
Learning from Deaths National framework introduced by the National Quality Board (membership includes NHS England, NHS Improvement, NHS Digital Care Quality Commission, Public Health England , NICE, Department of Health and Social Care and Health Education England). Key requirements on how to identify, report, investigate and learn from deaths in care. Learning should be integral to clinical governance and quality improvement work. Care Record Review A review of a patient’s medical records carried out by a member of the clinical team who has been directly involved with a patients care. Case record review is undertaken routinely at speciality Mortality & Morbidity (M&M) Meetings in the absence of any particular concerns about care, to learn and improve. Structured Judgement A structured desktop review of a patient’s medical records carried Review (SJR) out by a member of the clinical team who has not been directly involved with a patients care to determine whether there were any problems in the care provided to a patient. Reviewers make subjective judgements on quality and safety over phases of care with a specific care score for each phase. SJR is undertaken in the absence of any particular concerns about care, to learn and improve. It can also be done where concerns exist, such as when the bereaved or staff raise concerns about care. Investigation A systematic objective analysis of what happened, how it happened and why, usually following an adverse event when significant concerns exist about the care provided. Investigation draws on evidence, including physical evidence, witness accounts, organisational policies, procedures, guidance, good practice and observation, to identify problems in care or service delivery that preceded an incident and to understand how and why those problems occurred. The process aims to identify what may need to change in service provision or care delivery to reduce the risk of similar events in the future. Investigation can be triggered by, and follow, case record review and/or SJR, or may be initiated without a case record review and/or SJR happening first. Preventable Death An investigation where death has been assessed as the outcome for the patient. Note, this is not a legal term and is not the same thing as ‘cause of death’. The term ‘avoidable mortality’ should also not be used as this has a specific meaning in public health that is distinct from ‘death due to problems in care’. Speciality Mortality & An M&M meeting is a regular meeting held in hospitals by different Morbidity (M&M) Meeting medical specialities which involves a peer review discussion and review of deaths as part of professional learning.
Mortality Oversight Group Mortality surveillance group with multi-disciplinary and multi- (MOG) professional membership that peer discusses mortality data, themes and learning from deaths. Quality Improvement (QI) A systematic approach to achieving better patient outcomes and system performance by using defined change methodologies and strategies to alter provider behaviour, systems, processes and/or structures. NCA # 274090 Hospital Standardised HSMRs are a calculation used to monitor death09/25/2020 rates in a trust, 10:33:46 which Mortality Rate (HSMR) are published by Dr Foster – Telstra Health. HSMRs are based on the
1/3 97/163 Appendix 3 Glossary of Key Terms
routinely collected administrative data often known as Hospital Episode Statistics (HES), Secondary Uses Service Data (SUS) or Commissioning Datasets (CDS).
The HSMR is the ratio of observed deaths to expected deaths for a basket of 56 diagnosis groups, which represent approximately 80% of in hospital deaths. It is a subset of all and represents about 35% of admitted patient activity. Further information can be found at http://www.drfoster.com/about-us/our-approach/metrics- methodologies-and-models-library/
In order to give an indication of how performance for the current incomplete year compares to the national average HSMR is rebased annually. This is estimated for each of the 56 diagnoses by dividing the trust's SMR (using the existing benchmark) by the national SMR and multiplying by 100. The 56 rebased SMRs are then aggregated to produce the estimated rebased HSMR relative risk figure. Relative Risk (RR) The HSMR score is worked out by looking at performance in the NHS and adjusting the mortality risk in a spell of patient care for risk factors such as their age, gender, health conditions and palliative care. The HSMR uses risk models to provide the number of ‘expected deaths’ per trust per month, compared with the number of actual deaths at the trust. This helps to produce the level of risk, called the ‘relative risk figure’ for each trust, which shows how each trust performs against the NHS average.
This is calculated by dividing the actual number of deaths by the expected number and multiplying the figure by 100. It is expressed as a relative risk, where a risk rating of 100 represents the national average. If the trust has an HSMR of 100, that means that the number of patients who died was exactly as it would be expected taking into account the standardisation factors. An HSMR above 100 means more patients died than would be expected. This ratio should always be interpreted in the light of the accompanying confidence limits. Standardised Mortality A calculation used to monitor death rates within HSMR. The Ratio (SMR) standardised mortality ratio is the ratio of observed deaths to expected deaths, where expected deaths are calculated for a typical area with the same case-mix adjustment.
The SMR may be quoted as either a ratio or a percentage. If the SMR is quoted as a percentage and is equal to 100, then this means the number of observed deaths equals that of expected. If higher than 100, then there is a higher reported mortality ratio. Summary Hospital-Level SHMI reports on all mortality at trust level across the NHS in England. Mortality Indicator (SHMI) It is produced and published monthly as a National Statistic by NHS Digital. The SHMI was developed in response to the public inquiry into the Mid Staffordshire NHS Foundation Trust. It is used along with other information to inform the decision makingNCA of# trusts, 274090 regulators and commissioning organisations. 09/25/2020 10:33:46
2/3 98/163 Appendix 3 Glossary of Key Terms
SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. The expected number of deaths is estimated using the characteristics of the patients treated: age, sex, method and month of admission, current and underlying medical condition(s) and birthweight (for babies). It covers patients admitted to hospitals in England who died either while in hospital or within 30 days of being discharged.
Further information can be found at https://digital.nhs.uk/data-and- information/publications/ci-hub/summary-hospital-level-mortality- indicator-shmi Rolling 12 Month Data Rolling 12 month data is a moving average series of 12-monthly averages over monthly consecutive periods. This statistical tool helps the overall direction of a series of monthly data because it smooths out the effects of month-to-month changes. Month-on-Month Data Month-on-month data is rates of change expressed in absolute value in respect of the previous month. Crude Rate (%) Unadjusted mortality with no standardisation. Mortality Alert HSMR and SHMI is not a measure of quality of care. A higher than expected number of deaths should not immediately be interpreted as indicating poor performance and instead should be viewed as a 'smoke alarm' which requires further investigation. Similarly, an 'as expected' or 'lower than expected' SHMI should not immediately be interpreted as indicating satisfactory or good performance. CUSUM Alert A cumulative sum statistical process control chart plots patients’ actual outcomes against their expected outcomes sequentially over time. The chart has upper and lower thresholds and breaching this threshold triggers an alert. If patients repeatedly have negative or unexpected outcomes, the chart will continue to rise until an alert is triggered. The line is then reset to half the starting position and plotting of patients continues.
CUSUM alerts with a with a probability of a false alarm less than 0.1% are monitored by the Dr Foster Unit at Imperial College London. The Care Quality Commission of the alert. Special Cause Variation Control limits tell us the range of values which are consistent with random or chance variation. Data points falling within the control limits are consistent with random or chance variation and are said to display ‘common-cause variation’; for data points falling outside the control limits, chance is an unlikely explanation and hence they are said to display ‘special- cause variation’ – that is, where the trust’s rate diverges significantly from the national rate.
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3/3 99/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Intentional Inclusion At the Heart of the Communities We Serve Title of Report Our 10 Year Vision for Change
Meeting Group Board (Committees in Common)
Nicky Clarke, Chief of People Author (s) Naheed Nazir, Group Associate Director for Inclusion & Engagement
Presented by Nicky Clarke Date 28th September 2020
Executive We have an ambition as an organisation to be the most inclusive employer in Summary Greater Manchester. We are building our 10 year strategy to help deliver this. This strategy when fully developed will map out how we have the right structures, support and resources in place to accelerate the impact we have on reducing workplace and health inequalities over the next 10 years.
To date the strategy has been developed through understanding feedback from staff and through discussion at the Inclusion Committee and presenting it at Board is an opportunity to get further input before the strategy is finalised. The paper therefore is a ‘work in progress’ and there are some elements where further content will be drawn from other strategies, e.g. patient experience and our Anchor Institution ambitions. This is not the finished product and the Board are invited to offer comment and input to enable the strategy to be further developed – this approach was agreed at Inclusion Committee.
Annual Plan Caring for and Inspiring our People Objective Associated Risks IF we fail to have in place a process to improve the experience our staff THEN we may not achieve a reliable and resilient workforce and our operational performance and service developments will not be delivered
Recommendations The Group Board is asked to: acknowledge the 10 year plan as a work in progress document agree the Engagement timeline offer further views
Equality Does this paper relate to a matter where equality issues may arise? Y The paper is all about actions we need to take to mitigate the risk of equality issues across our organisation Freedom of This document does not contain confidential information and can be made Information available to the public. NCA # 274090 09/25/2020 10:33:46
1/1 100/163 Intentional Inclusion At the Heart of the Communities We Serve Our 10 Year Vision for Change
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1/12 101/163 Our Inclusion Road Map sets our ambition as an organisation ensuring we have the right structures, support and resources in place to accelerate the impact we have on reducing workplace and health inequalities over the next 10 years
Key Features . Board agreed targets now replicated across all Public Sector Organisations in GM delivering a 10/15% shift in the number of BME leaders and additional work to ensure trajectories for senior, middle & junior staff align across our future talent pipeline. . In partnership with Royal College of Nursing introduce Cultural Ambassadors aimed at reducing the inequalities identified across our disciplinary and recruitment processes. . Inclusion embedded into existing leadership & performance structures not stand alone. . Group Inclusion Council to bring together staff, patient & citizen Voices to help shape our future work and in partnership with senior leaders monitor our performance. . Multi year focus allowing us to develop evidence based practice to reduce inequalities for one group and allow this to be adapted to reduce inequalities for others as we progress year on year (BME, Disability, LGBT).
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2/12 102/163 We must hear the voice for change
The phrase nothing about us without us has become synonymous with disability equality since the early 1990s and is often used widely across the NHS and public sector when discussing the needed to involve either staff or patients to shape the direction of decisions within organisations. But while there are many examples of initiative across public services that have utilised the power of colleague, patient and community experience effectively very few organisations have managed to mainstream the concept into the heart of their work.
Taking a lead from the 2020/2021 NHS People plan which has centred lived experience voices as the fuel to motivate and drive effective change, as an organisation we will work to mainstream the voices of staff, patients and citizens from underserved communities into the heart of decision making forums across the NCA.
To achieve this we it will need an underserved communities involvement model which recognises that while there is a specific need to hear the voices of staff and patients due to their unique experiences as an information source for decision makers, these groups are also not as discrete and separated as they are often treat. We therefore want to ensure a focus on citizen led voices from our local community as whole in order to hear the full range of voices needed to support evidenced based decision making this includes staff and experiences too. Finally while informing decision makers through sharing the experiences of colleagues, patients and community voices is a vital step forward in order to ensure those decisions are the most effective we need to ensure we also empower those whose stories we need to hear are involved in making the decisions themselves. We will work hard to diversify decision making groups and intentionally build in structures that ensure underserved community voices are included in our decision making bodies.
Orgnisational Decision Making Forums
Colleague and Patient Experience Groups Citizen Led Forums and Networks
Our Underserved Involvement Model NCA # 274090 09/25/2020 10:33:46
3/12 103/163 The Way We Do Things
As one of the largest NHS organisations in the country we recognise the importance of having robust governance and effective policies in place that support our workforce in delivering the highest quality services within an inclusive workplace environment focussed on employee wellbeing and development.
Research has shown us the harm that institutional and structural discrimination can have on the individual lives of our community and on the quality of the decisions and ultimately the services we provide. Another driver we can identify around inequalities we see across our workplaces and that contributes to the wider health inequalities in our communities are the biases built into everyday human decision making and amplified by those existing structural inequalities our systems have.
Recognising this as our first step for change on our Intentionally Inclusive Road map is to ensure our organisation’s process and policies have been built to intentionally tackle structural inequalities and limit the ability for bias to continue to drive inequalities across the Northern Care Alliance.
Staff need to have the confidence that When I read the NCA’s policies do I people making decisions understand see LGBT people intentionally the impact on people other than included? themselves Salford LGBT Staff Network Chair Salford BAM Staff Network Chair
We have made positive steps working I’m passionate about being able to with the NCA and hope to be able to support recruitment processes that be confident that we see are fair for all. We need to see communications that reach all our cultural ambassadors used more. communities Cultural Ambassador Director of CAHN
Vision we have (10 Years) – work in progress
The future we will see is an organisation that…
This part of the strategy is work in progress and we are keen to explore views across a range of stakeholders including the Board to answer the following questions:
What will it feel like for patients in 10 year’s time?
How will it be different for staff in 10 year’s time? NCA # 274090 09/25/2020 10:33:46 What would be the headline to describe our progress in 10 years’ time?
4/12 104/163 EDI Governance
It’s vital we have effective governance models across the organisation that embed inclusion within business as usual and supports active inequality reduction approaches. This outlines the ambition over the next 4 years and our 10 year plan will emerge as we make progress in the earlier years.
Progress we will see
All functions across the Northern Care Alliance will have inbuilt actions to reduce inequalities both in terms of workplace and inequalities experienced in the community or our services built into their annual operational plans as part as business as usual. We will see change and development within Care organisations initiated by the involvement of representatives from citizen led Inclusion councils. Performance against the Group and Care Organisations Inclusion Ambitions is utilised as part of the organisations Governance and Risk Assurance Framework in the same manner as Financial or Service Quality metrics and performance is.
Making it work
Our Equality and Inclusion Governance model is effective in mainstreaming the ownership and decision making around reducing inequalities into leadership responsibilities in every clinical and corporate function in the organisation We will build in underserved communities citizen engagement into the heart of our Care Organisation governance models with the development of place based Inclusion Councils. The new EDI summary dashboard presented at Board will be viewed and utilised as an integral part of the organisation’s Governance and Risk Assurance Framework.
Policies, Processes and Decision Making
Progress we will see
We have no measurable inequalities for any group of staff entering our disciplinary process or being dismissed by the organisation. We have no measurable inequalities in the likelihood of staff being appointed after shortlisting for BAME and Disabled Colleagues Recognising the quantitative data gaps around LGBT staff and patient demographics we can demonstrate a direct link between consideration of LGBT inclusion within our policies and processes to feedback from LGBTQ+ Staff Networks, LGBTQ+ community organisations and patients NCAabout # impact 274090 they are having. 09/25/2020 10:33:46
5/12 105/163 We see significant increases in the consistency and quality of reasonable adjustment plans with over 80% of disabled staff reporting they have one in place.
Making it work
There is confidence that no decision, service change or policy is developed without demonstrating effective due regard for the impact on underserved communities, ensuring the use of culturally appropriate and gender neutral language. The utilisations of demographic data will be at the heart of all of our organizational processes and governance systems and where local equalities data is not available we will utilise regional and national data sets or qualitative information. We have policies that ensure the needs of Trans and Non Binary Patients and Staff are recognised and met. A robust process to ensure line managers are consistently working in partnership with disabled staff to have reasonable adjustment plans in place at the earliest possible opportunity.
Approach to Recruitment and Talent
Progress we will see
We will be able to measure the number of leaders who move across organisational functions from underserved communities The organisation will exceed the trajectory set by the NHS Model Employer targets and see at least 66 more BAME leaders above a band 8A and 30 more Disabled leaders. We have no measurable inequalities in the likelihood of staff being appointed after shortlisting for BAME and Disabled Colleagues We will see a significant change in our Gender Pay Gap (% being worked up) We will see a significant change in our ethnicity pay Gap (% being worked up)
Making it work
Our approach to talent development is focused around valuing the diversity of or workforce and harnessing the untapped potential of colleagues who have faced disadvantages due to structural inequalities and will be evaluated to ensure our approach has an active role in reducing inequalities. We will enable the diversification of career portfolios above Band 8A and increase the opportunities for colleagues to move across corporate and clinical senior leadership roles with a particular focus on support for staff from underserved communities to be successful in accessing these. The organisation can demonstrate how positive action measures have been built in to our group and localised talent programmes and seniorNCA leadership # 274090 09/25/2020 10:33:46 recruitment activity.
6/12 106/163 We are confident that all recruitment activity that take place across the organisation involves at least one leader who is confident at ensuring their local process will minimise the opportunity for bias to have an impact and maximise the opportunity for underserved communities to be successfully appointed. Our trained Cultural ambassadors are valued and utilised as a matter of course to support all disciplinary processes and targeted inequalities within recruitment. We will utilise existing leaders from underserved communities who have broken through the glass ceiling to support peers to navigate any structural inequalities while the organisation goes through a period of change to remove these.
Communications
Progress we will see
We can demonstrate that the organisation is using media platforms whose consumer base are specific underserved communities across our local geographic footprint. We are confident that our communications reflect the full diversity of both our workforce and local population Stories that add value to Our Inclusion Centre of Excellence are embedded across our organisational communications
Making it work
Communicating the progress we have made against EDI ambitions will be built into our regular organisation communications channels and publications An annual audit of Trust communications will take place to review the diversity We can demonstrate a clear intentional approach to building in representation from underserved communities across our organisational communications.
Design of Services
Progress we will see
We can demonstrate that for at least five protected characteristics we can evidence how the design of all future services meet patient and workforce needs with no demonstrable inequalities.
Care pathways – we will ensure digitalisation (particularly for outpatients) doesn’t disadvantage some of those groups even more due to lack of connectivity.
We will ensure we do the right impact assessments and ensure patients have the choice that meets their circumstances
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7/12 107/163 Making it work
All new service changes will be expected to evidence and report on what inequalities data has been utilised to inform the final decision making Services will regularly utilise the experiences of colleagues from our staff networks and citizen inclusion councils in the design and planning of future services Our services will be encouraged to identify a national or regional comparator service who is designed to meet the diverse needs of their local population for comparison and to allow for future development aspirations to be identified..
How it Feels around Here
Culture is at the heart of any organisation and no matter how good the strategy, process or policy without an inclusive culture historic inequalities and disparity in how colleagues experience work and how divergent some patients experiences are when accessing out services will continue.
Recognising this our second stop for change on our intentionally inclusive road map is to ensure we shift our organisational cultural to one where equality and inclusion are at the heart of everything we do and where wellbeing and expectation at delivery a positive experience for all is part of our business as usual.
Staff need to have the confidence Staff need to have the confidence that people making decisions that people making decisions understand the impact on people understand the impact on people other than themselves other than themselves Salford BAM Staff Network Chair Salford BAM Staff Network Chair
Leadership Development
Progress We Will See
We actively use underserved staff experiences to measure and evaluate leadership performance across functions and services. We can demonstrate that every senior has objectives which prioritise the reducing of workforce and service inequalities as part of their everyday role. We have a workforce that is empowered and is working collectively as a social movement to identify and reduce inequalities at a micro as well as a strategic level. NCA # 274090 09/25/2020 10:33:46
8/12 108/163 Making it work
Practical understanding and learning will be built into every module of our organisational wide leadership programmes this will be delivered through the embedding of our Intentional Inclusive Leadership content within them. We will ask leaders to demonstrate their leadership competencies specifically within the context of equality and inclusion as a requirement of completion of all leadership programmes Equality objectives will be visible in all CF2 conversations. A range of stretch based change programmes to empower colleagues to work on reducing workforce and service inequalities will be resourced and introduced. EDI dashboard intelligence alongside staff survey data will be utilised to carry out a planned cycle of leadership cultural audits at a function or service level.
Colleague Experience
Progress We will See
Care Organisations will be empowered to develop initiatives focussed around local disparities in staff culture and experience and ensure learning can be shared at a Group wide level. Reducing the inequalities identified by our Underserved groups voices and experiences will be the foundation for all organisational colleague experience activity.
Making it Work
We will grow and develop our staff networks to be at the heart of our staff experience strategy amplifying the voices and stories of BAME, Disabled and LGBTQ+ colleagues and using their feedback as a catalyst for change and to evaluate its impact. The drivers to initiate change at a local level to reduce the inequalities in experiences of staff from BAME, Disabled and LGBTQ+ communities will be built into expectations on leaders across clinical divisions and corporate functions with progress towards agreed targets monitored on at least a quarterly basis. We provide practical information and guidance to ensure managers have the cultural competence to effectively support colleagues particularly considering inequalities relating to race, sexual orientation, disability, religion and belief or being trans or non- binary. We will see no inequalities between the experiences shared by staff in terms of experiencing abuse from their line manager or another colleague based on ethnicity, disability, gender or sexual orientation. Patient Experience NCA # 274090 Progress We Will See – 09/25/2020 10:33:46 Link in with Patient Experience Strategy
9/12 109/163 We will be able to demonstrate across the majority of our services that there are no or few inequalities in relation to patients experiences when accessing our service from at least five of the protected characteristics.
Making it Work
Patient Experience action plan
Inclusive Services and the Impact on our Communities
We understand the barriers many communities still face when accessing services across our NHS and the scale of health inequalities across the localities we are based in here in Greater Manchester. As one of the largest employers in the region and with ability to impact on 40% of the localities in Greater Manchester through our place based working we have the opportunity to play a major role in not just leading the way to deliver accessible inclusive care but as an anchor institute having a significant impact on reducing the wider inequalities across society today.
Recognising this is our third stop on our Intentionally Inclusive Road Map Journey we must she transformational rather than incremental shifts in the way we deliver services to better meet the needs of our diverse communities and in how our workforce and leaders see the role of the organisation as a positive resource to contribute to reducing inequalities in all the localities we are based.
When I read the NCA’s policies do I see LGBT people intentionally included? Salford LGBT Staff Network Chair
Health Inequalities
Progress we will see
Majority of all of the organisations services being able to evidence that there are no or few inequalities in terms of design of services, access to services, health outcomes, transitions to services, safety and risk of harm when in services and accessing additional health promotion information for at least five protected characteristics.
We will be see measurable progress and meet targets set against a number of community health inequality goals through working in partnership within our place based Care Organisations NCA # 274090 09/25/2020 10:33:46
10/12 110/163 Making it work
We will set and work towards bold and ambitious targets for the organisation to demonstrate that communities are not facing barriers to accessing services and receive equal outcomes when in our care We are able to identify gaps and inequalities in services by utilising data on Age, Disability, Gender, Race, Religion & Belief, Sexual Orientation and Pregnancy/Maternity. We will have a defined programme of actions focussed on reducing community health inequalities in each of our four locality footprints. Connecting with local communities – we will understand what messages are important for them and how we can improve communication as well as setting up preventative and management programmes for long term conditions / those with mental health issues / learning disabilities, including specifics like flu vaccination uptake Accessible Services
Progress we will see
We will ensure that our EDI governance model is extended to ensure actions to reduce inequalities across our estates and facilities teams and buildings are part of business as usual with a dedicated senior leadership lead. We will see a review of all our estate footprint and work with Accees able to improve accessibility across our sites We will ensure all new buildings have access to toilet and changing facilities that recognise the dignity and wider needs of our communities to not have to access communal single gender spaces Staff will have access to non communal changing spaces and single gender toilets across all our operational services. We have robust data for the reporting of access to services of patients based on sexual orientation across all services.
Wider Community Impact
Progress We Will See – Link with the Anchor Institute work
Making it Happen
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11/12 111/163 Our Inclusion Centre of Excellence
Equality and Inclusion Professionals are a vital resource in ensuring organisations have the internal expertise to drive truly evidence based change methodology around reducing inequalities and are able to turn energy and resource directed at meeting statutory and contractual compliance relating to Equality & Human Rights regulation into meaningful change for our staff, patients and local community.
By developing our own Inclusion Centre of excellence we hope to support the organisation to have the structures and support in place to accelerate the impact we can have on reducing the inequalities we see for our staff, patients and local community. As health and social care services changes we recognise that for the impact we want to see our ambitions have to be bolder than simply affecting change within our own organisation and that its vital we can play a positive role across other organisations. The original roadmap that was agreed in relation to this ambition is included in Appendix 1.
We support the organisation improve against the majority of our EDI ambitions year on year
We generate EDI resources that can be easily shared and utilised by organisations across our system including our locality and community partners.
We are seen as a lead provider of EDI learning and development across the NHS
We are viewed as an exemplar across Greater Manchester in developing inclusive community and stakeholder engagement activity
We are included annually in Top 50 Inclusive Employers list and our EDI work is shortlisted for at least one regional or national award annually
Next Steps
Board are asked to comment on the content on the emerging strategy in order that it can be finalised. Further input will be sought through a variety of sources as outlined in Appendix 2 which shows the engagement plans we have in place.
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12/12 112/163 Inclusion and Engagement 2022 plan Oldham | Bury | Rochdale | North Manchester Our journey to be a centre of excellence for inclusion and engagement Our aims ■ We aim to be a Centre of excellence for Inclusion ■ We aim to create an environment and culture that and Engagement ensuring that as an organisation celebrates inclusion and engagement, diversity, we are naturally inclusive as an employer but as a dignity & respect and values difference, harnessing service provider. the benefits both for our employees but also for our patients, clients, their families, carers and members ■ We want to be the employer of choice, who not only of the general public. attracts but retains the best talent through the provision of an inclusive, nurturing culture and ■ We want to be the partner of choice working both provides the best quality of care through a workforce locally, regionally and nationally creating innovative that is truly inclusive and reflects the communities solutions to meet both employee and patients’ that we serve. needs through a truly inclusive culture, that effectively engages with all. The road map is the Gathering Data blueprint for the inclusion Our Base line Robust and engagement strategy Governance & Assurance which incorporates our 5 Framework year plan. with clear Embed accountabilities Inclusion & Engagement into Frame- Develop I&E works and Agree local KPIs internal Kite Business marks and plans achieve external kite marks
Years 1-2
Years 3-4
1st on the Years 4-5 Top 50 Inclusive Outstanding Employers list on the CQCs Well-Led Domaine Centre of Excellence for Inclusion and Engagement
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1/2 113/163 The Inclusion & Engagement Road Map is the blue print for the Inclusion & Engagement Strategy, illustrating our vision and setting out our five year plan which will see the Northern Care Alliance NHS Group moving from our baseline to becoming a Centre of Excellence for Inclusion & Engagement. The road map will reflect and incorporate NCA values of providing respect and empowerment for our staff and patients through effective, inclusive engagement and involvement. It will set goals, key performance indicators (KPIs) and objectives to ensure continuous improvement, and providing clear transparent accountability.
Key Milestones We will be developing local KPIs for our Care Organisations based on and inclusive of local data which will feed into the overall targets, monitored by the Programme Board and CIC. These include: ■ Minimum of 10% improvement on their base year position (2017/18) by year 3 (2021/22); with stretch target of 15% ■ Trajectories set for Senior, Middle and Junior grade leaders (with bandings relevant to organisation)
To measure the success we need to establish our baseline picture, set Measuring aspirational targets for the next 3 - 5 years and measure progress against those success targets annually. We also need to be transparent about how we are performing.
Getting a job is the first step on the career ladder. We need to ensure that we have an effective accessible talent management, leadership strategies in place, Supporting accessible learning & development opportunities & robust HR Policies in places progression as per the People Strategy. We also need to work with our workforce & OD colleagues to ensure inclusion & engagement is the golden thread that runs through everything.
We need to support how individuals get opportunities. A review of all Improving recruitment processes including internships and apprenticeships is necessary to processes ensure they are accessible for all and this has to be done in line with the NCA’s People Strategy and its 6 pillars.
Changing culture takes time. The aspirational targets set will provide the Changing catalyst for change. Staff from under-represented groups such as BAME, culture Disabled and LGBT need to be confident of the same opportunities, and feel able to speak up if they find they are subject to direct or indirect discrimination.
As an employer of over 17,000 staff, the greatest benefit to the NCA and its care Inclusive organisations will be experienced when diversity is 'business as usual'. This is workplaces where everyone in the organisation sees diverse teams as the norm and celebrates the benefits that a truly inclusive workforce canNCA del #iver. 274090 09/25/2020 10:33:46
October 2018 2/2 114/163 Intentional Inclusion at the Heart of the Communities We Serve 10 Year Strategy Engagement Timeline
Recognising the organisations strength of commitment to equality & inclusion as a driving force behind the creation of our 10 year Inclusion Strategy we have developed a focused timeline that balances both effective engagement and a desire to realise early progress and change over the short term as we work towards a more long term vision.
Collating existing NCA short term Inclusion goals and ambitions
Setting out existing progress and activity to deliver Inclusion across the NCA
Create an engaging and useable Inclusion Strategy Structure
A variety of targeted and open engagement Will take place during October 2020
Inclusion of Interdependency Targeted Focus Groups with Key Expertise: Stakeholders: Patient Experience Team BAME Leadership Council Director Social Value Staff Networks Workforce Team Trade Unions
Wider Colleague Engagement Delivery of four executive led “Intentional Conversation” virtual webinars discussing our Story so far and explore a 10 year vision for change. NCA # 274090 09/25/2020 10:33:46 Feedback incorporated into final draft by 19th November
1/1 115/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Social Value Update
Meeting Group Board (Committees in Common) Donna McLaughlin, Director of Social Value Creation Patrick Youngblood, Administrative Assistant, Division of Integrated Care, Author (s) BARCO Victoria Thorne, Divisional Director of Nursing and Therapies, Bury and Rochdale Care Organisation Presented by Nicky Clarke, Chief of People Date 28th September 2020
Executive Patrick Youngblood will join the Board, supported by his line manager Victoria Summary Thorne, to present his lived-experience of obtaining employment through a supported internship programme. In order for Patrick to fully engage with the board colleagues are asked to switch off their video whilst he answers three questions. He was given the opportunity to pre-record this session but he would prefer to present directly to you.
The purpose of this report is to provide an update on progress since the NCA approved its Anchor Mission in January 2020; to discuss the impact of COVID- 19 and to confirm members of the Committees in Common are supportive of the proposed ambitions.
Our Anchor Mission is our approach to social value which is the use of our power in a purposeful and intentional way to support the reduction of poverty through employment and job creation; anchoring wealth to place through our procurement process and challenging the current economic and regeneration policies and practices which are not necessarily supporting the most vulnerable within society through our national and local influences. COVID has provided a stark reminder of the health inequalities in the communities we serve and like the disease the economic and social consequences will have disproportionate impact.
In January 2020 when the NCA set out is position unemployment rates were 3.9%. This is likely to rise significantly with further increases as the government subsidies which are supporting 9.1 million workers come to an end in October. “Human health and social work activities” is now the largest sector with vacancies and accounts for a third of all job opportunities in the country. Public sector employment has continued to increase driven by the NHS. Therefore, our anchor mission to use our power in a purposeful and intentional way to support the reduction of poverty through employment and job creation has become more critical in this climate which is destined to see health inequalities widen.
The paper summarises progress to date including attracting some additional income to support this work and strengthening relationships within each locality against our ambition by 2025 to: Create 1000 pre-employment opportunities forNCA those # 274090furthest away from the employment market from 320 09/25/2020 10:33:46 85% of whom these to be supported into paid work – up from 55% 50% of those employed by the NCA to be local residents from 45% an
1/8 116/163 increase in 750 jobs (based on NCA configuration of Oct 19) Increase to 1000 NHS Career Ambassadors who are available to support schools and colleges with career advice and positive role models from 411. Annual Plan - Partnership in Place Thriving Communities. We will continue to play an Objective active leadership role in each locality supporting system wide recovery. We will deliver on the milestones identified in the Anchor Institute plans - Caring for and inspiring our People – doing the right thing. We will create employment and training opportunities in our local communities. We will develop and implement the Anchor Institution programme to raise levels of local employment Associated Risks This programme will assist in the address the following BAF risks
1.2.1 IF we fail to sustain and develop positive relationships within each locality THEN we may not secure our enhanced leadership role in place and deliver the required changes for our populations.
2.3.1.IF we fail to increase the percentage of locally employed staff THEN we will not optimise our contribution to the wellbeing strategies. Recommendations Group Board is asked to 1. note the report progress made on social value despite the pandemic 2. note the greater urgency of this programme of work as a result of the pandemic to mitigate the effects of the pandemic on worsening health inequalities in our local boroughs; 3. Agree and support our key ambitions; 4. note the reliance on attracting external resources to develop the necessary infrastructure to achieve these ambitions; and 5. note the development of key relationships and that Board approval will be explicitly sought before agreeing to partnership with external profit-making bodies.
Equality Pre-existing racial and socio-economic inequalities have not only been amplified by the COVID -19 pandemic they have been made worse. Structural inequalities drive poverty which is one of the major contributing factors to poor health. This paper addresses matters where inequality issues arise and it outlines how the NCA could address the adverse impact by purposefully using its power to address one of the underlying determinants of ill health – poverty. It proposes positive action to address structural inequalities. Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless. NCA # 274090 09/25/2020 10:33:46
2/8 117/163 1. Introduction
In January 2020 the Northern Care Alliance NHS Group Board overwhelmingly endorsed becoming an Anchor Institution. That is the deliberate and purposeful use of its power to support the economic development of place to improve population health and well-being. Our approach is focused on the leadership and action ‘delivered by place’ through the local care organisations and ‘enabled by group’. Embracing social value creation as the way we do business in the same way we approach quality improvement, core to our strategy, integrated business planning, our policies, procedures and practices. Pre-existing racial and socio-economic inequalities have not only been amplified by the COVID -19 pandemic they have been made worse. Structural inequalities drive poverty which is one of the major contributing factors to poor health. And an important means of improving health in local communities is to provide pathways to good employment.
Since this report was last presented the world particularly of work has changed significantly. In January 2020 when the NCA set out its position unemployment rates were 3.9%. This is likely to rise significantly as the government subsidies which are supporting 9.1 million workers come to an end in October 2020. “Human health and social work activities” is now the largest sector with vacancies and accounts for a third of all job opportunities in the country. Public sector employment has continued to increase driven by the NHS. 31.9% of all people employed are in the public sector, civil service, public bodies and HM Forces. Therefore, our ambition to use our power in a purposeful and intentional way to support the reduction of poverty through employment and job creation has become more critical in this climate which will see health inequalities widen and deepen in NCA communities who were already disadvantaged by structural inequalities.
There is also strong connectivity with this programme work to the equality and inclusion agenda, notably race and disability. COVID-19 disproportionately impacted members of UK BAME communities with mortality rates 1.5 to 3 times higher. BAME employees accounted for 72% of healthcare worker deaths. Bangladeshi men were four times, and Pakistani men nearly three times, as likely as white men to work in jobs that were directly impacted by the lockdown. Of Bangladeshi working-age men, 29% work in sectors shut down by COVID-19 and have a partner not in paid work, compared with only 1% of white British men. This economic deprivation widens existing chronic health inequalities and wider determinants of health (Tinson, 2020) and given NHS recruitment practices disproportionately favour white applicants (Kline, 2013). Yet diverse teams contribute to better health outcomes (West, 2012). Therefore the NCA Workforce Race Equality Standard and Disability Equality Standard action plans need to talk to this agenda and celebrate the diversity of the communities we are part of.
The purpose of this report is to approve the commitment to: create 1000 pre-employment opportunities for those furthest away from the employment market from 320 85% of whom these to be supported into paid work – up from 55% 50% of those employed by the NCA to be local residents from 45% an increase in 750 jobs (based on NCA configuration of Oct 19) NCA # 274090 Increase to 1000 NHS Career Ambassadors who are available to support09/25/2020 schools 10:33:46 and colleges with career advice and positive role models from 411.
3/8 118/163 2. Vocabulary The term “Anchor Institution” was used in the NHS Long Term Plan and is widely used within the NHS, particularly by NHSI/E and NHS associated think tanks e.g. Health Foundation, Kings Fund and was used together with the term “anchor mission” in January 2020 NCA Board Paper. The term social value is more commonly used in sectors away from the NHS and includes sustainability and environmental action, although often as an additional value rather than a purposeful one. There is a growing use of “community wealth building” or “inclusive economy” to create a counter narrative for decision makers on the current economic and regeneration policies and refers to the economic impact of anchor institutions within a place and highlights the structural inequalities of the existing economic practices.
Therefore, it is suggested that the NCA adopts the following:
Social Value as the overarching umbrella term which includes sustainability and environmental commitments included in the Sustainability Development Plan which was approved by CIC in January 2020. This overarching umbrella also references the NCA commitment of its purposeful use of power to elevate poverty: o for place o for people o for purchasing o and to anchor (previously to influence)
The term “anchor institution” is used for NHS audiences to reference the NHS plan commitment. A communication strategy has been drafted and recommends the use of “This is the place” branding for work undertaken within employment (for people) for consistency and is creating info graphics, consistent vocabulary and powerful stories.
3. Place It was agreed to take an 18 month phased approach to developing a place based programme in each locality against starting with Oldham and ending with Bury by June 2021. However, the initiation has been rapid with success being generated in most systems, despite inactivity during March – June. Each Care Organisation has a responsible Director who is working with the Director for Social Value Creation to ensure a system wide approach.
4. People This has been the main focus of the work so far in creating pre-employment talent pipelines to increase the number of local people employed by the NCA. This is summarised in the driver diagram below. A half day workshop “recruit local” was held at the end of August having been rescheduled from March 20. As a result of which, the Care Organisation and Corporate/ Group functions are required to submit their trajectories against 5% improvements in local recruitment to October’s Executive People Committee following a successful Recruit Local Workshop in August. (Rescheduled from MarchNCA 20). # These 274090 will be monitored moving forward. 09/25/2020 10:33:46
4/8 119/163 Employ Local - Social Value Creation Understand population demographics and need and local Enablers Draft Driver Diagram (v1.04) employment market forces Understand the workforce opportunities and risks Data and insights Develop pre-employment pipelines, matching population need to Recruitment workforce opportunity and risk Workforce strategy Supportive person-centred approach to recruitment to pipeline programmes with a guaranteed offer of paid employment Positive , values based employment policy for Supportive person-centred transition to substantive employment To increase local people the number Job satisfaction of local Partnership working Value and celebrate the contribution of local employees – creating with other local people in Retention positive role models and good news stories - local perception employers meaningful & Social Mobility Index Accreditation - Living wage employer sustainable Partnership working employment with local education Talent Management Strategy providers and colleges to align access Development and training access and provision programmes & Creating pathways to jobs that break the 30K ceiling influence training upstream Progression Creating access pathways to professional education and training Support, mentorship and coaching Awareness raising and training for NCA Targeted role model programmes recruiting managers Keeping in touch and placements – staff in full time education
4.1 Oldham Obtained non recurrent £54k for NCA and established 6 projects within Oldham including increasing volunteering opportunities, work experience, curriculum design with Oldham College for T levels and pre-employment activity. Secured over £100k for the Oldham system to create 20 apprenticeships and improve the employability skills of 80 people from BAME community in Coldhurst (in partnership with Get Oldham Working and Oldham Council) and 16-25 years old including looked after children (in partnership with Positive Steps and Oldham Council). These programmes together with existing pre-employment programmes are being reviewed together through a “Recruit Local” Task and Finish Group chaired by Helen Dixon, ADW Oldham Care Organisation. Should all these activities be successful this should mean there is a sufficient talent pipeline in 2 years to support vacancies in band 2 -4 from a pre-employment learner and not through a “shirt and tie” interview. There is an outstanding bid with Oldham Opportunity Area to develop digital capability and expand some of the 6 projects into an additional year. A decision is anticipated by end of October 2020. 4.2 Rochdale Rochdale has high conversion into employment from its internship programme and the existing work of the Rochdale Social Value Alliance. There is a planned meeting with Hopwood Hall College in September to review the curriculum design forNCA business # 274090 09/25/2020 10:33:46 administration and digital T levels and the development of a cadet scheme. There are also plans to increase in NHS Career Ambassadors to support schools. However, no resources
5/8 120/163 have been identified to progress this although conversations through LCO board are on- going.
4.3 Salford Progress has been made in supporting the Salford City system to create digital pipeline career prospectus which has just been published and an internal working group has been established to operationalise employment opportunities within the NCA. The Director of Social Value creation has made the necessary contacts to increase the number of employment opportunities for people with learning disabilities and mental health conditions and over the next few months will match these organisations with vacancies within Salford (Care Organisation and corporate services) on individual specific plans for these people who require high intensive support. The individuals being target into employment are adults who are in receipt of adult social care support to live independently. This is in line with the Greater Manchester Mayor’s commitment and if successful can be rolled out across the other localities.
Bury No progress to date as focus has been on the other localities although there is an already established Cadet programme with Bury College which could be expanded. Following the disestablishment of BARCO it is likely that the majority of staff on the Fairfield site will come under the responsibility of Bury CO including community health services.
5. For Procurement A NCA Procurement strategy will be presented to a future CiC Board and has been delayed due to COVID-19 operational pressures.
6. To Anchor Social value is about connecting with our local communities through our novel place-based organisation form and using our power of scale to influence this agenda at a local and national level. This has been progressed by: Designed with AQUA a framework for social value which can be used to highlight strengths and prioritisations for leadership teams Member of the NHS Confederation and Colleges of the Future national working group on NHS relationship with Further Education (FE) colleges which published findings in September 2020 and included showcasing the NCA’s work with Oldham College. Shortlisted to run for the Health Foundation their NHS Anchor Learning Programme with NHS Horizon’s and AQUA. This was not successful but may lead to other opportunities. There is a Community of Practice scheduled for 30th October which will bring all four localities within the NCA together to share learning, launch our ambition and challenge each other further. We have identified six other NHS institutions; Bolton NHS Foundation Trust, Lancashire Teaching NHS Trust, Cheshire and Merseyside Partnership;NCA Warrington # 274090 and Halton NHS Foundation Trust and Liverpool University Hospitals NHS Foundation09/25/2020 Trust 10:33:46to
6/8 121/163 learn with us. Each locality will have the opportunity through the Chief Officer of the Care Organisation to show a 15 minute video of their progress to date and future aspirations. There is an outstanding bid for a COVID research project looking into BAME communities’ perceptions of the NHS as an employer using Rochdale as a case study. This is highly speculative given the competition for such funding but highlights commitment to research in this area.
7. Impact of COVID
The response to COVID has shown us what can be achieved through working together and how we are able to respond with pace and deliver significant changes through working collectively beyond normal organisational and service barriers. The pandemic is impacting disproportionally on low income households, the elderly, BAME communities and those within insecure employment. It is highly likely that the negative economic impact will also be felt hardest by the most vulnerable and marginalised communities. As unemployment increases, it is pushing out opportunities for young people entering the job market (16- 25years) which, as previous economic recessions have shown, will detrimentally impact on their earning potential and social mobility for life. It is also been forecasted that the gains of the last two decades in diversity and equality are also at risk. Therefore, those furthest away from employment, or in low paid insecure work, are likely to be pushed further from “decent employment” and we will see a widening of inequalities. The Covid-19 response has seen state intervention to maintain employment levels through furlough schemes and other incentives. It is likely that there will be further government intervention to protect the economy. The NCA needs to be in the position to exploit these opportunities and accelerate its social value offer to recruit more local people and create an inclusive economy as a means to support our local economic recovery in place.
8. Resource Requirements The development of our social value approach has so far been met with significant enthusiasm with staff across Care Organisations and corporate services. Recruiting staff and purchasing goods and services can be argued is core business, however we are not currently resourced to run the numbers and variety of programmes that this work will need and our pace of change is set by available capacity and resourcing. The capacity of the one dedicated person (Director of Social Value Creation) is fully consumed with the activity outlined in this report. A proposal for upfront resources to create some infrastructure was not able to be supported due to lack of available resource. As a consequence, non- recurrent investment opportunities are being proactively sought through bids and we are also developing a bid to go to the Charity.
Where we are reliant on external bids this can mean the focus is not 100% aligned with our priorities and successful bids are usually those submitted by partners working collaboratively. Strategic relationships continue to be developed and could lead to new formal partnership arrangements. The NCA Board are required to approve any strategic partnerships outside existing arrangements with local councils, FE and other educational establishments, voluntary community and not for profit organisations within place. An NCA # 274090 explicit board mandate will be sought prior to agreeing any strategic alliance with a profit 09/25/2020 10:33:46 making organisation.
7/8 122/163 9. Governance
A social value task and finish group was already in existence and has been converted to a steering group with the additions of the Care Organisations responsible Directors and members of the Strategy team to support the place based strategy. This ensures the benefits of group are achieved whilst maintaining a local focus. This is supported by two group wide sub groups – one on data and insight and the second, recruitment practices. Governance was paused during COVID and will be back in place by October 2020.
Assurance to the CiC is through the Equality Diversity &Inclusion committee and the Executive People Committee who will both receive the Social Value Performance Dashboard. This also goes to the Sustainability Task and Finish Group to retain connectivity to our environmental mission.
10. Recommendations The Board is asked to support our ambitions to: - Create 1000 pre-employment opportunities for those furthest away from the employment market from 320 - 85% of whom these to be supported into paid work – up from 55% - 50% of those employed by the NCA to be local residents from 45% an increase in 750 jobs (based on NCA configuration of Oct 19) - Increase to 1000 NHS Career Ambassadors who are available to support schools and colleges with career advice and positive role models from 411.
Donna McLaughlin
Director of Social Value Creation
21st September 2020
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8/8 123/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Seasonal Influenza Vaccination Programme
Meeting Group Board (Committees in Common) David Hargreaves, Director of HR Author Maxine Pamphlett, Head of Occupational Health Presented by Nicky Clarke, Chief of People Date 28th September 2020
Executive We have a comprehensive flu vaccination programme in place ensuring Summary sufficient vaccinators and access for staff. We have a programme of communications planned which will promote the flu vaccination campaign more proactively than previous years learning from other organisations.
We have self assessed against the national checklist to ensure our plan covers everything required and the details are included in the report. Annual Plan Caring for and Inspiring our People Objective Associated Risks IF we fail to have in place a process to improve the working lives of our staff THEN we may not achieve a reliable and resilient workforce and our operational performance and service developments will not be delivered
Recommendations The Group Board is asked to note the update and offer any insights.
Equality Does this paper relate to a matter where equality issues may arise? N Freedom of This document does not contain confidential information and can be Information made available to the public. x Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
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1/1 124/163 INFLUENZA PROGRAMME 2020- 2021
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1/5 125/163 Occupational Health – Influenza Programme 2020 – 2021
Introduction
This report provides an overview of the current planning for 2020 Influenza immunisation programme for the staff within the NCA.
The 2020-2021 flu campaign has been discussed by the Executive and plans for delivery to our staff have been developed with Occupational Health. A stretch target for uptake has been set at 100% of staff with designated healthcare workers being prioritised in the early stages of the flu campaign.
The Chief Medical Officer as the Director of infection Prevention and Control will act as Board Champion to promote uptake of the vaccine in order to underpin the importance of staff having the vaccine to protect patients and colleagues.
We are mindful that there may be issues associated with changes to Covid IPC measures that may impact on vaccination delivery and will keep this under review as IPC measures are reviewed and Infection Control advice and support will be sought in respect of any changes.
An initial assessment against the national checklist is attached (appendix 1) which will be reviewed and updated as the campaign progresses and published to the internet as required prior to the December deadline.
Recording and reporting
We have ordered the vaccines to cover general staff, staff over 65 and staff with albumen allergies and the first deliveries are expected by the end of September. Vaccines have also been ordered to cover external contracts
Staff lists have been extracted from ESR and these will be recorded against and weekly reports will be produced by Care Organisation to show progress against trajectory and to allow for intervention as necessary. Reports will be provided to the Executive and to Care Organisations weekly.
The vaccinations totals will be reported for the 2 statutory bodies and for the individual Care Organisations/services on Immform from the 31 October.
All staff who decline the immunisation or have received it elsewhere will also be recorded – new staff attending induction for instance will be targeted to determine if they have had the vaccine elsewhere.
Dedicated members of staff within Occupational Health will input data into internal electronic reporting system each weekday as data is returned to Occupational Health.
Governance arrangements
Group Patient Group Directives will be signed off for both Salford andNCA Pennine # 274090 – these are currently being reviewed by the OH clinical lead and will be signed off by 09/25/2020the end of July 10:33:46 by the respective Medicines Management Committees or their Chairs.
The Group Associate Director of Infection Control will chair the regular meeting of the NCA Influenza Committee and Head of Occupational Health will be vice-chair of that committee. This 2/5 committee will escalate any operational issues and ensure vaccinations are seen as part of the 126/163 NCA overall response to flu including response to outbreaks.
High risk wards will be identified to that Committee and prioritised for the flu vaccination of staff.
Local CO flu meetings attended by OH staff have commenced or are due to commence imminently at Oldham, Bury and Rochdale and at North Manchester.
Occupational Health have reviewed the previous year’s campaign and discussed approaches with colleagues from elsewhere and developed their approach following those inputs.
Delivery of the vaccine
An online training programme is being developed in order to train the link nurses and other health professionals and this should be available in August.
Discussions are on-going between OH and the Corporate Matron in order to identify 2 link nurses for each ward who will undertake the training and provide vaccinations for their areas of work. A minimum of XXX are to be identified for training and their names will be publicised on the intranet.
Funding is requested in order to recruit 8 additional nurses through NHSP who will be deployed as appropriate across the NCA to support the campaign for 3 months from October 2020 which will allow OH services to continue as normal during the flu programme with OH staff supporting on- going drop in sessions and providing vaccinations to staff attending OH.
Arrangements will be made for Board members to receive the vaccine at the beginning of the campaign (arrangements will be made to visit the Board meeting to provide the vaccine, photographs will be taken and used for advertising).
High risk areas will be targeted in the first 2 weeks of the flu campaign (dates tbc) by Occupational Health staff.
A programme of ward/departmental visits along with drop in sessions is currently being put together and this will include coverage of community staff – at present the Gateways are closed and as such delivery will need to be considered in the light of the Covid IPC measures in place later in the year. Dedicated sessions will be provided for night staff and at weekends. Rooms are currently being sourced but the focus needs to be on delivery through link nurses or targeted delivery by OH staff in the ward/departmental environment.
Targeted support from OH staff will be provided to underperforming areas.
Publicity
The rationale for flu vaccination programme will be promoted through fact sheets, information posted on the intranet and attendance at management meetings. Meetings will be held with staff side and health and safety representatives to engage with them. Staff and patient stories will be used to promote the campaign.
Details of the national flu campaign and associated publicity are awaited and we will use that material, adapted as necessary when it becomes available. Confirmation is awaited as to a dedicated communications support for the campaign.
The drop in clinics which are to be organised will be publicised through the intranet and the NCA newsletter with planned ward/department visits arranged and publicised to staff through their manager. with the drop-in sessions across the NCA also being publicised on line and through the newsletter.
Weekly feedback on percentage uptake will be provided to encourage staff uptake
Depending on Covid IPC measures flu stalls to be organised for vaccination in strategic points on all NCA sites where possible.
Non HCWs will be vaccinated at drop in sessions and within the OH departments and specific sessions for those staff will only be considered if we are ahead of trajectory or if uptake from HCWs tails off. The Group Associate Director of Infection Control will chair the regular meeting of the NCA Influenza Committee and Head of Occupational Health will be vice-chair of that committee. This committee will escalate any operational issues and ensure vaccinations are seen as part of the NCA overall response to flu including response to outbreaks.
Local CO flu meetings attended by OH staff have commenced at Oldham, Bury and Rochdale and at North Manchester. Arrangements are being put in place at Salford
Delivery of the vaccine
Training is being and will be provided to 400 planned link nurses from all the Care Organisations through Teams and this will continue into October.
Funding has been agreed and additional nurses have been engaged through NHSP who support the vaccination programme across the NCA from October 2020 which will allow OH services to continue as normal during the flu programme with OH staff supporting on-going drop in sessions and providing vaccinations to staff attending OH.
Arrangements will be made for Board members to receive the vaccine at the beginning of the campaign – dates are being sought via the Executive Office
The focus for delivery will be through link nurses or targeted delivery by OH staff in the ward/departmental environment but dates and rooms have also been arranged for staff to attend for vaccination outside of their clinical areas.
Targeted support from OH staff will be provided to underperforming areas.
Publicity
The rationale for flu vaccination programme will be promoted through fact sheets, information posted on the intranet and attendance at management meetings. Staff and patient stories will be used to promote the campaign. Material from the national flu campaign material has been obtained to support locally. Occupational Health are working with a dedicated link from the NCA Communications team on publicising the campaign to our staff. This programme has been informed through learning from other Trusts who have had extremely positive response rates in previous years. As ever we will be dependent on local line managers prioritising this for their staff as local leadership of the programme will be key to its success.
David Hargreaves Maxine Pamphlett-Jones
Director of Human Resources ADNS Occupational Health
September 2020
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3/5 127/163 Appendix 1: Healthcare Worker Flu Vaccination Best Practice Management Checklist
For public assurance via trust boards by December 2020
A Committed leadership Trust self- assessment
Board record commitment to achieving the ambition of vaccinating all Completed A1 frontline healthcare workers
Trust has ordered and provided a quadrivalent (QIV) flu vaccine for Ordered in March. Initial A2 healthcare workers supplies arriving at end of September and scheduled beyond that.
Completed Board receive an evaluation of the flu programme 2019/20, including A3 data, successes, challenges and lessons learnt Completed – Chief A4 Agree on a board champion for flu campaign Medical Officer A5 All board members receive flu vaccination and publicise this Dates being sought NCA Group established. A6 Flu team formed with representatives from all directorates, staff groups COs local groups in place and trade union representatives at Bury/Rochdale, Oldham and North. Salford to be set up. Staff side to be invited. Commenced in July and A7 Flu team to meet regularly from September 2020 are being held monthly B Communications plan Joint communications Rationale for the flu vaccination programme and facts to be published – B1 sponsored by senior clinical leaders and trades unions planned with LNC Chairs and Staff Side Leads and medical directors. Staff side confirmed support at GNCC Due to Covid-19 can’t B2 Drop in clinics and mobile vaccination schedule to be published hold drop in sessions, electronically, on social media and on paper therefore holding clinics that staff can book in as well as visiting teams in situ. Schedule to dates, times NCA& #venues 274090 in place through 09/25/2020to November 10:33:46 so far – dates with Communications team for posting.
4/5 128/163 B3 Board and senior managers having their vaccinations to be publicised On plan
Flu vaccination programme and access to vaccination on induction On plan B4 programmes On plan – ordered B5 Programme to be publicised on screensavers, posters and social media promotional material. Poster and badges received – downloads available to be customised. Screensaver to be confirmed – (issue at PAT) Weekly feedback on percentage uptake for directorates, teams and On plan – target high risk B6 professional groups areas in first instance. Baseline established. C Flexible accessibility
Peer vaccinators, ideally at least one in each clinical area to be Planned to have 2 peer C1 vaccinators per area. identified, trained, released to vaccinate and empowered Training commenced and ongoing into October C2 Schedule for easy access drop in clinics agreed Due to Covid-19 can’t hold drop in sessions, therefore, holding clinics that staff can book in as well as visiting teams in situ. (see B2) On plan –have NHSP staff C3 Schedule for 24 hour mobile vaccinations to be agreed who will undertake this alongside OH staff. Timetable to be determined – focus on volume in core hours in initial phase D Incentives
D1 Board to agree on incentives and how to publicise this Peer vaccinator prizes to be offered –vaccinators to go into draw for - 1 entry per 20 vaccinations undertaken. Leader boards to be developed for COs, D&P, E&F and Corporate. D2 Success to be celebrated weekly Planned – comms to celebrate good news NCA # 274090 09/25/2020 10:33:46
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Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report The Geoffrey Jefferson Institute for Brain Research
Meeting Group Committee in Common Professor Andrew King, Professor of Neurosurgery Author (s) Professor Stuart Allan, Research Domain Director, Neuroscience & Mental Health Zoe Coombe, Service Strategy & Planning Presented by Professor Andrew King, Professor of Neurosurgery
Date 28th September 2020 This paper describes the creation of the Geoffrey Jefferson Institute for Brain Research, a translational neuroscience research institute and a partnership between the NCA and the University of Manchester. The Institute offers an exciting opportunity to make a real difference to the health and wellbeing of the people of Greater Manchester and beyond, to accelerate ground-breaking innovation, develop new treatments and translate our research into healthcare benefit. The Institute will be at the forefront of international neurosciences research thereby attracting significant external investment and international recognition. This paper describes the Institute’s organisational form, a five year investment plan required to establish the Institute, as well as key enablers and existing infrastructure that will be essential to the success of the Institute. Annual Plan Strategic priority 5. Digital, Research and Innovation- Pioneering Practice Objective Associated Risks If unsupported NCA will not realise its potential to be at the forefront of neurosciences translational research. This will impact:
a) patient outcomes and access to new treatments/interventions b) opportunities for income generation c) recruitment and retention of high calibre clinicians and scientists d) overall profile of the organisation
Recommendations The Committee in Common is asked to:
1) Support the creation of The Geoffrey Jefferson Institute for Brain Research 2) Note the investment required to establish the Institute 3) Note the requirement to formalise the partnership arrangement between the UoM and NCA
Confirm support for the enabling functions described within the proposal
Equality Does this paper relate to a matter where equality issues may arise? Y/N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be made
Information available to the public. Please ‘cross’ one This document contains some confidential information that would need to be of the boxes redacted before the document was made available to the public. X This document is entirely confidential, as the redaction of confidential information would render the document meaningless.NCA # 274090 09/25/2020 10:33:46
1/7 130/163
Northern Care Alliance The Geoffrey Jefferson Institute for Brain Research
NCA # 274090 09/25/2020 10:33:46 September 2020
The Geoffrey Jefferson Institute for Brain Research Page 2 of 7
2/7 131/163 Context Greater Manchester (GM) has the potential to be internationally leading in neurosciences research. Over 10 million people in the UK are affected by neurological conditions, bringing significant health care costs and major social and economic burdens of long-term disability. Manchester Centre for Clinical Neurosciences (MCCN) case volumes and outcomes match the best leading international centres. This and the breadth and scope of neurosciences research across the Northern Care Alliance (NCA), The University of Manchester (UoM) and other GM partners1 offers an exciting opportunity to make a real difference to the health and wellbeing of the people of GM and beyond. Developing a Translational Research Institute will unite expertise in the NCA and UoM to deliver ambitions in key areas of neurosciences research, and to accelerate ground-breaking innovation and translation in healthcare.
This vision will build upon existing neurosciences research infrastructure as illustrated below:
15 Clinical Academics in the following specialties: Clinical Academics Neurology, Neurosurgery, Neuropathology and Stroke
c. 150 UoM scientists in neurovascular, neuroimaging, neurooncology and Scientists neuroimmunology
Research Registrars 5 Neurology and 3 Neurosurgical Research Registrar positions
Consultant PAs 16.5 Consultant PAs (6.5 funded by NCA Research & Innovation and 10 by MCCN)
Manchester Brain Bank Resource of over 1000 brains donated for translational research
Biorepository Supporting processing, storage and distribution of samples
Investigating of the basis of disease and the translation of experimental Clinical Research Labs laboratory research for patient benefit at SRFT
Clinical Research Facilities Three NCA CRFs supporting phase I-IV clinical trials
Research Delivery Staff Supporting recruitment to and delivery of clinical research studies and trials
Research Offices Management and oversight of research across the NCA and UoM
Supports discovery, development and deployment of solutions to improve MAHSC Neurosciences health & wellbeing
Supports the design, coordination and analysis of clinical trials and other MAHSC Clinical Trials Unit studies
Supporting research through the capability to link clinical information with Electronic Patient Records tissue donated for research and research imaging
NCA # 274090 1 GM Partners including University of Salford, Manchester Metropolitan University, UoM institutes09/25/2020 such as the10:33:46 Lydia Becker Institute of Immunology and Inflammation, MICRA (Manchester Institute for Collaborative Research on Ageing), MCRC (Manchester Cancer Research Centre), Health Innovation Manchester and other NHS trusts.
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3/7 132/163 Vision
We aim to become a leading institute for translational brain research in the UK, combining outstanding discovery science and experimental medicine to rapidly translate our research into healthcare benefit. We will develop new treatments and implement optimal care pathways that provide better outcomes and transform the lives of patients with neurological disease. The initial strategic focus of the institute will be in the areas of stroke, brain tumours and brain inflammation, with cross-theme research in brain rehabilitation, brain imaging and brain pathology.
A unique aspect of our research is that is covers the entire translational pathway, from discovery science to applied health, with close interactions between researchers at all stages, and forward and back-translation. We also have access in GM to a diverse patient population and integrated health ecosystem allowing rapid translation of new ideas and treatments to the clinic. To underpin the latter the institute has developed a portfolio of preclinical and clinical candidate molecules targeting components of inflammatory pathways in disease and is scoping interest in pharma and drug discovery institutes to partner early stage trials.
The UoM has a long history of developing imaging-based biomarkers including those required to diagnose and study patients with brain tumours and cerebrovascular disease. The ongoing installation of a new 3T MRI scanner on the SRFT site jointly purchased by SRFT and the UoM exemplifies our ambition to translate these and other novel techniques into clinical practice. This translational research will leverage the size of the MCCN, the specialist patient populations and treatments, the availability of electronic patient records and the wider research activity for patient benefit.
Organisational Form
The institute will be named in honour of Professor Sir Geoffrey Jefferson FRS, the UK’s first Professor of Neurosurgery at UoM and the first Chair of the MRC Clinical Research Board. Professor Sir Geoffrey Jefferson worked at both Salford Royal and Manchester Royal Infirmary in the 1920s & 1930s respectively.
The Geoffrey Jefferson Institute for Brain Research will be a partnership between the NCA and the UoM. Professor Andrew King (NCA/UoM) and Professor Stuart Allan (UoM) will lead the institute and leadership for the research themes will be:
Stroke: Professor Craig Smith Brain Inflammation: Professor Dave Brough Brain Tumours: Mr Omar Pathmanaban Brain Imaging: Dr Laura Parkes & Dr David Coope Brain Pathology: Professor Federico Roncaroli Brain Rehabilitation: Professor Audrey Bowen
The Institute will be directed and overseen by a Board reporting to UoM, the NCA and other partners. The Board will include the Institute and Research Theme leaders, UoM and NCA senior leaders, as well as representatives for philanthropy, medicinal chemistry and patients. The Institute will benefit from both internal and external advisory/review groups to ensure progress is being made in meeting its ambitions and NCA # 274090 that the strategic focus is appropriate. 09/25/2020 10:33:46
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4/7 133/163 Membership of the Local Advisory Group and External Review Group is to be fully confirmed, though Professor Nigel Hooper (Associate Vice President for Research, UoM) and Professor Rob Bristow (Director, MCRC) are already members of the former.
Investment Plan
Core infrastructure is required to establish, grow and market the institute, to support clinical academics to undertake research and to ensure robust intellectual property arrangements between the NCA and UoM. A five-year investment plan is described below:
Purpose Band WTE 20-21 21-22 22-23 23-24 24-25 TOTAL Institute Manager NHS 8a 1 £14,358 £58,582 £59,754 £60,949 £62,168 £255,811 Institute Administrator NHS 4 0.5 £7,438 £30,347 £30,954 £31,573 £32,204 £132,515
Research Lab Manager* NHS 7 1 £13,057 £53,274 £54,339 £55,426 £176,097
Institute Research Fellowship** UoM 6 1 £13,914 £56,770 £57,905 £59,063 £187,652 MR Physicist UoM 6 1 £13,642 £55,659 £56,770 £57,905 £59,063 £243,039 Lab Technician UoM 4 1 £9,309 £37,979 £38,739 £39,513 £40,304 £165,843 Running costs (incl. marketing, events, £38,000 £39,000 £40,000 £41,000 £42,000 £200,000 IT & lab equipment, IP support, etc.) Hosting costs £3,750 £15,000 £15,000 £15,000 £15,000 £63,750 Total £86,497 £263,538 £351,260 £358,185 £365,227 £1,424,706 *1 year UoM funding from 1st Jan 2021; NCA ask thereafter **1 year R&I/HIM funding from 1st Jan 2021; NCA ask thereafter
The Institute will seek external funding (e.g. UKRI, NIHR, philanthropic, charitable) for additional clinical academic positions to lead key elements of the Institutes research programme. The target number of posts over 5 years is ten, with additional focus on securing external PhD support and development Fellowships for talented early career researchers.
Beyond 2025, the Institute aims to be self-funded through external sources of funding such as grant & trial income, commercial and academic partnerships, charitable & philanthropic income and through the commercialisation of new treatments, as appropriate. In Spring 2021 an applicationNCA will # be274090 made to UMRI (University Manchester Research Institutes) to provide support for development of09/25/2020 the Institute. This10:33:46 will include costs for the Institute Manager and for networking and communication activities. Some recovery of costs detailed above is therefore possible.
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5/7 134/163 Enablers/dependencies
In addition to continued access to the existing research infrastructure described earlier (see Context), to realise its full potential, The Geoffrey Jefferson Institute for Brain Research would benefit from a commitment from the NCA Executive Board for:
Access to: o the planned NCA early phase clinical trials unit o MRI scanner for research scans o informatics and machine learning/data engineering PACs/Imaging support for data transfers between UoM and SRFT Co-location of research, pathology, brain bank and tissue repository in the Clinical Sciences Building Targeted and strategic use of internally awarded neuroscience Consultant PAs Targeted and strategic approach to allocating neuroscience research trainee fellowships, in collaboration with the Institute The development of themes to be included in the BRC 2022 bid and the establishment of a CRF at SRFT as part of the Manchester NIHR CRF renewal Marketing the institute, including brand and website development Prioritisation of philanthropic endeavours to support the Institute A launch event on 29th Jan 2021, with a drive to target major philanthropic investment and inform key funders of our ambition
Return on Investment
The primary return on investment will be the development of new treatments and interventions which will improve outcomes and transform lives. We have already proven we can achieve this, through effective collaboration between NCA and UoM (Tyrrell/Rothwell), developing the anti-inflammatory drug anakinra for stroke. This is currently in Phase 3 trial for subarachnoid haemorrhage. If trial results are positive, Anakinra will become the first ever treatment for stroke, other than thrombolysis. This has however taken over 25 years to get to this stage, a timeline that could have been dramatically shortened had an Institute as proposed here been in place.
The Institute also expects to generate significant additional income from grant funding bodies, charities, philanthropy and commercial partners, as well as securing externally funded Centre Status in at least one research area, which brings substantial international recognition and infrastructure support. Whilst predicting increases in charitable and philanthropic income are challenging, the return on investment through grant income, commercial trial income and external Centre Status (e.g. from the MRC) alone, by 2025, is expected to be:
Income Source SRFT Neurosciences Ambition by 2025 Expected Income 2025/26 Income 2019-20 NIHR Grants £175,576 Triple NIHR grant income £526,728 Research Capability Funding £49,161 Triple RCF funding £147,483 Commercial Trials £268,377 20% growth year on year £667,807 Secure one externally External Centre Funding £0 Est. £5 million over 5 years funded Centre Status NCA # 274090 09/25/2020 10:33:46
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6/7 135/163 Benefits & Impact
The Institute will discover and develop new treatments through an ongoing programme of innovative research, with a focus on developing novel interventions in-house thus maximising commercial opportunities. In addition, the Institute will look to implement new technologies for patient diagnosis and treatment and to apply evidence based approaches for improved care and rehabilitation. Through these approaches the institute aims to improve the lives of patients in GM and beyond by:
significantly reducing the harm caused by brain tumours, thus improving survival and quality of life reducing damage to the brain after stroke, thus improving recovery for patients accelerating the deployment of new approaches for diagnosis and treatment of disease
In achieving the above, as well as having impact on the lives of patients, their carer’s and families, it will showcase the NCA, UoM and GM as a leader in translational neuroscience research; thereby enhancing our profile and reputation. This will have the knock-on effect of attracting high calibre clinicians and scientists and retaining our brightest talent, allowing us to broaden the scope of our research and continually improve future healthcare.
Key Risks
If investment cannot be secured to establish and grow The Geoffrey Jefferson Institute for Brain Research, then NCA/UoM will not realise its potential to be at the forefront of neurosciences translational research and will not become an internationally recognised Centre of Excellence. This will impact:
a) Patient outcomes and access to new treatments/interventions b) Opportunities for income generation c) Recruitment and retention of high calibre clinicians and scientists d) Overall profile of the organisation.
Recommendations
CIC is asked to:
Support the creation of The Geoffrey Jefferson Institute for Brain Research Note the investment required to establish the Institute Note the requirement to formalise the partnership arrangement between the UoM and NCA Confirm support for the enabling functions described within the proposal
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7/7 136/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Chairman’s Report from the Group and Salford Royal NHS Council Title of Report of Governors Meeting on 23rd September 2020
Meeting Group Board (Committees in Common) Author (s) Rebecca McCarthy, Deputy Trust Secretary Presented by Jim Potter, Chairman Date 28th September 2020
Executive This paper provides the Group Board with a summary of the key issues Summary discussed and the decisions made at the meeting of the Group Council of Governors and Salford Royal NHS Foundation Trust Council of Governors meetings held on 23rd September 2020.
Annual Plan N/A Objective Associated Risks N/A
Recommendations The Group Board is asked to review and confirm the information provided.
Equality Does this paper relate to a matter where equality issues may arise? N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and Information can be made available to the public. X Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
NCA # 274090 09/25/2020 10:33:46
1/4 137/163 Group Council of Governors – 23rd September 2020
The Trust’s Chairman presided over the meeting and 21 governors were present. The Deputy Chief Executive/Chief Medical Officer and Group Secretary supported the meeting.
The Chief Delivery Officer, Chief Financial Officer, Chief Nursing Officer, Chief Strategy Officer, Chief People Officer, Chief Officer Oldham Care Organisation, Director of Nursing Salford Care Organisation, Deputy Group Secretary, Membership and Public Engagement Manager, Engagement & Corporate Services Officer and 5 Non-Executive Directors were in attendance.
1. Declarations of Interest – No interests were declared.
2. Minutes of the Previous Meeting – Approved as a correct record.
3. Matters Arising - None
4. Group Transaction – Presentation The Chief Financial Officer provided comprehensive update of the Group Transaction reaffirming key benefits, financial solution, impact of Covid-19 and the recovery plan and next steps.
5. Summary Performance Report Governors received a presentation on key performance indicators from the NCA Performance Scorecard and Phase 3 Recovery Planning.
6. People Plan - Presentation The Chief People Officer provided an overview of the NCA’s People Plan including the impact of Covid-19.
7. Research & Innovation Strategy Update – Presentation Governors received update on key facets of the Research & Innovation 5 Year Strategy.
8. Reports from the Nominations, Remuneration and Terms of Office Committee
- Performance review of the Chairman 2019/120 – Approved - Performance Review of the Non-Executive Directors 2019/20 – Approved. - Re-appointment of Non-Executive Directors – Approved - Review: Remuneration of Non-Executive Directors including the Chairman – Approved
9. Governance - Shadow Group Council of Governors Terms of Reference – Approved - Annual Members Meeting 2020 – Arrangements & Draft Agenda – Approved - Report from Audit Committee – July 2020 – Reviewed and confirmed - Process: External Auditor Appointment – Approved. Governors were encouraged to express an interest in joining the Audit Working Group for this procurement process.
10.Proposed Changes to the Foundation Trust’s Constitution - Future Membership Structure and Composition of the Council of Governors following the briefing paper and workshop – Approved the final proposal - Proposed changes to the Foundation Trust’s Constitution – Approved
11.Annual Report & Accounts 2019/20 – Received. NCA # 274090 09/25/2020 10:33:46
2/4 138/163 12.SRFT External Auditors Report – Governors received the outcome of the External Audit 2019/20.
13. Action Sheet – Reviewed as progressing appropriately
14. Any other business – No other business
15.Message from Governors to the Chairman – The Lead Governor conveyed a farewell and message of thanks to the Chairman wishing him well in his forthcoming retirement.
16. Date and Time of Next Meeting: Group Council of Governors followed by Salford Royal NHS Foundation Trust Council of Governors Meeting Monday 7th December 2020 at 2.00pm, MS Teams
17. Papers for Information:
Governor Election Briefing Report Group Board Performance Scorecard PAHT Annual Report & Accounts: https://www.pat.nhs.uk/about-us/annual-reports.htm PAHT External Auditor Annual Audit Letter NRTO Committee Minutes – 16th September 2020
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3/4 139/163 Salford Royal NHS Foundation Trust Council of Governors – 23rd September 2020
The Trust’s Chairman presided over the meeting and 9 governors were present. The Deputy Chief Executive Officer/Chief Medical Officer and Group Secretary supported the meeting.
The Chief Delivery Officer, Chief Financial Officer, Chief Nursing Officer, Chief Strategy Officer, Chief People Officer, Director of Nursing - Oldham Care Organisation, Director of Nursing - Salford Care Organisation, Deputy Group Secretary, Membership and Public Engagement Manager, Engagement & Corporate Services Officer and 5 Non-Executive Directors were in attendance.
1. Declarations of Interest – No interest declared.
2. Minutes of the previous meeting held on 23rd June - Approved as correct record
3. Matters arising – No matters arising.
4. Shadow Group Council of Governors of Governors Terms of Reference - Approved
5. Annual Members Meeting Agenda 2020 - Approved
6. Outcome: Performance Review of the Chairman 2019/20 - Approved
7. Outcome: Performance Review of Non-Executive Directors 2019/20 - Approved
8. Reappointment of Non-Executive Directors - Approved
9. Remuneration of Non-Executive Directors including the Chairman - Approved
10. Future Membership Structure and Composition of the Council of Governors - Approved
11. Proposed Changes to the Trust’s Constitution - Approved
12. SRFT Council of Governors to confirm receipt of SRFT Annual Report and Accounts 2019/20 and External Auditors Reports – Received.
13. Any other business - No other business
14. Date and Time of Next Meeting: Group Council of Governors followed by Salford Royal NHS Foundation Trust Council of Governors Meeting: Monday 7th December – 2pm, MS Teams
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4/4 140/163 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Report from Audit Committee – 30th July 2020
Meeting Group Board (Committees in Common) Author Rebecca McCarthy, Deputy Trust Secretary Presented by Tim Crowley, Chairman of Audit Committee Date 28th September 2020
Executive A summary is provided for the Group Board of the key matters and decisions Summary from the Audit Committee meeting on 30th July 2020. Annual Plan N/A Objective
Principal N/A Associated Risks
Recommendations The Group Board is asked to review the summary and the agreed actions from the meetings held on 30th July 2020
Equality Does this paper relate to a matter where equality issues may arise? No Freedom of This document does not contain confidential information and can Information be made available to the public. X Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
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1/3 141/163 Summary of Group Audit Committee meeting held on 30th July 2020
Present: Mr Tim Crowley, Chairman of Audit Committee Mr Kieran Charleson, Non-Executive Director Mrs Carmen Drinkwater, Non-Executive Director Mrs Chris Mayer CBE, Vice-Chair Professor Chris Reilly, Senior Independent Director
Attendance: Mr Chris Brookes, Chief Medical Officer Mrs Jane Burns, Director of Corporate Services/Group Secretary Mr Darrell Davies, Assistant Director, MIAA Mrs Sarah Dowbekin, Internal Audit Engagement Manager, MIAA Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer Mr Ian Moston, Chief Financial Officer Mr Stephen Nixon, Engagement Manager, External Auditor Mrs Nicky Tamanis, Deputy Chief Financial Officer Ms Nicky Clarke, Chief of People Mr John Llewellyn, Chief Information Officer Mr Richard Wakefield, Chief Technical Officer
Apologies: Dr Hamish Stedman, Non-Executive Director Mr Mark Heap, Engagement Lead, External Auditor
1. Cyber Security Governance: Covid-19 – Reviewed cyber security arrangements in place across the NCA, including resources, technology and processes employed by the Digital Team to manage cyber security.
2. Internal Audit Progress Report & Work Plan 20/2120 – Reviewed all remaining audit findings, including key themes, and management actions from the 2019/20 internal audit plan, and an update on the 2020/21 Internal Audit Plan.
3. Internal Audit Outstanding Digital Actions Review – Received the outcome of a review of all outstanding digital audit actions to ensure actions were being tracked, actioned and reported. Confirmed adequate processes were in place to address the outstanding audit issues
4. Anti- Fraud Progress Report – Reviewed and confirmed counter fraud work that had taken place during Quarter 1 2020/21, including the work that had specifically taken place in light of Covid-19.
5. Review of Arrangements by Which Staff Raise Issues – Reviewed and confirmed arrangements in place by which staff raise issues. The report provided assurance to Audit Committee with respect to the means by which staff can raise issues in confidence about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.
6. People/Human Resources (HR) Governance: Covid-19) – Reviewed and confirmed self- assessment and compliance against a checklist, developed by MIAA, in response to a number of guidance documents that had been published during the Covid-19 pandemic in order to support organisations to manage people issues. NCA # 274090 7. Group Board Assurance Framework/Corporate Risk Register: Selection of Risks for 09/25/2020 10:33:46 Deep Dive – Selected the below risks for deep dive during 2020/21
4.2.1 If we fail to secure the capability, capacity and investment to undertake effective workforce planning then we will fail to deliver staffing for the clinical services strategy
2/3 142/163 1.1.1 If robust discharge to assess processes, and the implementation of a safe and reliable discharge service is not implemented across all localities then more hospital acquired harm will occur.
3.2.1 If restoration of critical non-COVID 19 services is not delivered and this is balanced with managing further COVID 19 waves then there is increased likelihood of patient safety harm and mortality incidents arising.
8. Group Governance Framework Manual (GGFM) Review – Reviewed and approved the revised GGFM ahead of presentation to Group Board for final approval.
9. Update: Declarations of Interest & Gifts & Hospitality– Reviewed and confirmed completion of actions including compliance check for Declarations of Interest and publication of Gifts & Hospitality Register during the Covid-19 pandemic.
10. Chief Financial Officer Report – Reviewed and confirmed information on a number of finance-related matters.
11. External Auditor Report Final SRFT Audit Findings Report & External Audit Opinion 2019/20 – Reviewed and confirmed. Final PAHT Audit Findings Report & External Audit Opinion 2019/20 – Reviewed and confirmed.
12. NAAS Thematic Analysis – Reviewed overview of actions taken in regards to the NAAS accreditation system during the Covid-19 response, including the interim process of ‘mini- assessments’ during the recovery phase and a thematic analysis of the non-compliant elements of the NAAS.
13. CQC Mock Inspections – Infection Control - Findings and key actions from the targeted CQC mock inspections against the CQC Emergency Framework, Infection Prevention Control (IPC) Board Assurance Framework and the Infection Prevention and Control CQC Key Lines of Enquiry.
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3/3 143/163 The Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Report from Audit Committee – 24th September 2020
Meeting Group Board (Committees in Common) Author Rebecca McCarthy, Deputy Trust Secretary Presented by Tim Crowley, Chairman of Audit Committee Date 28th September 2020
Executive A summary is provided for the Group Board of the key matters and decisions Summary from the Audit Committee meeting on 24th September 2020. Annual Plan N/A Objective
Principal N/A Associated Risks
Recommendations The Group Board is asked to review the summary and the agreed actions from the meetings held on 24th September 2020
Equality Does this paper relate to a matter where equality issues may arise? No Freedom of This document does not contain confidential information and can Information be made available to the public. X Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
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1/3 144/163 Summary of Group Audit Committee meeting held on 24th September 2020
Present: Mr Tim Crowley, Chairman of Audit Committee Mr Kieran Charleson, Non-Executive Director Mrs Chris Mayer CBE, Vice-Chair Mr Jim Potter, Chairman (By invitation) Professor Chris Reilly, Senior Independent Director Dr Hamish Stedman, Non-Executive Director
Attendance: Mr Howard Bethall, Head of Transitional Service & Stabilisation Mrs Jane Burns, Director of Corporate Services/Group Secretary Ms Nicky Clarke, Chief of People Mr Darrell Davies, Assistant Director, MIAA Mrs Sarah Dowbekin, Internal Audit Engagement Manager, MIAA Mr Joe Lever, Group Director of Procurement Ms Siobhan Moran, Director of Quality Improvement Mr Ian Moston, Chief Financial Officer Mr Stephen Nixon, Engagement Manager, External Auditor Mr Mark Stocks, External Auditor
Apologies: Mr Chris Brookes, Chief Medical Officer Mrs Carmen Drinkwater, Non-Executive Director Mrs Elaine Inglesby-Burke CBE, Chief Nursing Officer
1. Transaction Risks Deep Dive – Deep dive of key issues and significant risks relating to the transaction.
2. Internal Audit Progress Report – Reviewed audit findings, including key themes, and management actions from the 2020/21 internal audit plan.
3. Internal Audit Follow Up Report – Reviewed and confirmed appropriate progress towards the implementation of recommendations made from internal audits.
4. Outstanding Digital Internal Audit Actions – Received and confirmed the governance arrangements to manage the outstanding digital internal audit actions.
5. Anti-Fraud Progress Report – Reviewed and confirmed counter fraud work that had taken place since July 2020, including the work that had specifically taken place in light of Covid-19.
6. Redundancy & Settlement Agreements Report – Reviewed redundancies or settlement agreements made during February – August 2020.
7. Group BAF Deep Dive Risk 4.2.1 IF we fail to secure the capability, capacity and investment to undertake effective workforce planning THEN we will fail to deliver staffing for the clinical services strategy
Audit Committee reviewed the risk and considered: How the risk has been identified/considered and scored The controls in place to mitigate the risk The assurances in place, seeking verification that the assurances are effective, robust and reliable Audit Committee made recommendation with respect to the strengtheningNCA of # assurances 274090 in place. 09/25/2020 10:33:46
8. Briefing - Transaction People Risk – Reviewed and confirmed appropriate ‘people’ risks in relation to the Transaction were in place.
2/3 145/163 9. Preparation: Group BAF Deep Dive Audit Committee considered the scope of the deep dive to take place at the next meeting with respect to: Risk 1.1.1 If robust discharge to assess processes and the implementation of a safe and reliable discharge service is not implemented across all localities then more hospital acquired harm will occur.
10. Statutory Responsibilities Assurance Report – High-level review of compliance with key statutory/regulatory requirements and roles. Confirmed appropriate arrangements in place throughout 2020/21 to date.
11. Self-Assessment: Key governance considerations for Audit Committee Chairs – Reviewed and confirmed self-assessment, acknowledging further work to describe lesson learning from changes to governance arrangements during Covid-19 and future action.
12. Chief Financial Officer Report – Reviewed and confirmed information on a number of finance-related matters.
13. Procurement Work Programme Progress Report – Reviewed and confirmed progress against the procurement work plan, including Covid-19 response and procurement performance.
14. Draft PAHT Quality Report 2019/20 Draft SRFT Quality Report 2019/20 Reviewed draft Quality Reports 2019/20 ahead of final approval in November 2020.
15. External Auditor Progress Report – Reviewed and confirmed.
Papers for Information - Audit Committee Work Plan 2020-21 - Addendum: Arrangements by Which Staff Can Raise Issues - Cyber Security Risk Row - Social Media Policy - Mock CQC Inspection Programme
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3/3 146/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Title of Report Summary: Group Executive Risk & Assurance Committee, August 2020
Meeting Group Board (Committees in Common) Author (s) Sian Hassel, Corporate Governance Officer
Presented by Raj Jain, Chief Executive Officer Date 28th September 2020
Executive A summary is provided of the key matters and decisions from the Group Risk & Summary Assurance Committee (GRAC) meeting held in August 2020.
Annual Plan N/A Objective Associated Risks N/A
Recommendations Group Board is asked to Review and confirm the outcomes of the Group Executive Risk and Assurance Committee meeting held in August 2020.
Equality Does this paper relate to a matter where equality issues may arise? N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. X
Please ‘cross’ one of This document contains some confidential information that would the boxes need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
NCA # 274090 09/25/2020 10:33:46
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1/8 147/163 Northern Care Alliance NHS Group Minutes of Executive Committee Meeting
Committee: Executive Group Risk & Assurance Committee Date/Time of Meeting: 26th August 2020 Venue: MS Teams
In attendance: Raj Jain, Chief Executive Officer (Chair), Chris Brookes, Chief Medical Officer/Deputy Chief Executive; Judith Adams, Chief Delivery Officer; Jym Bates, Senior Information Risk Owner; Jane Burns, Director of Corporate Services and Group Secretary; Jacqui Burrow, Director of Nursing Bury & Rochdale Care Organisation; Nicky Clarke, Chief People Officer; Paul Downes, Director of Patient Safety; Nicola Firth, Chief Officer/Director of Nursing, Oldham Care Organisation; Elaine Inglesby-Burke CBE, Chief Nursing Officer; John Llewellyn, Chief Information Officer; Lindsay McCluskie, Group Director of Capital, Estates and Facilities; Ian Moston, Chief Financial Officer; Tyrone Roberts (for Pete Turkington), Director of Nursing, Salford Care Organisation; Jack Sharp, Chief Strategy Officer; Andrew Stallard, Managing Director of Operations, Diagnostics & Pharmacy Group Business Unit; Steve Taylor, Chief Officer Bury & Rochdale Care Organisation; Emma Wright, Director of Business Intelligence & Information
Apologies: Jayne Downey, Group Director of Governance & Corporate Nursing
No Agenda Item Minute: Confirmation of information provided; Summary of Key discussion points; Agreed actions
1. Apologies As above
2. Declarations of None Interest 3. Approval: Minutes The minutes of the previous meeting, held on 20th July 2020, were approved as an accurate record subject to the following of Previous amendment: Meeting Item 2: Ophthalmology risk (Bury & Rochdale Care Organisation Statement of Assurance) - Reference to ‘clinical review’ to be changed to ‘diagnostic review’, in order to reflect the fact that the review covered both clinical and administrative elements.
4. Items Referred 4.1 Group Transaction: Consideration of the impact of the Transaction on our people from Audit Following consideration of the Board Assurance Framework (BAF) at Audit Committee in July, GRAC considered whether the Committee impact of the transaction on our people required inclusion as a risk. The Chief People Officer advised that a number of people risks had been identified on process for monitoringNCA compliance # 274090 with Fire the Transaction Risk Register, albeit did not require escalation to the Group BAF. On enquiry, the Chief09/25/2020 People Officer 10:33:46 confirmed that the Transaction Risk Register was comprehensive with respect to the identification of people risks and that an appropriate process was in place to consider and escalate risks where necessary.
2/8 148/163 Agreed Actions: - Review Transaction risk register and determine any risks to be reported to GRAC – Chief People Officer - Briefing note for Audit Committee, confirming the people risks identified on the Transaction Risk Register and confirmation that the impact on people has been included/scored appropriately – Chief People Officer
4.2 Fire Safety Triangulation: Fire Safety Internal Audit, Health & Safety Annual Report, PAHT Estates Due Diligence The Group Director of Capital, Estates and Facilities presented the Annual Fire Safety Statement of Assurance. The report detailed the work achieved over the last 12 months to enhance and enforce fire safety across the organisation, including the impact of Covid 19, with monthly monitoring via the Fire Safety Group (FSG).
Key discussion points included: GRAC discussed the requirement for effective fire responses, and the need for regular visibility at Care Organisation (CO) assurance committees with respect to Fire Marshall training. GRAC emphasised the importance of focussed attention on Fire Marshall training at both hospital and community sites, and requested that this be reviewed by the Care Organisations, with the reliability of processes documented in the CO Risk Registers. GRAC considered fire safety arrangements with respect to the NCA and North Manchester Care Organisation (NMCO) during the transaction period. On enquiry, GRAC was informed that NMCO’s assurance was still incorporated within the overall regular report to the FSG. It was agreed that, in future, a separate section would be produced for NMCO. The lack of alignment between the Fire Safety Internal Audit, the Health & Safety Annual Report and the PAHT Estates Due Diligence was highlighted and discussed by GRAC. It was acknowledged that the Annual Fire Safety Report must respond to the internal audit outcomes, with the current position of the recommendations checked for progress. The impact of COVID-19 and capacity constraints with respect to face-to-face fire safety training was discussed by GRAC. It was acknowledged that changes may be required to the training format to ensure compliance with mandatory training, while ensuring that the training itself remained effective.
Agreed Actions: - Check the current position of the Fire Safety internal audit recommendations/actions and ensure that the internal audit outcome is fully reflected in the Fire Safety Report - Group Director of Capital, Estates and Facilities - E&F Statement of Assurance to confirm how the NCA ensures reliability and compliance regarding fire training - Group Director of Capital, Estates and Facilities - Fire Officers to review and agree the mostNCA effective # 274090 method for mandatory fire training going forward - Group Director of Capital, Estates and Facilities09/25/2020 10:33:46
3/8 149/163 5. Group Board GRAC received and noted the Group Board Performance Scorecard, ahead of its presentation to Group Board. Performance Scorecard Key discussion points included: GRAC acknowledged performance information had not been received from Salford City Council in relation to Social Services since the onset of the pandemic. GRAC were advised that receipt of performance information was expected to recommence imminently, whilst receiving assurance that internal metrics had continued to be monitored throughout the pandemic. The Chief Nursing Officer queried data with respect to the nursing fill rate for Salford, and requested that each CO ratified data. GRAC discussed the percentage rise in C-Difficile at Salford Care Organisation (SCO), along with consideration of a trajectory/target baseline in the current year. GRAC discussed the importance of scrutiny to ensure that appropriate antimicrobial guidelines were being followed, and it was agreed that a proposal would be brought to the next meeting. The Chief Financial Officer noted the significant reduction in the figures for ‘Did Not Attend’ appointments where the appointment was virtual. GRAC confirmed medical suspension would be removed from the sickness absence data going forward
Actions agreed: - Present a proposal at the next meeting for monitoring reliability of compliance with Antimicrobial Stewardship, covering both COs and Community Services – Chief Medical Officer 6. Booking & The Chief Delivery Officer presented the Management of Planned Patients and Planned Care Process Improvement Progress Scheduling Report, including: an update on the progress of the action plan to support the management of follow up patients; changes to Update: the plan due to COVID-19, as well as the impact of COVID-19 on the progress being made; and the next steps for recovery Management of and restart of the new normal ‘business as usual’ (BAU) for the management of planned patients across the NCA. Planned Patients and Planned Care Highlights of the review and subsequent discussion included: Process Elements of the planned BAU process work would require additional investment and resource. This would be Improvement discussed via the CO finance committees and onward to the Executive Strategic Finance & Information Committee. Progress Report A Patient Safety Review Group had been established, with connection to effective waiting list management. The importance of clinical and CO involvement at this meeting was discussed and the Director of Patient Safety confirmed that membership would be reviewed at the first meeting. GRAC discussed the complexities and challenges affecting the effective management and standardisation of booking and scheduling across the NCA, noting there was no centralised booking team across the NES. Also considered by GRAC was the need to map the current processes and identify where digitisation and streamlining would be possible. The extensive re-organisation work that wouldNCA #be 274090required to address waiting list management was highlighted, and GRAC acknowledged current capacity constraints.09/25/2020 10:33:46 On enquiry, it was confirmed that a waiting list management audit was included on the Internal Audit schedule.
4/8 150/163 Actions agreed: - Confirm the most recent Waiting List Management Internal Audit to the next meeting of GRAC – Director of Corporate Affairs - Review the risk score assigned to waiting list management for SCO - Director of Nursing, Salford Care Organisation
7. Estates & Facilities The Group Director of Capital, Estates and Facilities presented the Estates & Facilities Statement of Assurance and Board Statement of Assurance Framework, for GRAC’s information and assurance. Also included were the annual plan objectives. Assurance & Board Assurance Key discussion points included: Framework GRAC discussed master planning in detail, with particular focus on current gaps in controls and whether the risk scores accurately reflected the current position. It was agreed that, while the current score accurately reflected those elements controlled by E&F, there was a need for the overall risk – covering both E&F and those elements controlled by the COs – to be held in a single BAF in order to allow a full view of the overall position. Following detailed discussion, it was agreed that this would be held on the E&F BAF, acknowledging elements of the risk were controlled by COs. Also highlighted was the need to be aware of the wider system when considering master planning. A wider discussion was held by GRAC regarding risks that were disaggregated across CO/Departments and that consideration must be given to ensuring the totality of the risk was visible. GRAC reviewed the most significant risks on the E&F BAF, including delayed sustainability work; financial stability with including the impact of COVID-19 on income streams; and concern regarding ‘single points of failure’ in a number of areas. GRAC were informed that work was taking place to address the single points yet this remained a key risk. The Director of Corporate Services and Group Secretary recommended that the risk score be reviewed in light of controls in place, and E&F was also asked to consider inclusion of fire safety within the E&F BAF.
Agreed Actions: Master Planning risk to be included in the E&F BAF, including acknowledgement that elements of the risk are controlled by COs - Group Director of Capital, Estates and Facilities Consider most effective way to centralise cross-cutting risks in the NCA – Chief Delivery Officer
8. Digital Statement The Chief Information Officer presented the Digital Statement of Assurance for the GRAC’s assurance and review. of Assurance Highlights of the review and subsequent discussion included: The progress of the digital work related to the transaction was discussed, and it was agreed that the risks specific to the transaction would be included as a separateNCA # section.274090 GRAC discussed two significant risks related09/25/2020 to compliance 10:33:46 with mandated standards; and resourcing against demand. GRAC received update with respect to work in progress in relation to the stabilisation of infrastructure and noted that work was on-going via the Executive Digital Health & Enterprise Committee (EDHEC) to understand and
5/8 151/163 map the source of the demand, and place it in the context of the NCA’s transformation aspirations. GRAC considered the underlying drivers and controls for the resourcing risk in further detail, noting the key importance of a stable digital foundation when pursuing major transformational change, as well as the wide-ranging impact from any failure in core digital functions. After discussion, it was agreed that the critical focus for digital would be prioritisation and that, following an upcoming planned discussion at Executive Management Committee, the Digital Annual Plan objectives and deliverables would be revised and brought to the next meeting of GRAC. GRAC confirmed significant risks from the Digital SoA would be monitored via the EDHEC agenda
The Chief Nursing Officer left the meeting at this point.
Actions agreed: Present the Digital Annual Plan to the next GRAC meeting - Chief Information Officer
9. Diagnostics & The Managing Director of Operations, Diagnostics & Pharmacy Group Business Unit (D&P), presented the D&P Statement of Pharmacy Assurance, including a summary of the risks, key actions and progress in mitigating these risks. Five risks with a score of 12 Statement of were highlighted, including a new risk associated with D&P’s governance arrangements; particular attention was given to the Assurance PCR testing capacity risk, along with the actions underway to address this. Two emerging risks were also noted, both currently scored as 11 and both related to D&P’s response to COVID-19 recovery.
Key discussion points included: GRAC discussed the wider GM, regional and national programmes with respect to testing, and importance of engagement. GRAC requested the governance risk was reviewed in further detail.
Actions agreed: - Review the governance risk on the D&P BAF, and provide an update to the next GRAC – D&P Managing Director of Operations/ Director of Corporate Services and Group Secretary
10. Oldham Care The Chief Officer/Director of Nursing, Oldham Care Organisation, presented the OCO Statement of Assurance. Key matters Organisation of discussion included service provision continuity and general surgical services. (OCO) Statement of Assurance 11. Salford Care The Director of Nursing, Salford Care Organisation (SCO), presented the SCO Statement of Assurance. GRAC received Organisation (SCO) information with respect to improvements in elective capacity, cancer, and endoscopy, albeit noted the challenges with Statement of respect to further recovery. GRAC were informedNCA that #winter 274090 planning was underway, including the costing of schemes and Assurance prioritisation of impact. The importance of on-going09/25/2020 and continuous 10:33:46 benchmarking and challenge of the NCA’s capacity and utilisation was highlighted by the Chief Delivery Officer.
6/8 152/163 12. Bury & Rochdale The Chief Officer, Bury & Rochdale Care Organisation (BRCO), presented the BRCO Statement of Assurance, summarising Care Organisation significant risks, and highlighting the increase from 12 to 13 for the risk relating to Ophthalmology waiting list management. (BRCO) Statement GRAC were informed that a diagnostic review was underway, and a first draft of the review was anticipated at the September of Assurance meeting of GRAC.
The BRCO Chief Officer highlighted the importance of the Rochdale Infirmary day-case unit with respect to operating recovery across the NCA. GRAC confirmed this would be reviewed further as part of the winter planning discussion due to take place at the following day’s Executive Management Committee meeting.
13. Group Board The Director of Corporate Services and Group Secretary presented the Group Board Assurance Framework/Corporate Risk Assurance Register for the GRAC’s information; confirming that the document had been presented to the Group Board (CiC) meeting in Framework/ July. Corporate Risk Register GRAC were informed that a review of the BAF format was currently underway, and would be discussed at Executive Management Committee.
A query was raised regarding the Salford ARC, and whether recent queries from the Treasury would affect the score. Following discussion, it was agreed that the score did not require any alteration at present.
14. Assurance The GRAC received and noted the Joint Highlight Summary Report from Executive Sub-committees, which provided Reports/Escalation assurance and updates from the July/August 2020 meetings of GRAC’s sub-committees. of Issues from Executive Subcommittees ‐ Joint Highlight Report 15. Referral of matters Two items were referred to Audit Committee: to Audit Committee - Waiting list management - GRAC to provide briefing note with respect to people risks within the Transaction Risk Register, confirming the process for review was comprehensive and that the impact on people has been included/scored appropriately.
16. Action Sheet GRAC reviewed and confirmed the action sheet.
17. Any Other COVID-19 NCA # 274090 Business GRAC was advised that there had been three episodes09/25/2020 of nosocomial 10:33:46 COVID-19 infection at NES Care Organisations. The Chief Medical Officer and Chief Nursing Officer provided assurance that they were working to support colleagues in managing the response, including adherence to the Infection Prevention & Control (IPC) principles. GRAC requested that CO provide
7/8 153/163 report to GRAC that the results from Reality Rounding were appropriately specific and that any actions were being formally monitored via the CO governance structures.
The Chief Medical Officer discussed the learning thus far from the review of the incidents.
Actions agreed: - CO Management Assurance Report to GRAC on how outcomes from Reality Rounding are being actioned and monitored – Care Organisation Chief Officers
IG Training The Senior Information Risk Owner requested that GRAC members request required colleagues to complete IG training, as failure to meet the 95% compliance standard would cause the NCA to fail the DSPToolkit. This would then lead to reduced ability to data share, reduced presence in GM and have a direct effect on CQC findings.
18. Date and Time of Monday 21st September 2020, 1pm – 2.30pm Next Meeting
NCA # 274090 09/25/2020 10:33:46
8/8 154/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Summary: Group Executive Risk & Assurance Committee, September Title of Report 2020
Meeting Group Board (Committees in Common) Author (s) Sian Hassel, Corporate Governance Officer
Presented by Chris Brookes, Deputy Chief Executive Officer Date 28th September 2020
Executive A summary is provided of the key matters and decisions from the Group Risk & Summary Assurance Committee (GRAC) meeting held in September 2020.
Annual Plan N/A Objective Associated Risks N/A
Recommendations Group Board is asked to Review and confirm the outcomes of the Group Executive Risk and Assurance Committee meeting held in September 2020.
Equality Does this paper relate to a matter where equality issues may arise? N If so, has due regard been given to equality analysis of any adverse impacts Freedom of This document does not contain confidential information and can be Information made available to the public. X
Please ‘cross’ one of This document contains some confidential information that would the boxes need to be redacted before the document was made available to the public.
This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
NCA # 274090 09/25/2020 10:33:46
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1/7 155/163 Northern Care Alliance NHS Group DRAFT Minutes of Executive Committee Meeting
Committee: Executive Group Risk & Assurance Committee Date/Time of Meeting: 21st September 2020 Venue: MS Teams
In attendance: Chris Brookes, Chief Medical Officer/Deputy Chief Executive (Chair); Judith Adams, Chief Delivery Officer; Jym Bates, Senior Information Risk Owner; Jane Burns, Director of Corporate Services and Group Secretary; Jacqui Burrow, Director of Nursing Bury & Rochdale Care Organisation; Nicky Clarke, Chief People Officer; Victoria Dickens, Director of AHPs; Paul Downes, Director of Patient Safety; Simon Featherstone, Director of Nursing Salford Care Organisation; Nicola Firth, Chief Officer/Director of Nursing, Oldham Care Organisation; Katie Foster-Greenwood, Director of Operations Salford Care Organisation; John Llewellyn, Chief Information Officer; Lindsay McCluskie, Group Director of Capital, Estates and Facilities; Ian Moston, Chief Financial Officer; Tyrone Roberts, Chief Officer Bury Care Organisation; Jack Sharp, Chief Strategy Officer; Andrew Stallard, Managing Director of Operations, Diagnostics & Pharmacy Group Business Unit; Steve Taylor, Chief Officer Bury & Rochdale Care Organisation; Emma Wright, Director of Business Intelligence & Information
Apologies: Raj Jain, Chief Executive Officer; Elaine Inglesby-Burke CBE, Chief Nursing Officer; Pete Turkington, Chief Officer, Salford Care Organisation.
No Agenda Item Minute: Confirmation of information provided; Summary of Key discussion points; Agreed actions
1. Approval: The minutes of the previous meeting, held on 21st July 2020, were approved as an accurate record. Minutes of Previous Meeting 2. Matters Arising Fire Safety: The Group Director of Capital, Estates and Facilities confirmed a paper was to be presented to Executive Management Committee (EMC), and onward to GRAC, addressing all matters raised with respect to ‘Fire Safety’ at the previous meeting. GRAC requested the paper was presented to GRAC in October 2020.
Waiting List Management – The Group Secretary confirmed the Internal Audit Plan 20/21 included the following audits: Group: Performance related reviews focusing on systems for the Management of Appointments and Care Organisation: Reviews of systems and processes for booking and Management of Appointments. The audit was at the planning stage, with the Chief Delivery Officer as the Group Executive Lead. GRAC were informed that internal audit would encompass all elements of waiting list management, including patient safety. GRAC noted the primary importance of identifying improvement within systems and processes to support capacity issues as reducing long waits was key to resolving patient safety issues.
3. Group Board The Group Secretary confirmed that the Group Board Performance Scorecard had been reviewed via the Executive Team, and included an Scorecard Executive Summary with commentary for each strategic priority and key KPI’s requiring focussed attention. GRAC thanked Mr Ivan Conyon for the work undertaken in this regard. The Group Secretary confirmedNCA # 274090that the Scorecard would be presented to Group Board on 28th September 2020, with comment from the Chief Officers regarding key risks09/25/2020 and mitigating 10:33:46 actions. Action: Group Secretary to disseminate the final Executive Summary and Group Board Performance Scorecard to GRAC members.
2/7 156/163 GRAC noted the criticality of standardisation of data to ensure flow via the Care Organisation governance frameworks through to the Group governance framework.
4. Care GRAC comprehensively reviewed the following Statements of Assurance, focused on the identification of all principal and significant Organisation operational risks, identification a target risk profile, assessment of the effectiveness of identified controls and appropriate assurances, Statements of identification of remedial actions to ensure actual risk change matches target profiling. Assurance Key discussion points from each Statement of Assurance (SoA) are described.
Capital, Estates and Facilities (CEF) Financial Control Total and BCLC Plans – GRAC were informed that management team restructure and additional processes for the identification, capturing and monitoring of cost pressures had been established.
Single Point of Failure – Following discussion in August 2020, GRAC received update on controls established to mitigate ‘single points of failure’ (specialist skills) within CEF.
GRAC discussed two cross-cutting risks: Estates Masterplanning and Sustainability which had been incorporated on the CEF Board Assurance Framework (BAF), however required Care Organisation (CO) and Corporate actions to address gaps in control.
Estates Masterplanning – GRAC acknowledged the key gaps in control and key mitigating actions; understanding of clinical service strategies for each site and CO representation at key masterplanning forums. GRAC acknowledged that the Salford SoA included an Estates Masterplanning risk scored 12, and considered this in light of the current CEF Estates Masterplanning risk scored 10. GRAC confirmed that the Salford CO risk referred specifically to capacity and demand challenges and remodelling work underway. The Chief Strategy Officer confirmed the Service Development Strategy (SDS) refresh was underway, including reassessment of site configuration, and would engage with the Director of CEF to ensure alignment.
Sustainability – GRAC requested that the risk description was broadened to incorporate additional elements of sustainability linked to the Anchor Institution and Social Value, again acknowledging the responsibilities for delivery on this agenda by CO’s and Corporate functions. In relation to this risk, GRAC were informed that an Executive Sustainability Committee was to be established, to drive the sustainability agenda. GRAC reviewed and approved the Executive Sustainability Committee Terms of Reference and requested CO representation was confirmed to the Chair (Chief Delivery Officer) of the committee ahead of the first meeting.
Digital GRAC discussed the key risk related to infrastructure and systems needing to be replaced or upgraded. GRAC were informed that work was on-going to set a Digital Annual Plan and BAF, based on the ‘must-do’s, with a prioritisation exercise taking place with CO and Group Business Units (GBU) to facilitate a holistic view. The Director of Operations for D&P described the importance of a single digital infrastructure for LIMs in this regard. Action: Digital Annual Plan to be presented in October 2020. NCA # 274090 Acknowledging capacity challenges, GRAC requested assurance09/25/2020 that systems 10:33:46 were in place to maintain compliance with mandated standards. The Chief Information Officer confirmed assurance with respect to his matter would be presented to Audit Committee in September 2020, confirming the remediation programme in place to stabilise the digital infrastructure and the systematic reporting and closure of risk in relation to each work stream as completed.
3/7 157/163 GRAC noted that a number of remedial actions to digital risks related to confirmation of capital investment, and sought view on the Q3 and Q4 position with respect to the release of capital and investment, and the subsequent action required to mitigate the risks. The Chief Financial Officer confirmed that the resources required to progress the digital work programmes, and the actions specific to progressing each work programme, were fully understood. He acknowledged that a decision had been made, as part of recovery planning, to prioritise an amount of capital for patient care, in place of the digital infrastructure.
GRAC noted that the Group BAF included 3 digital risks, which would be reviewed and aligned ahead of presentation of the Group BAF to GRAC in October 2020.
Diagnostics & Pharmacy GRAC discussed the intrinsic link in relation to the medical staffing and testing risks. GRAC suggested engagement with Corporate HR to accelerate and support required recruitment and suggested further consideration of how other colleagues may be utilised. GRAC emphasised the importance of connecting with those colleagues who had, and continued to, sustain significant pressure due to medical staffing challenges.
GRAC noted the step change in increased demand for testing, recognising that suitable testing capacity was a key enabler to patient flow and safety throughout the CO’s. GRAC specifically acknowledged the separate requirements and demand for both patient and staff testing, and suggested that this matter required further discussion and planning with respect to the management of both elements ahead of further increases in demand. GRAC recognised that the Testing Cell was conducting an assessment of demand and that internal management of testing systems was also under review.
GRAC confirmed the criticality of providing sufficient PCR testing capacity and rapid testing capacity to support the recovery and requested weekly update was provided to the EMC as part of the Phase 3 recovery update.
GRAC specifically noted the descalation of the long-standing interventional radiology risk following effective controls related to medical staffing.
Oldham Care Organisation (OCO) With respect to the mortality risk, GRAC recognised the stated effectiveness of controls, and the supporting mortality data, and sought further view on the continued risk scored of 12. The Chief Officer OCO acknowledged this challenge, expressing view that this reflected the, as yet unknown, impact of Covid-19 over forthcoming months. Acknowledging that risks are to be escalated and descalated in line with current position, the Chief Officer for OCO confirmed that this risk would be reviewed via the OCO Clinical Effectiveness Committee.
GRAC recognised the work taking place with respect to Endoscopy within Greater Manchester and confirmed the importance of focussed attention on this matter via weekly update to the EMC.
GRAC discussed further action required to mitigate the risk associated with mandatory training, noting key gaps in control relating to the maintenance of accurate mandatory training records and challenge in accessing mandatory training as this was stepped back up. GRAC were informed that a review of system data had confirmed a significantNCA # level 274090 of accuracy with respect to manual training records; however the challenge in room availability to conduct socially distanced face09/25/2020 to face training 10:33:46 was a challenge for all CO’s.
Salford Care Organisation (SCO) GRAC requested further information regarding the Adult Social Care (ASC) and Mental Health overspend, specifically requesting confirmation
4/7 158/163 that SCO had appropriate visibility of ASC information/metrics in order to coordinate improvement action. Additionally, GRAC noted that ASC metrics included within the Group Performance Scorecard must be fit for purpose, with revision of metrics required in this regard. The Chief Officer for BRCO confirmed that, via the Community Board, the Director of Adult Social Care (SCO) was leading work, in contact with the Director of Adult Social Care (OCO), to determine appropriate metrics and KPI’s to be monitored at Care Organisation and Group level. Action: GRAC requested confirmation of this work in October 2020.
With respect to elective surgery, GRAC sought confirmation that all alternative options, including utilisation of Rochdale site, had been fully considered. The Director of Operations, SCO confirmed that comprehensive review of all options had been undertaken, highlighting the detailed triggers that were being piloted to support agile escalation and de-escalation for independent sector usage for certain specialties. GRAC emphasised the importance of stress testing plans for winter preparedness, paying attention to thresholds. GRAC requested all CO’s completed this work and provided report via EMC.
The Director of Operations, SCO provided contextual information regarding the risk associated with the digital control centre programme of work, specifically highlighting the significant workforce/resource requirements needed to roll out the infrastructure operational management system.
Bury & Rochdale Care Organisation (BRCO) GRAC received an update on the disaggregation of the BRCO, confirming work remained on track.
With respect to nutrition and hydration, GRAC emphasised the importance of all staff following policy and sought further information regarding assurances received in this regard. The Director of Nursing BRCO confirmed that this matter pertained to both nursing and medical staff, informing GRAC that, notwithstanding positive evidence gathered via walkarounds, a review of compliance via monthly audit had confirmed that the relevant nutrition and hydration policy was not implemented by all staff on every occasion. GRAC were informed that all nursing staff had been required to confirm that they had read the policy and suggested that this level of assurance was undertaken for all medical staff.
GRAC comprehensively discussed the importance of focussed attention on emergent harms as a result of Covid-19, as discussed comprehensively via the Executive Quality Committee. GRAC sought further update with respect to the extent to which harms associated with nutrition and hydration were still evident at BRCO. The Director of Nursing BRCO confirmed that, although an improving picture, patient safety data indicated harms were still taking place accentuated by the significant ward changes at the Fairfield General Hospital.
GRAC clarified the current control score (4); and mindful of the organisation’s risk appetite whereby risk to patient safety was not tolerated, requested focussed attention over the forthcoming weeks to ensure controls were in place and appeared to be effective. The Director of Nursing for BRCO acknowledged this directive and confirmed controls, including processes and structures within the CO, had now commenced within the BRCO including the nutrition review panel. The Chief Officer for BRCO confirmed a target risk score of 10 by the end of the quarter.
GRAC were informed that the SCO would provide peer review with respect to Emergency Department plans, specifically with respect to deflections. In addition, GRAC noted that processes for managing waiting lists were being developed and reviewed to address current deficits and that these would be submitted to and monitored via theNCA improvement # 274090 wall. 09/25/2020 10:33:46 5. Ophthalmology GRAC received a report providing overview of the current position of the Ophthalmology service, detailing the risks associated with the waiting Diagnostic list size, length of wait times and the associated actions that are being taken as part of a wide scale review of all elements of the Review Ophthalmology service.
5/7 159/163 GRAC acknowledged that a deep dive into all previous improvement plans and report recommendations had taken place in order to ascertain the level of changes that had been embedded and those that were outstanding. GRAC requested confirmation with respect to how the BRCO will ensure reliable and resilient system improvement and learning from previous reviews.
GRAC recognised that the potential risk of sight loss for patients as a result of waiting for treatment and, acknowledging the significant impact on quality of life, requested that the Recovery Plan specifically addressed the management and prioritisation of patient cohorts at the highest risk and associated timeline. Action: Recognising the urgency of this matter, GRAC requested further update in October 2020 including progress against key milestones.
The AHP Director highlighted the support offered from the Community Eye Team to this work. The Chief Officer for BRCO welcomed this support and confirmed engagement in the pathway redesign.
6. Learning from GRAC received the Learning from Deaths Report including: Deaths Key learning from deaths during Q1 2020/21 Mortality governance arrangements update Confirmation that 60% of Structured Judgement Reviews (SJRs) have been completed from across Q3 2019/20, Q4 2019/20 and Q1 2020/21, a reduction on the last reporting period. Covid-19 Crude mortality data and key learning identified in relation to acute frailty services Update on the deep dive mortality review undertaken at Fairfield General Hospital National Mortality Benchmarks (HSMR & SHMI)
The Chief Nursing Officer confirmed that the Learning from Deaths Report had been comprehensively reviewed via the Executive Quality Committee. She confirmed the specific intention of identifying learning and potential new/different harms occurring as a result of the necessary rapid changes taking place due to Covid-19. She highlighted that a paper detailing Harm Reduction and Safety Improvement would be presented to Group Board, emphasising triangulation of harm and mortality data.
GRAC discussed the importance of clearly articulating and demonstrating key learning and improvement actions that have been embedded in relation to themes identified via Structured Judgement Reviews.
7. Process for In August 2020, GRAC discussed the importance of scrutiny to ensure that appropriate antimicrobial guidelines were being followed. The Monitoring Director of Nursing, SCO, detailed the process embedded within the Salford Care Organisation (SCO), including a monthly antimicrobial Antimicrobial stewardship audit and application of results via the monthly Antimicrobial Steering Group. This provided assurance that SCO aligns with the Stewardship principles of the National Toolkit on Antimicrobial Stewardship ‘Start Smart then Focus’ published by PHE in 2011 and updated in 2015. GRAC were informed that across SCO and the NES two separate antibiotic guidelines are currently in place, with work underway to harmonise Antimicrobial Guidelines, with an NCA antibiotic guideline group established to progress this work. NCA # 274090 GRAC acknowledged factors that may contribute to increased09/25/2020 antibiotic prescribing, 10:33:46 including virtual appointments in the community. The Director of Nursing, SCO, confirmed that this would be monitored and discussed with system partners in order to determine a unified approach where required.
6/7 160/163 8. Reality GRAC received confirmation that all Care Organisations had implemented Infection Prevention Control (IPC) reality rounding. An overview of Rounding the reality rounding schedule for each Care Organisation and processes used for leadership to gather intelligence about IPC guidance was Assurance provided, alongside key findings from reality rounding/other local processes and associated changes. Report The Chief Officer for Bury Care Organisation confirmed that a nosocomial infections IPC Collaborative had commenced at the end of June, with CO and Departmental Leadership Teams due to meet with the Chief Nursing Officer to confirm metrics for audit, frequency, and administrators of the audit. GRAC requested that the outcome of the audits should be presented to the weekly IPC Meeting and onward Executive Quality Committee. The Chief Officer for Bury Care Organisation confirmed the intention for this to also be reported via CO governance committees.
9. Statutory GRAC received a high-level review of compliance with key statutory/regulatory requirements and roles, during the period of the Covid-19 Responsibilities pandemic, providing overview and assurance that, against the requirements listed, appropriate arrangements had been in place throughout & Requirements 2020/21 to date. Assurance Report GRAC reviewed the information provided and confirmed that no further assurance was required at this time.
10. Executive A summary of the key risks and assurances, including any actions and/or decisions from the Executive Subcommittees in August/September Subcommittee 20 was provided. Highlight Report Executive Quality Committee: The Chief Nursing Officer confirmed an update on harms had been received from each Care Organisation, including the extent to which harms had changed, with further work to be presented to GRAC and Group Board as described above.
11. Referral of No matters for referral. matters to Audit Committee 12. Action Sheet GRAC reviewed and confirmed appropriate progress against all outstanding actions.
13. Any Other No other business. Business 14. Date and Time of Monday 19th October 2020, 1pm – 4.00pm Next Meeting
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7/7 161/163 Northern Care Alliance NHS Group Salford Royal NHS Foundation Trust (SRFT)
Report from SRFT Charitable Funds Committee – 6th August 2020 Title of Report and 3rd September 2020
Meeting Group Board (Committees in Common) Author (s) Sian Hassell, Corporate Governance Co-ordinator
Presented by Kieran Charleson, Chairman of Charitable Funds Committee Date 28th September 2020
Executive A summary is provided of the key matters and decisions from the SRFT Summary Charitable Funds Committee meeting held on 3rd September 2020, and the extraordinary meeting held on 6th August 2020. Recommendations The Group Board is asked to review and confirm the summary of the SRFT Charitable Funds Committee meetings on 6th August and 3rd September 2020.
Equality Does this paper relate to a matter where equality issues may arise? No Freedom of This document does not contain confidential information and Information can be made available to the public. X Please ‘cross’ one of the boxes This document contains some confidential information that would need to be redacted before the document was made available to the public. This document is entirely confidential, as the redaction of confidential information would render the document meaningless.
Extraordinary Meeting – held on 6th August 2020
1. Charitable Funds Bid – Da Vinci Surgical Robot Reviewed and approved the proposal to purchase a surgical robot from charitable funds, to be used at Salford Royal Hospital, at a cost of £1,729,349 excluding VAT. Additional assurance regarding wide-ranging support for the purchase, and suitability of the proposal for charitable funding, to be provided outside the meeting.
Meeting held on 3rd September 2020
1. Finance Reports: − PAT − SRFT Reviewed and confirmed the draft income and expenditure positionNCA and # 274090the balance sheet position for the three months to 30 June 2020 with respect to Charitable09/25/2020 Funds for10:33:46 the respective statutory bodies.
1/2 162/163 2. Investment Portfolio Report - PAHT - SRFT Received and noted the Investment Portfolio Reports for SRFT and PAHT. Additional benchmarking information also received. The SRFT CFC acknowledged the significant changes in the economic environment since March 2020, and the assurance and confidence provided by the two investment portfolio updates.
3. Fundraising Strategy Implementation Progress – Update Received and discussed a presentation on current progress in mobilisation of the Fundraising Strategy in light of the COVID-19 pandemic. Presentation included updates on the mobilisation timeline; financial progress; progress with developing the branding for the charity; the current fundraising focus; an update on work taking place around fundraising appeals; expenditure of COVID-19 funds; phase 2 of the COVID-19 NHSCT funding process; and planned next steps. Proposed branding concepts for the charity were discussed in detail.
4. Draft Charity Annual Reports and Accounts Received and noted the contents of the draft Annual Report and Accounts, along with the timetable for audit and submission to the Charities Commission.
5. Surgical Robot: Governance Processes for Funding Update paper on governance processes used for the Surgical Robot bid received and noted.
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