Bolton NHS Foundation Trust – Board Meeting October 31St 2013 Location: Board Room Time: 0900 – 1300 Hrs

Bolton NHS Foundation Trust – Board Meeting October 31st 2013 Location: Board Room Time: 0900 – 1300 hrs

Time Topic Lead Process Expected Outcome 0900 1. Patient Story verbal Patient story and learning points noted 0920 2. Apologies for Absence – Trust Sec. verbal Apologies noted

3. Declarations of Interest Chairman verbal To note any declarations of interest in relation to items on the agenda

4. Minutes of meeting held 26 September 2013 Chairman Minutes To approve the previous minutes

5. Action sheet Chairman Action log To note progress on agreed actions

6. Matters arising Chairman verbal To address any matters arising not covered on the agenda

0930 7.1 Chairman’s Report Chairman verbal to receive a report on current issues

7.2 Reportable issues log CEO verbal To receive a report on any reportable issues including but not limited to SUIs, never events, coroner reports and serious complaints Safety Quality and Effectiveness 0945 8. Integrated Performance Report MD Report – enc To note and receive the integrated performance report

9. Mortality Report MD Report – enc To receive the regular mortality report

10. Pressure Ulcer Strategy DoN Report – enc To approve the new pressure ulcer strategy

11. Winter Plan COO Report – enc To approve the Winter Plan

12. Transparency in Care DoN Report – enc To approve involvement in the Phase 2 of the NHS North Transparency project Strategy 11.00 13. Towards a digital trust CIO Presentation To approve the proposal for the development of EPR and EDMS

14 Timetable to communicate the new strategy Dir Strat & Briefing To note the proposed timetable for the communication of the long Imp term strategy

Time Topic Lead Process Expected Outcome Governance 11.30 15 Board Assurance Framework Trust Sec Report – enc To receive the Board Assurance Framework and note the risks to the achievement of the Trust’s strategic objectives 16 Q2 Declaration to Monitor Trust Sec Report – enc To approve the Q2 declaration and note the introduction of the RAF 17 Changes to the Constitution Trust Sec verbal To consider a minor amendment to the constitution ahead of placing a formal proposal to the Annual Members meeting 12.00 18 Membership of AHSN Dir Strt and Report – enc To receive a six-month update on the benefits of AHSN Membership Imp Finance 12.15 19 Month 6 Finance Report DoF Report – enc To receive an update on the current financial position. For Information Chair reports of the following sub-committees will be noted – if any member of the Board wishes to raise a question regarding one of these items they should indicate this before the start of the meeting. 12.40 20 Finance and Investment Committee – Chair Report (meeting held -29th October 2013) – verbal 21 Quality Assurance Committee – Chair Report (meeting held 9th October 2013) – enclosure 22 Audit Committee – no meetings held during the reporting period 23 Charitable Funds Committee – enclosure 24 Any other business 2 Questions from Members of the Public 3 1250 25 To respond to any questions from members of the public that had been received in writing 24 hours in advance of the meeting. Resolution to Exclude the Press and Public To consider a resolution to exclude the press and public from the remainder of the meeting because publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted 1300 Lunch

Part Two

1330 1. Apologies for Absence Trust Sec To receive any apologies for absence 2. Declarations of Interest Chairman To receive any declarations of interest in items on the agenda 3. Minutes of the meeting held on 26th Chairman Minutes To confirm the minutes of the previous meetings September 2013 4 Matters arising Chairman Verbal to address matters arising from the minutes 5. Mandatory Training – sanctions to address Governance 1345 6.1 SUI – Bone cement DoN Report – enc To approve the final SUI report 6.2 SUI – wound packing DoN Report – enc To approve the final SUI report Finance and Strategy 1400 7. Market share report DoF Report – enc 1410 8. Focus on SLR DoF Presentation 1510 9. Corporate CIPs CEO Presentation Any Other Business 1530 Close

Next meeting Thursday November 28th 2013

Meeting Board of Directors Meeting Time 09.00 a.m. th Date 26 September 2013 Venue Boardroom Present:- Abbv.

Mr D Wakefield Chair DW Dr M Harrison Vice Chair Mrs C Davies Non-Executive Director CD Mrs G Ashworth Non-Executive Director GA Dr E Adia Non-Executive Director EA Mr A Duckworth Non-Executive Director Mr J Scott Chief Operating Officer JS Mr S Worthington Director of Finance SW Mrs T Armstrong Childs Director of Nursing TAC Mrs N Ingham Director of Workforce and OD NI Mr S Hodgson Acting Medical Director Mrs A Schenk Dir. Strategy and Improvement In attendance:- Mrs E Steel Trust Secretary ES Miss K Bancroft HoD Family Division KB Dr M Grey HoD Acute Adult Division MG

1. Patient Story Deferred due to sickness

2. Apologies Dr J Bene

3. Declarations of Interest

No additional interests declared

4. Minutes of The Board Of Directors Meeting Held on 1st August 2013 Approved subject to correction of a typographical error

5. Action Sheet

The Action Sheet Was Updated To Reflect Progress Against Agreed Actions.

FT/13/74 The HoD for the Family Care Division advised that the division have been working to address the specific issues raised in the patient story heard at the previous Board meeting including the management of transition from the Board of Directors minutes - September 26th 2013 2013 Page 1 of 8

highest level of dependency as the baby improves. The action plan is overseen by the Divisional Board [after the Board meeting a copy of the action plan was circulated to Board members] 6. Matters Arising

No matters arising not covered elsewhere on the agenda

7 Chairman’s Report

The Chairman updated the Board with regard to the following: Board Changes Heads of Division have now been invited to join Board meetings as non-voting members to support the Medical Director. Welcome to new Governors; Governors were invited to remain for the private session to observe discussions around the strategy for submission to Monitor Last Board meeting for Nicky Ingham before her move to Blackpool and possibly the last Board meeting for Jon Scott – both thanked for their contribution to the Trust. Performance C. difficile – progress is being made but further work needed as there is still more that should be done CQC – following review inspection the Trust is now completely compliant with no outstanding conditions A&E – continues to perform well, unfortunately this means the Trust is not on the list of Trusts who will get additional funding to support this areas Monitor – review meetings now bi-monthly in London with a meeting by conference call on the intervening months. The last call on Friday 20th September went well, the Trust is on track with agreed actions to meet the enforcement notice. During the call Monitor asked why the Trust does not do more to communicate about good performance. Winter – the winter plan will be brought to the October Board meeting – the Trust must meet the challenge of maintaining performance and finding future savings. 18 weeks – continues to be delivered as an aggregate and is close to delivery in all specialities. Stroke performance has improved and is back on plan – this has been achieved by ring fencing additional beds on the stroke unit. The TIA target has also been achieved.

9. Performance Dashboard

The Medical Director highlighted the following areas of performance on the dashboard: Mortality – remains green and is moving in the right direction. Board members noted that although HSMR and SHMI had remained steady RAMI had increased. An explanation of this change was requested – it was agreed that this could be covered in the routine Mortality report due in October. Appraisal performance improved but further work needed to achieve the mandatory

Board of Directors minutes - September 26th 2013 2013 Page 2 of 8

training target. Divisions are re-enforcing the importance of mandatory training and are targeting areas of patient facing training. The Board agreed to focus on the exception reports where issues/concerns had been identified and to take other exception reports as read. Board members were reminded that the new integrated performance report would replace the dashboard and exception reports from October.

Mortality report to October Board to include detail on work done to review notes of FT/13/88 SH unexpected deaths and exploration of increased RAMI

10. Exception Reports – Quality

Deaths following elective admission All deaths following elective admission are reviewed by the Head of Division; any areas of learning identified by this review are shared within the Division. The vast majority of deaths recorded as being following an elective admission are in fact following an urgent admission from clinic when a decision is made to admit the patient the next day, often in patients with advanced cancer. The four patients in June/July came into this category – the reviews did not identify any patient safety issues and concluded that all were cancer patients who did not survive the post-operative period. It has been agreed to move to a system of reviewing unexpected deaths defined as those patients who had a low expectation of death but subsequently died. Board members challenged as to whether unexpected death could be an objective measure – the Medical Director advised that a validated scoring system gives a severity score which can be used to compare performance – where the chance of death was felt to be low this should be investigated. Board members challenged whether intervention was appropriate in patients if death was not unlikely; the Medical Director advised that no defects of care had been identified in the cases reviewed, the risks had been explained to the patients and their families and on balance it was right to give the patients a chance. The Chair of the Quality Assurance Committee confirmed that the Committee had discussed the peer review of case notes following an unexpected death. Resolved: The Board noted the report and the reassurance that the patients reviewed had received appropriate care. Pressure Ulcers The Trust report on all ulcers acquired in the care of the Trust with an aim to reduce category two ulcers by at least 50% and zero tolerance for cat 3 and 4. An improvement has been made on performance since 2012/13 but this is still not good enough and further work is needed. A strategy is being formulated which is intended to equip staff and hold to account – this will be brought for approval at the October Board meeting.

C difficile At the end of August the Trust had reported 23 cases of C difficile against a target of no more than 28 in the year. The two main issues identified through RCA are non-adherence to the antibiotic policy and inappropriate sampling. The new Consultant Microbiologist is now reviewing policies and working to make the policy accessible following comments from junior doctors who have reported difficulty in accessing policies. Board of Directors minutes - September 26th 2013 2013 Page 3 of 8

The External Reviewer conducted a review of actions taken against the plan agreed following the initial review and in a verbal debrief advised that positive improvements had been made – a formal written report will be provided. The issue of access to policies was challenged; Board members felt that rather than developing an app for policies the challenge should be put back to consultants and their teams to ensure that all members of the team take responsibility for compliance with antibiotic stewardship. Board members discussed the use of antibiotics, whilst it is accepted that their use saves lives the policy for review of IV antibiotics after 48 hours must be followed. The Director of Nursing confirmed that junior doctors are provided with feedback from the rcas. The Director of Finance confirmed that a provision of £2m has been made in the financial assumptions to address the financial penalty associated with failing this target.

Complaints Performance against the target to respond to all complaints within the agreed timescale deteriorated in July and August following a decision to give priority and focus to managing the backlog of 137 complaints. A new complaints policy was approved by the Executive Board and a system is now in place to track and provide early warning of overdue responses. Performance is forecast to be on track by November 2013. Board members asked for assurance that in addition to responding to the complaints, learning points were identified and communicated to teams. The Director of Nursing confirmed that this is covered in the new policy

Staffing Incidents All staffing incidents are reviewed on a daily basis with the majority being as a result of staff being moved to provide cover in other areas. In August it was recognised that the freezing of vacancies implemented as part of the original turnaround plan was causing unacceptable pressure and the number of beds on one ward was temporarily reduced to require fewer nurses and thus relieve this pressure. Expenditure on wards was higher in August reflecting an increased spend on bank and agency staff. It was accepted that once wards are at full establishment wards must manage within this establishment through the planning of leave and the building in of contingency for times of high pressure. Staffing levels was one of the standards reviewed by the CQC; the CQC looked at the systems to manage, risk assess and escalate staffing issues and triangulated this with feedback from staff before concluding that the Trust was now compliant with this standard.

10 Falls Strategy

The Director of Nursing presented the Falls Strategy for formal approval from the Board of Directors. The strategy sets out a systematic proactive approach to falls prevention and includes the role of a ward Fall Champion and Trust Fall Coordinator. The Board discussed the strategy and requested further information with regard to implementation and risk assessments. Board members asked for assurance that with a full

Board of Directors minutes - September 26th 2013 2013 Page 4 of 8

complement of staff wards would be able to implement the strategy and deal with the management of patients identified as being at risk of falls. The Director of Nursing confirmed that she was confident that the identification of high risk patients was improving enabling “specialing” to be targeted at those identified as at risk. A question was raised with regard to the management of falls in the community, the Director of Nursing advised that there are community falls clinics to ensure possible actions such as safe footwear and appropriate walking equipment is provided. Resolved: the Board approved the Falls Strategy.

11. Exception Reports – Operational

Readmissions The COO advised that the target of no more than 8% readmissions had been agreed on the understanding that support/follow up services would be available to care for patients after discharge. This target will be reviewed and based on available services following an audit to be conducted with the CCG. Non-Executives challenged this explanation on the basis of the dashboard showing an increase in readmissions of approx. 1% month on month since September 2012 and asked for assurance that patients were not being discharged before they are ready. Resolved: Board members requested that a further report be provided in November after the audit with the CCG.

FT/13/90 Report back on readmissions following audit with CCG COO

Diagnostic waits Diagnostic waits were included on the dashboard from April following a recommendation from the Intensive Support team. The majority of these were patients waiting for endoscopy screening, this is being addressed by the mobile unit which came on stream in August, was fully operational by the end of August and is on track to achieve the 1% target by the end of November 2013. There has been an increase in the number of patients waiting more than 6 weeks for an MRI, this is as a result of the increase in activity following the end of additional CCG funded provision in a mobile unit. Capacity to undertake this work within the Trust has been increased and performance should be within tolerance for MRI scans by the end of September 2013.

13. Quality Strategy

The Acting Medical Director presented on the development of the Quality Strategy setting out the Trust’s commitment to ensure that quality principles, systems and processes are adopted and embedded throughout the organisation. Meeting the challenge of improving quality while reducing costs. Board members agreed the importance of good consistent quality and asked for assurance that the strategy would address the need for consistent 24/7 quality. The Acting Medical Director confirmed that this has to be addressed, reducing the variation in quality at times of day, across wards and between teams is one of the biggest steps to achieving the overall quality goal. Board members agreed that ensuring a consistent approach to quality Board of Directors minutes - September 26th 2013 2013 Page 5 of 8

is a key objective. Board members supported the core goals in the strategy but felt the current policy was too gentle in supporting the achievement of quality with no explicit detail on performance management. Resolved: The Board endorsed the further development of the Quality Strategy

14.1 Medical Staff revalidation

Board members were asked to approve the appointment of the Acting Medical Director as the responsible officer for revalidation. The Acting Medical Director confirmed that he had been revalidated and that there was a good support structure in place to ensure the Trust is operating in line with the requirements for medical staff revalidation. Resolved: The Board approved the appointment of Steve Hodgson Acting Medical Director as responsible officer for revalidation.

14.2 Norman Lamb letter re end of life care

Board members noted the letter from Norman Lamb regarding the phasing out of the Liverpool Care Pathway and the requirement to provide assurance on the provision of end of life care. The Board noted the requirement for a clinical review to be undertaken by a senior clinician. The Director of Nursing advised that the bereavement and palliative care team would develop guidance for staff and audit practice, any complaints or concerns would be escalated to the Quality Assurance Committee. Board members asked if the change in practice and requirements has had any impact on the Trust and if there were any financial implications of changes. Resolved: The Board approved the appointment of the Director of Nursing as the Board member with responsibility for overseeing complaints about end of life care and for overseeing how end of life care is provided. A report will be provided to the November QA meeting to provide assurance with regard to the care of end of life patients. On a separate but related issue the Board were advised that figures from CHKS show that the trust has a higher than average number of end of life patients. A review of notes by a clinical team including a GP has confirmed that these cases are being coded correctly

FT/13/91 Report to November QA Committee on end of life care

15. Month 5 Finance Report

The Director of Finance presented the key points of the month 5 Finance report, Board members noted that this had previously been considered in the Finance Committee meeting held on 18th September 2013. The forecast shows that the Trust’s plan deficit of £7.8m is still achievable The financial position for month 5 was a deficit of £ (1.4) m which is £ (0.9) m worse

Board of Directors minutes - September 26th 2013 2013 Page 6 of 8

than planned reversing the trend of the first four months. The year to date position is better than planned at £ (4.7) m deficit compared to the planned £ (5.6) m. Income has fallen this month due to a reduction in volume across most specialties. Divisions are confident that they will catch up on the income shortfall. Pay costs overall are in line with previous months. Although salaried pay costs have continued to fall over the last 2 months, bank and agency spend has risen by an identical amount resulting in no overall fall in pay costs The increase in non-pay is driven by the temporary mobile endoscopy unit and pass through drugs Turnaround savings are below plan year to date. It is forecast that the full amount of savings will not be delivered by the end of the year The CCG remain very supportive for both the development of the long term financial strategy and in supporting the winter plan. The CCG are considering additional funding to support community services – a paper is due to be discussed at the CCG Board. In order to achieve run rate balance the corporate CIP is being brought forward. Board members commented that although in the current position it is hard not to feel nervous it does feel as though the financial strategy, clinical services strategy and quality strategy complement each other in a logical manner to set out the future purpose and direction of the Trust. Concern was expressed that bank and agency spend had not yet been addressed, the Director of Nursing confirmed that the Finance Committee had requested assurance that controls were in place to manage this area of spend effectively and with regular monitoring. Board members acknowledged the need to recognise improvement and to continue with year on year efficiencies. The Chairman reminded Board members that one of the key issues in addressing performance for Monitor will be to put forward a plan to manage without funding from the DoH.

16. Finance and Investment Committee Chair report (27/08/13 and 18/09/13)

The Chair of the Finance Committee provided his report on the business conducted at the August and September 2013 meetings of the Finance and Investment Committee. The September meeting had focused on a detailed review of the strategy papers with a view to ensuring that plans were deliverable.

17. Quality Assurance Committee Chair report (07/08/13 and 11/09/13)

The Chair of the QA committee provided her report on the work of the QA Committee: In future meetings the three Division quality reports will be reviewed in the same meeting rather than one per meeting – this has been agreed to enable better sharing of learning between divisions. The Committee considered the process for reporting on and closing SUIs and approved a proposal to support the timely sign off for SUIs by the Board with ongoing actions monitored through the QA Committee. It was also agreed that although all efforts should be made to secure NED attendance on SUI panels the preliminary meeting could go ahead without a NED in attendance and with an Exec Board of Directors minutes - September 26th 2013 2013 Page 7 of 8

Director Chair. The Committee approved the deferment of the CNST level 2 assessment, the Trust will offer to be a pilot for the new NHSLA/CNST approach.

18. Audit Committee – Chair Report (17/09/13)

The Chair of the Audit Committee provided a report on the recent meeting of the Audit Committee. The new external and internal auditors had now been appointed and had been in attendance at the September meeting. Although it is early days the Committee felt invigorated by the attendance of “fresh eyes” The Committee had previously been concerned about the response to a no assurance report on Medicines Management but had been assured by a report provided by the Director of Nursing and now felt more confident that although not yet embedded actions have been taken. The Committee were concerned that the BAF had not been reviewed for some time, they had accepted that the BAF was being reviewed but had set a deadline for the new BAF to be received by the Board in October

FT/13/93 BAF to October Board meeting ES

19. Any other business

No further business

20. Questions From Members of the Public

No questions were received in advance of the meeting

Date And Time Of Next Meeting

31st October 2013

Resolved: that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest (Section 1(2) Public Bodies (Admission to Meetings) Act 1960).

Board of Directors minutes - September 26th 2013 2013 Page 8 of 8

September Board actions Code Date Context Action Who Due Comments FT/13/74 01/08/2013 patient story - maternity Exec Directors to ensure issues raised in patient story are captured CEO Sep-13 working to address the specific actions - and addressed KB to respond to further query on step down once baby starts to recover

FT/13/84 01/08/2013 no smoking site update to solutions to address smoking around entrances JB Oct-13 matters arising verbal update FT/13/73 04/07/2013 Market share report to be quarterly agenda item with information about potential AMS Oct-13 agenda item opportunities included FT/13/76 01/08/2013 Pressure ulcers Paper to be provided on approach and measuring TA Oct-13 agenda item FT/13/38 07/04/2013 Academic Health Science Report to be provided on benefits being realised from membership AMS Oct-13 agenda item Networks of AHSN FT/13/60 06/06/2013 mortality regular reports through QA committee with quarterly Board reports - JB Oct-13 agenda item next October FT/13/87 26/09/2013 Performance Winter plan to October Board meeting JS Oct-13 agenda item FT/13/88 26/09/2013 Performance Mortality report to October Board to include detail on work done to SH Oct-13 agenda item review notes of unexpected deaths and exploration of increased RAMI FT/13/89 26/09/2013 Pressure ulcers Pressure ulcer strategy to October Board meeting TA Oct-13 agenda item FT/13/93 26/09/2013 Audit Committee report BAF to October Board meeting ES Oct-13 agenda item FT/13/94 26/09/2013 Mandatory training report on proposals to address mandatory training compliance NI Oct-13 matters arising verbal update

FT/13/95 26/09/2013 Authorisation of high level SW to provide DW with breakdown of spend through the deanery SW Oct-13 contracts FT/13/92 26/09/2013 Finance and Investment IT investment strategy to November 2013 Board meeting SW Oct-13 agenda item for October FT/13/82 01/08/2013 Stroke clinical audit to validate provision of appropriate care to stroke JB Nov-13 delayed to November to incorporate patients - report back to QA Committee latest census numbers FT/13/77 01/08/2013 Medication incidents QA Committee to receive detailed report on themes including TA Nov-13 delayed to November to incorporate benchmarking if possible latest census numbers FT/13/61 06/06/2013 equality and diversity report to October Board to overlay staff data with patient data and TA Nov-13 delayed to November to incorporate to correlate profile of patients and staff with population of Bolton latest census numbers

FT/13/78 01/08/2013 complaints complaints strategy to the Board TA Nov-13 FT/13/90 26/09/2013 readmission report back to Board after audit with CCG JS Nov-13 FT/13/91 26/09/2013 End of life care report to QA Committee in November 2013 to provide assurance TA Nov-13 scheduled for November to fit with that palliative care patients have senior review and a responsible Committee cycle clinician FT/13/96 26/09/2013 Estates strategy Report back on possible solutions to lease the land to potential ST Nov-13 developers FT/13/97 26/09/2013 Estates strategy Outline plan with timescales for moves detailed within draft estates ST Nov-13 strategy Safe, High Quality Care, Fit for the Future

Report Trust Objectives

Quality and Valued Financially Great place Fit for the Well TRUST BOARD Safety Provider viable and to work future Governed sustainable Subject Integrated Performance Report zzzzzz

Prepared By Executive Summary

Approved By Executive Management Team Please see the High level Executive Summary section at the beginning of the report Presented By

Purpose Key Recommendations

This report sets out the Trust’s integrated performance against leading national and local targets and draws attention to key areas The Board are asked to receive the report and give approval. for specific review by the Trust Board.

Driven by the Trust’s strategic objectives this report is underpinned Acronyms/Terms used in Report by a strong platform of integrated governance and assured data quality controls allowing the Trust Board to make effective decisions and demonstrate its commitment to delivering high quality Appendix A healthcare for the people of Bolton.

Report change log

Appendix B

Safe, High Quality Care, Fit for the Future

Contents

Executive Apex Reports High Level Executive Summary High Level Executive Dashboard • Monitor Governance Compliance Framework • Monitor Risk Assessment Framework • Mortality • Readmissions

Section 1 Improving the Quality of Care and Safety of our patients • Quality and Governance Scorecard • Quality and Governance Charts • Quality and Governance Report • Acquired Infection • Falls • Pressure Damage • CQUINS

Safe, High Quality Care, Fit for the Future

Section 2 Valued provider of Integrated Services • Operations Scorecard • Operations Charts • Operations Report

Section 3 Financially viable and sustainable • Finance Scorecard • Finance Report

Section 4 A great place to work • Workforce Scorecard • Workforce Charts • Workforce Report

Section 5 Ward to Board Overview/Early warnings

Section 6 Fit for the Future

Section 7 Well Governed

Appendix A Acronyms/Terms used in Report

Appendix B Dashboard Change log - in month

Executive Summary

This executive summary provides an integrated overview of the Trust Board Performance Report. Supporting the Trust's Strategic Objectives it orientates executives quickly to the areas that have been escalated, are of particular note or political significance. The accompanying High-Level Dashboard and narrative gives further analyses. Compliance levels with the Monitor Risk Assessment Framework and CQC (Care Quality Commission) are also shown.

Improving the Quality of Care and Safety of our patients A great place to work

79 patient falls in month is less than our threshold of 86. First Local induction attendance (starters in the last 12 months) has six months data is on trend to achieve 13/14 year end target. fallen to 59.5%

Acute Inpatient acquired pressure damage is above the monthly Mandatory Training compliance is 81% against a target 100%. target at 8. This target has not been met in the last 18 months.

Infection Control (C.diff) reports 2 occurrences in month. This The number of staff absent for 3 months+ has risen to 79. represents the lowest figure in the last six months.

The latest Mortality position is: 83.6% of staff appraisals are completed representing the SHMI - 1.01, RAMI - 85.0 and HSMR - 92.9. highest figure in the last six months. All measures are within confidence intervals.

Valued provider of Integrated Services Fit for the future

A&E 4 hour target did not achieve in month at 94.4%. Local integration policy

18 week referral to treatment targets were achieved for Market share analysis admitted, non-admitted and incomplete pathways. Patients

Significant improvement in Diagnostic waiting times for tests >6 Electronic Patient Record weeks but still above National target of 1%. Our 13.6 % of patients were re-admitted within 30 days against a Monitor escalation target of 8%. Target level under current review with CCG.

Financially viable and sustainable Well Governed Monitor Compliance Framework Red Forecast in year deficit of £7.8m is on plan 1 Governance Risk Rating Finance Risk Rating

Run rate balance in March is not certain Monitor Risk Assessment Framework Governance Finance (To be Reported from October 2013) Year to date deficit is £0.9m ahead of plan The Trust continues to be licensed to carry out CQC regulated activities with no conditions imposed September in month deficit of £0.7m is on plan on our registration status High Level Executive Dashboard

Plan Improving The Quality Of Care And Safety Of Plan Plan Actual Monthly Monthly On Plan Plan Plan Actual Monthly Monthly On Plan Our Patients 13/14 YTD YTD Actual Change Off Plan Financially Viable And Sustainable 13/14 YTD YTD Actual Change Off Plan Well Governed Status

Total number of new SUIs received within the Æ 4 month 0 0 11 3 Forecast year end deficit – (full year) -7.8 -7.8 -7.8 -7.8 0 0 Monitor Compliance Framework 4 Off Plan Æ 4 Monitor Risk Assessment Never Event 0 0 1 1 Forecast year end recurrent run rate - (full year) 0 0 -8.8 -8.8 0 -8.8 Framework Pending Æ 5 CQC Essential Healthcare All Patient Falls 1034 502 519 79 Forecast year end income and cost imp – (full year) 16.2 16.2 13 13 - -3.2 Standards (5) 5 On Plan Acute Inpatients acquiring pressure damage Æ 4 CQUINS: National Clinical (grades 2+) 84 42 52 8 Actual position against plan - YTD -7.8 -6.3 -5.4 -0.7 0.5 0.9 Quality Indicators (4) 4 Off Plan Æ 5 VTE Assessment Compliance 95% 95% 96.6% 96.7% Actual Income and Cost Improvement -YTD 14.6 5.6 5.4 0.8 0.7 -0.2 Report to prevent future deaths 5 On Plan Å 5 Catheter Associated Urinary Tract Infection 95% 95% 94.6% 95.6% Capital Expenditure YTD -5.9 -3.2 -1.2 -0.3 0 2 Litigation 5 On Plan Ä 5 MRSA Bacteraemia Pre 48 Hours admission 0 0 0 0 Cash Position YTD 0.3 0.2 0.5 0.5 -0.1 0.3 Formal Contract Notices 4 Off Plan MRSA Bacteraemia Post 48 Hours Ä 5 admission 10 0 0 0 Continuity of services rating 1 1 1 1 - - Formal Performance Notices 5 On Plan Å 4 C Diff Hospital aquired 28 17 25 2 Contract Fines/Penalties 4 Off Plan Ä 5 CHKS RAMI (Rolling 12 months) 100.0 100.0 85.0 85.0 Ä 5 SHMI 1.000 1.000 1.015 1.015 Plan Plan Actual Monthly Monthly On Plan Surgical WHO Checklist compliance 100% 100% To be Developed Developing Our Staff 13/14 YTD YTD Actual Change Off Plan Fit for the Future Status Ä n/a Local Induction Attendance (starters in the last 12 Æ 4 Formal complaints from patients n/a 325 43 months) 100% 100% 68.9% 59.5% The Trust Strategic Direction 5 On Plan Complaints responded to within the time Å 4 Æ 4 period % 95% 95% 73.8% 78.0% Number of staff absent for three months + n/a n/a 70 79 Local Integration Policy 5 On Plan Å 5 Appraisals completed % 80% 80% 81.2% 83.6% Market Share Analysis 5 On Plan Æ 4 Sickness days % of days lost 3.75% 3.75% 4.7% 4.97% Winter Planning 5 On Plan Plan Plan Actual Monthly Monthly On Plan 4 Valued Provider Of Integrated Services 13/14 YTD YTD Actual Change Off Plan Mandatory Training Compliance % 100% 100% 79.6% 82.5% Å Electronic Patient Record 5 On Plan

Æ 5 A&E 4 hour target 95.0% 95.0% 96.5% 94.4% Monitor Escalation 5 On Plan Æ 5 RTT Admitted Clock Stops % 90.0% 90.0% 95.1% 95.0% Æ 5 Å RTT Non-Admitted Clock Stops % 95.0% 95.0% 96.7% 95.8% Performance improved but off target in month RTT: Incomplete pathways within 18 weeks Å 5 Æ % 92.0% 92.0% 95.9% 94.9% Performance deteriorated and off target in month Å 4 Å Diagnostic waits >6 weeks % 1.0% 1.0% 9.7% 7.1% Performance improved and on target in month

% of patients who spend 90% of their stay on Æ 5 Æ the stroke unit 80.0% 80.0% 82.7% 83.3% Performance deteriorated but on target in month The On Plan / Off Plan Columns represent a projected Year End position. The Æ 4 % Readmissions within 30 days of discharge 8.0% 8.0% 12.7% 13.6% status columns represents the current status of the initiative detailed Monitor Risk Assessment Framework 2013/14

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Area Indicator (All measured Quarterly) Threshold Weighting Actual Actual Oct-13 Nov-13 Dec-13 Actual Actual Maximum time of 18 weeks from point of referral to 1 treatment in aggregate – admitted 90% 1.0

Maximum time of 18 weeks from point of referral to 2 treatment in aggregate – non-admitted 95% 1.0 Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete 3 pathway 92% 1.0 A&E: maximum waiting time of four hours from 4 arrival to admission/ transfer/ discharge 95% 1.0

5 All cancers: 62-day wait for first treatment from: Urgent GP referral for suspected cancer 85% 1.0

Access NHS Cancer Screening Service referral 90% All cancers: 31-day wait for second or subsequent 6 treatment, comprising: Surgery 94% 1.0 Anti-cancer drug treatments 98% All cancers: 31-day wait from diagnosis to first 7 treatment 96% 1.0 Cancer: two week wait from referral to date first 8 seen, comprising: All urgent referrals (cancer suspected) 93% For symptomatic breast patients (cancer not initially 1.0 suspected) 93% Clostridium (C.) difficile – meeting the C. difficile 14 objective DM* 1.0 Certification against compliance with requirements regarding access to health care for people with a 19 learning disability N/A 1.0 Data completeness: community services, 20

Outcomes comprising: Referral to treatment information 50% Referral information 50% 1.0 Treatment activity information 50% High Level Executive Report

Improving the Quality of Care and Safety of our Patients

• 3 new Serious and Untoward Incidents have been reported in month. 11 incidents have been reported for the first six months of this year against a total of 9 for 12/13.

• There is one Never Event recorded for September 2013. This incident is currently being further investigated.

• 79 patient falls were reported in September with 4 sustaining a degree of severe harm. Three patients in the adult acute division each resulting in a fractured neck of femur and 1 in the elective care division resulting in a fractured shoulder.

• 8 Inpatients acquired pressure damage in September exceeding the monthly target of no more than 7. The table below shows both inpatient and community pressure damage incidents and their level of severity.

Performance Indicator Sept 2013 Pressure damage (grade 2) 5 Hospital Pressure damage (grade 3) 2 Pressure damage (grade 4) 1 Pressure damage (grade 2) 6 Community Pressure damage (grade 3) 2 Pressure damage (grade 4) 1 17

• VTE assessment and Catheter Associated Urinary Tract Infection indicators have both achieved. VTE has been compliant for the last six months.

• There have been no MRSA Hospital Acquired Infections in the last six months.

• In September C.Diff has seen the lowest number of incidents reported monthly this year at 2. Unfortunately we have still exceeded the quarterly target of 7 on the Monitor Compliance Framework returning a figure of 9. This area still remains a formal Monitor concern.

• There are currently two measures for mortality which are reported nationally for all NHS providers and across all specialties. They are both known by four letter acronyms HSMR and SHMI. Bolton also uses the CHKS mortality ratio known as RAMI. There are differences between all three measures. HSMR and RAMI consider deaths in Hospital whereas SHMI considers death in Hospital and deaths up to 30 days after discharge. Currently all three measures are within confidence intervals. SHMI at 1.01, RAMI at 85.0 and HSMR at 92.9.

• The World Health Organisation (WHO) Surgical Checklist has been introduced as a new metric for the organisation. It is a patient safety alert and a tool for use in operating theatre environments. It is designed to help clinical teams improve the safety of surgery.

• 31 formal complaints have been received in September 2013. This represents the lowest number received in the last 3 months.

Valued Provider of Integrated Services

• The 4 hour A&E target has not been met in September achieving 94.4% against the 95% National Standard. This target has been achieved for the previous 18 months. There were 8,978 attendances with 503 patients breaching the 4 hour wait. The table below gives the breach reasons:

1. 226 of them were due to waiting for a bed, 2. 79 due to clinical need, 3. 77 were delays to be seen, 4. 64 were awaiting psychiatric review, 5. 43 waiting for surgical review 6. 14 due to other reasons.

Additional actions that are being taken by Divisions include working to improve discharges, monitoring patient flow and ensuring that capacity is available together with seeking to improve the delays in transfer of care.

• 18 week admitted, non-admitted and incomplete pathways were all achieved. Orthopaedics still remains a challenge at specialty level.

• The stroke target of 80% has been achieved for the second month running with a delivery of 83.3%. Although not in the Compliance Framework Monitor still review this as a cornerstone target.

• Readmissions were 12% against an 8% target. This target is currently under review with the CCG. The chart below shows the CHKS National analysis for the year August 2012 to July 2013 and whilst the methodology is not consistent with the PBR rules it does give a like for like comparison with other Trusts. This analysis shows that we are in the middle of the pack and not an outlier.

Workforce

• Local induction performance has deteriorated (59.5%) partly due to a high number of Nursing staff and Health Care Assistants starting in month. The low attendance is of concern as the CQC review this area for assurance that all new staff have the basic safety, governance and mandatory training required to do their job.

• A verbal report is scheduled for October’s Trust Board on Mandatory Training. Medical and dental staff have the lowest rate of compliance at 73%. Out of 13 subject areas 11 improved in month with 2 slightly deteriorating. These two areas are infection control and moving and handling.

• The number of staff with more than 3 month’s absence has increased from 59 in July 2013 to 79 in September. The three major reasons are; stress and anxiety (28), back/musculoskeletal (18) and cancer (7).

• The sickness absence rate has increased in September to 4.97% from 4.86%. This is due to the increase in long term sickness absence particularly in the Adult Acute and the Elective Care Divisions.

Finance

• The forecast shows that the Trust’s plan deficit of £7.8m is achievable by utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes of £1m to offset recurrent shortfalls.

• The Trust is currently not forecasting to achieve recurrent run rate balance by the end of the year. Action is being taken to secure run rate balance by the year end as follows:

1. Bringing forward of the corporate directorate CIP requirement for 2014/15 into 2013/14. 2. Work with Bolton CCG the community service model. £1.2m non recurrent support to community services has been allocated by the CCG in this financial year. 3. Work with Bolton CCG on the “Making it Better” service specification 4. Other improvements in the clinical divisions cost improvement programmes. 5. Divisions with forecast underspends are being required to maintain these.

• The full year forecast for income and cost improvements is £13m v £16.2m plan. The shortfall is being covered by utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes of £1m.

• The financial position for month 6 was a deficit of £(0.7)m which is slightly worse than the £(0.6m) deficit planned. The year to date position is a deficit of £(5.4)m which is £0.9m better than the planned deficit of £(6.3)m.

• Income and cost improvements year to date at £5.4m are now £0.2m behind plan due to the Board decision to reinvest nursing savings on the wards and lower delivery rates in some other work streams than planned at the start of the financial year. This is being mitigated by additional CIP plans which are in place in the divisions and are part of the division’s financial recovery plans.

• The Trust capital plan as submitted to Monitor is £5.9m As at the end of September capital was £2m underspent. The underspend is in a number of areas of replacements, maintenance and enhancements.

• Cash has been managed effectively with a £0.5m cash balance at the end of September. The year-end position assumes support of £17.25m from DoH. • Fit for the Future

• The Strategic Direction document 2013/14 – 2018/19 has just been completed in October and sets out a number of strategies for the Trust. It gives clear direction of travel for the organisation for the next 5 years.

• The Trust is participating fully in the Health and Social Care Integration agenda by ensuring representation at the Integration Board, leading relevant work stream initiatives and participating actively in other work streams as appropriate.

• During Quarter 4 2012-13, Bolton NHS FT had 58% of all of Bolton PCT's elective admissions. Salford Royal is the next biggest provider of elective activity for Bolton PCT with 3144 spells; over 80% of these spells were for Nephrology, which is not a specialty that we would provide. The Trust has seen an increase in volume of elective spells and market share for Bolton PCT patients over the last 2 financial years. When comparing Q1 11-12 with Q4 12-13 there has been an over 5% increase in market share. The increases in market share have been seen in the Elective Surgical specialties of General Surgery, Urology, Orthopaedics and Plastic Surgery.

• The outline business case has been completed for an Electronic Patient Record (EPR) and an Electronic Discharge Monitoring System and an overview will be presented at the October board. Both projects are now expected to proceed to full business case. The outcome of the Department of Health funding bids made to the Safe Hospitals Safer Wards fund from NHS England should be known on the 31st October. Further benefits work is being undertaken to validate EPR benefits validation. A full EPR benefits model will be finished in November and integrated with the full business case.

• We are on track to address the recommendations in the KPMG and Deloitte reports by the end of October. We will then seek external assurance from PwC to assure the Board and Monitor that the recommendations have been addressed.

Well Governed

• At Quarter 2 we are not fully compliant with the Monitor Compliance Framework. Although the majority of our performance targets are met, C.Diff remains a concern together with our financial risk rating of 1.

• The new Monitor Risk Assessment Framework replaces the Compliance Framework from October 2013. A paper is scheduled for discussion at the October Board.

• There are 5 Essential Healthcare Standards which have 17 outcomes for delivery. The Trust is currently recognised by the CQC as meeting the standards.

• The Trust is not meeting 2 of the 4 National Quality Indicators namely the Friends and Family Test and Dementia screening.

• There is one formal contract notice issued concerning 52 week performance.

• The table below shows the fines and penalties for current performance for month 6.

Plan Actual

Penalties (250) (115)

C‐Diff ‐(800)

TOTAL (250) (915)

Agenda Item No 9

Meeting Trust Board

Date 31st October 2013

Title Mortality Report

Executive Summary

Why is this paper going to the Board Quarterly update of Trust’s mortality rate and factors affecting it To summarise the main points and key issues that the Board Adverse movement of SHMI but still within expected parameters, should focus on explained by increased mortality over last winter period including risk, compliance priorities, cost and penalty Favourable trending of more up to date RAMI and HSMR implications, KPI’s, demonstrating improved performance since. Trends and Projections, conclusions and proposals

Next steps/future actions

Clearly identify what will follow a Board decision i.e. future Discuss  Receive KPI’s, assurance requirements Approve Note

Assurance to be Positive trending of RAMI and HSMR provided by:

This Report Covers (please tick relevant boxes) Strategy Financial Implications Performance Legal Implications Quality  Regulatory Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Prepared by Dr Jackie Bene Presented by Dr Jackie Bene

MORTALITY UPDATE FOR BOARD OF DIRECTORS – 31st October 2013

Overview

The mortality rates at Bolton NHS Foundation Trust are monitored monthly by the Trust Board within the Performance Board report. The programme of work around mortality reduction and more detailed analysis of the mortality data are overseen on a monthly basis by the clinically driven Mortality Reduction Group chaired by the Medical Director.

The Trust measures crude (actual deaths) and risk adjusted deaths by using the Risk Adjusted Mortality Indicator (RAMI) and the recently developed national Summary Hospital Mortality Indicator (SHMI).

Crude Mortality

The actual number of deaths in Bolton NHS FT has been reducing consistently over the past few years and currently stands at 2.0.

Figure 1

Crude Mortality Rates 3.5% 3.0%

2.5% 2.0% 1.5% 1.0% Crude Mortali… 0.5%

CrudeMortality% 0.0% 2008/0 2009/1 2010/1 2011/1 2012/1 2013/1 9 0 1 2 3 4 Crude Mortality % 3.1% 2.9% 2.8% 2.6% 2.4% 2.0%

Risk Adjusted Mortality

In the last quarter, the SHMI has moved adversely (Fig 2) but is still within the “as expected” range. This metric is continuously rebased each quarter but the data period is always six to nine months behind. The RAMI is rebased annually but it is more up to date, lagging by only two months. The RAMI is useful to monitor trends but less useful as a benchmarked metric given that peers are generally improving at similar rates. The RAMI is trending below peer as shown in Figure 3. It is clear that the RAMI deteriorated over last winter trending very close to the peer group between November 2012 and February 2013. The trend is shown over a longer period in Figure 4 which covers the two previous SHMI periods. It is expected therefore that as the RAMI has improved in more recent months that the SHMI will do so too.

Figure 2 SHMI

SHMI 1.1

1.05

0.95

0.9 Jan 11 - Dec Apr 11- Mar Jul11 - Jun Oct 11- Sep Jan 12 - Dec Apr 12 - Mar 11 12 12 12 12 13

Figure 3 RAMI

Figure 4

At the last Trust Board meeting it was reported within the Board Performance report that the RAMI had jumped from 71 in June to 85 in July and was again 85 in August. It remains 85 as of September 2013. Over the previous 12 month period the RAMI had been fairly static around 70 to 73. The reason for the sudden jump was the annual rebasing exercise undertaken by CHKS in July.

The Acting Medical Director updated the Board at the last meeting on the findings from surgical elective death case reviews. He concluded that all were urgent admissions from clinic and were in fact very ill patients rather than more healthy patients that one would expect in those undergoing elective surgery. The Head of the Acute Adult Division reported within the quarterly Divisional Quality Report to the September Quality Assurance meeting a case note review of ten patients with the highest RAMI ie unexpected deaths. The outcome of the review is detailed in Appendix 1. It is clear that most of these patients were equally very ill and would not be regarded as suffering an unexpected death. This once again highlights the limitations of risk adjusted mortality data as a reliable indicator of quality. However the review did highlight a potentially avoidable death and lessons have been learned within the Division from this.

Benchmarking

The Trust monitors its mortality rate (RAMI) against a peer group of similar Trusts across the country. The Mortality Reduction Group also monitors performance against a selection of North West Trusts as shown in Figure 5 below. Bolton NHS FT has the second best RAMI in Greater Manchester second only to Salford. Our HSMR is currently 92.9 which is in the middle of the pack compared with other Greater Manchester Trusts. The most recent AQUA Mortality Report for Bolton attached with this report gives further positive reassurances around Bolton’s mortality performance.

Figure 5

Deaths vs Expected Deaths using CHKS RAMI Spells

3000 120

2400 100 80 1800 60 1200

40 RAMI 600 20

Number Of Deaths Of Number 0 0 BTH RBH LTH PAH SRFT SFT THFT UHSM WWL RAMI Deaths 1,647 1,047 1,365 2,462 801 1,169 751 1,059 1,041 Exp Deaths 1,665 1,203 1,304 2,602 1,108 1,215 659 1,039 1,102 RAMI 98.9 87.1 104.7 94.6 72.3 96.2 114.0 102.0 94.5 RAMI Deaths Exp Deaths RAMI

The main causes of mortality at Bolton NHSFT have remained fairly constant over the last three years and the top five in terms of observed deaths currently are

Pneumonia Septicaemia Heart Failure Aspiration pneumonia Stroke

The main focus of mortality reduction work is around these conditions. The Mortaility Reduction Group monitors the progress against the actions and the current RAG rated action plan which is attached at the end of this report.

As well as the work focussed on specific disease groups there is also a significant amount of work underway around the whole areas of acute illness management, end of life care and pathway work in surgical areas. The work around enhanced monitoring in acute medical and surgical areas (Level 1 care) is progressing and the plan to co-locate ITU and HDU was discussed in the Estates Strategy at the last Board meeting. Both require additional investment. In the meantime each Division has been progressing seven day working and there is now weekend working by Consultants in all the major specialities. In addition there has been an enhancement of the Hospital at Night Team. All this plus the restructuring of acute medical pathways with the introduction of the Clinical Decision Unit last winter has resulted in greater decision making by senior medical staff at night and at weekends. As such, out of hours and weekend mortality is not significantly greater as demonstrated in Figures 6, 7 and 8.

Figure 6

Deaths In/Out of Hours Trust Overall

100 80 60 40 20 0 Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

NumberofDeaths Deaths Between: 8am - 8pm 43 53 69 83 64 62 66 59 54 40 61 50 Deaths Between: 8pm - 8am 45 53 55 50 67 58 67 52 40 40 47 28

Figure 7

Total Deaths In/Out of Hours

602 Deaths Between: 46% 8am - 8pm 704 Deaths Between: 54% 8pm - 8am

Figure 8

Total Deaths per Day of Week

Monday 176 181 Tuesday 14% 14% 203 197 Wednesday 16% 15% Thursday 162 175 Friday 12% 13% 212 Saturday 16% Sunday

The current performance in terms of risk adjusted mortality for the main causes of death in the Trust are shown in Appendix 2. It is clear that the work being undertaken is continuing to drive down mortality in the main. The graphs show a deterioration in risk adjusted mortality over the winter period and this is the most likely explanation for the adverse move of the SHMI and the RAMI. As the overall Trust RAMI has recovered subsequently as has been the case in several disease specific groups then it is likely the SHMI will recover too.

Appendix 1

Appendix 2

Acute Adult Care Division – Overall Mortality

Elective Care Division – Overall Mortality

Trauma and Orthopaedics – Overall Mortality

Pneumonia

Heart Failure

Septicaemia

Stroke

Surgical Mortality

Overarching Mortality Reduction RAG Rated Action Plan- Jan 2013-Dec 2013

Work Stream Recognition and response to the physiologically deteriorating patient Aim Implement and improve robust recognition / response systems to optimize clinical outcome Improve compliance with NICE CG50 Leads Jez Wood – Anne Gerrard – Bet Fox

No Key Aims Actions Who When Progress RAG

Consolidate outreach to provide robust 7 JW/AG Oct 2013 1.2 WTE shortfall in nurses identified, Improve day 12 hour cover in line with H@N model included into appropriate business /response case. system to Information intelligence re outreach activity A NEWS and future service planning - needs to be Funding for MedICU’s outreach part of medium term trustwide IT strategy database no longer available.

Dr wood to present NICE 50 results at November MRG

1 Re audit NEWS compliance - start data AG/BF annual Data collection completed and collection April 2013 presented to MRG June 2013 A Audit NEWS Compliance improved to >60% - impact needs professional lead ownership/ accountability and feedback. Optimize response Re audit NICE 50 compliance JW/AG/ Nov Data collection complete – analysis in strategy Aim to present MRG Nov 2013 DK 2013 progress Identify themes to support onward planning To gather themes from NEWS compliance/NICE 50 audit and RCA arrests and present to quality assurance/ trust board

Development / Discussion/agreement for model re Level 1 Divisional Oct 2013 Target Oct 1st D2/ Nov1st D1 medical establishment of monitoring areas – workshop / clinical areas specialty based leads/ out Sept A 2 level one areas of hours 2013 Business case for surgical areas working being written – target Dec 1st 2013 Future strategic group Potential quality indicators for planning discussion LOS/ arrests/ level 0 HDU cases/ patient experience/delayed admissions/discharges

Trish Armstrong-Child will continue the work around level 1 care commenced by Dr Bene

Operational Development of upgraded level 2 - 3 areas Trust Unable On hold due to financial imperative – R model - Critical Plans completed but currently on hold Board to agree timeline to be determined by trust care/ critical as on strategic/ capital build priority care building hold infra structure

Development of operationally ‘closed’ Unable On hold currently due to financial critical care unit (ICU/HDU) in line with Trust to agree constraints. critical care network recommendation Board as on 3 Staffing expansion requirements quantified hold Staffing requirements quantified – no R – need to be realised funding agreed to date Currently northwest outlier – GM critical care core specification mandates closed A risk escalation process to be units – new critical care CRG core included on the risk register specification currently in draft will also include and will influence future service configuration/ commissioning

Understand Trust sepsis incidence / Discuss adaptation of arrest RCA outcomes / response Sepsis process to cover sepsis so that all A Forum considering lay member Forum sepsis deaths are reviewed directed Improve involvement back to parent clinical team compliance with Dr Grey to identify acute division sepsis Recommendations from Sepsis audit 4 Sepsis care lead incorporated into action plan. bundles Dr Wood to engage orthopaedics Rolling programme of audit on sepsis ongoing Note international surviving sepsis day JW/AG 13/9/13 Mr. D Smith identified as surgical sepsis lead Educational event + local publicity including media coverage - next Review of 2 x surgical cases from sepsis JW stage to embrace further community audit reviewed – enclosed engagement

Discuss availability of lactate testing on ABG

Junior doctors have presented at the sepsis study day and shared learning with use of MDT.

Sepsis form designed and will start using to improve screening for sepsis and encourage use of a similar process used in A/E.

Community matrons have recently attended the sepsis study day and are looking into how they can support early recognition and response from a community perspective.

5 RCA arrests Continue to embed into demonstrable SJT 21/25 RCA returns received by clinical clinical team learning effectiveness, reflecting a good A response. Dr Grey to take this back to clinical teams to discuss and encourage they continue to complete and return.

6 AKI pathway Promote awareness of regional AKI AH/KJ/AB Acute physicians to promote and pathway include on acute medicine web page A Biochemistry automatic prompt introduced by Andrew Hutchinson

Work Stream Heart Failure Aim To ensure high quality care is achieved for patients with heart failure within the integrated organisation from diagnosis to end of life Leads Dr Karen Lipscomb and Tracey Garde

No Key Aims Actions Who When Progress RAG 3 Appropriate and Re structure/review of specialist nurses with TG October Independent review to be conducted safe defined roles and responsibilities to each team 2013 to look at the non ward based A management member and consideration to expanding nursing strand. Awaiting a date for and treatment of service to 7 days a week. work to be commenced and Heart failure completed.

Consultants buddy wards: PJS-B2, KL-B4, SL-B3, FK-C4, C2-on call A consultant-in place since August 2012. Plans to extend the ward areas covered. Kay Lewtas to provide AQ data in a more up to date fashion to allow targeted management to ward areas failing on measures.

5 Outreach to Specialist nurses to drive improvements and KL/TG Dec 2013 To reduce the ’breaches’ noted respiratory re-enforce adherence to NICE guidance. affecting NICE directives and AQ wards measures – Kay Lewtas provides Cardiologists to deliver a sustainable outreach monthly updates on breaches of A service to enable NICE compliance for medical care listing ward areas. AQ data review for heart failure patients during being received 3 months admission. retrospectively, rather than previous

6 months, allowing practice impact to be monitored more closely.

E-job planning analysis to support delivering of a consultant outreach service 6 Re-creation of a Re-design a heart failure care bundle to KL/TG Nov 2013 Initial discussions within cardiology heart failure support new NICE directives and new AQ to commence before work can R care bundle measures proceed further.

Dr Bene requested that we hear at the next meeting from Dr Lipscomb on her plans to re-design HF care bundle to support new NICE and AQ measures

Work Stream Palliative and End of Life Care (EoLC) Aim To support delivery of high quality care in the last year of life, including promoting and enabling patient’s choice and delivering of high quality care of the dying Leads Dr Barbara Downes , Dr Kim Steel & Carmel Wiseman (Steven Wilson, Sharon France, Specialist Palliative Care Team, End of Life Care team)

No Key Aims Actions Who When Progress RAG Explore & Identify funding BD/CW Sept 13 On track. Meeting held to discuss funding allocation. Proposing monies used to fund a understand /KS project lead. Awaiting written confirmation of A further the benefits and funding to be received. resource implications of Develop implementation plan BD/CW Dec 13 CW & JS attended National AMBER care bundle workshop held in Manchester 18.7.13. 2. implementing /KS learning from event has supported decision to the Amber Care Bundle across appoint a facilitator to develop and lead on an RBH to improve implementation plan. A earlier identification of Progress made in identifying suitable pilot those at the end areas for rolling out amber care bundle. of their life in acute hospital th Review MDT decision making regarding BD/CW July 13 20 set of case notes audited 20 June and the use of the LCP /KS second set to be audited 17.7.13 to include surgical patients. 3. Embed use of A LCP within RBH

To implement Obtain update from NWAS regarding CW/JS March DNAR policy ratified at resuscitation committee NHS North of early implementer sites 2014 and going to the CCG for feedback. England unified Attend early implementers group Additionally awaiting regional feedback 6. DNACPR policy meetings A and integration Arrange steering group meeting to take of Trust DNAR implementation forward in Bolton policy Complete data collection for national BD/CW Dec Organisational & clinical data entry period (1st During the audit /KS 2013 October - 30th November 2013). Bereaved phasing out of Relatives Survey (1st October 2013 - 28th the LCP February 2014), questionnaires to be sent out A maintain and to relatives by 31st October. February 2014 - 7 monitor organisations to upload the information from standards of returned surveys. care in the last Repeat case note audit on those Date to be confirmed following review of days of life supported by LCP and those not on LCP, questions/standards and agreeing participants A in and out of hospital to undertake repeat audit. Identify and contact key people within BD/CW Dec Reconfiguration of strategy group, currently divisions /KS 2013 identifying people to join the group and re- Reconfigure Review and agree TOR’s writing terms of reference. Following MRG in September team asked to contact HOD’s for Palliative and Agree interim action plan pending review 8 divisional representation. R EofL Care of strategy Strategy groups Action plan commenced, yet to be finalised and agreed.

Work Stream Elective and Non Elective Surgical Workstream Aim Safer elective surgery and better urgent care outcomes Leads Daren Yates, Mr. Smith, Mr. Varghese and Dr Nethercott

No Key Aims Actions Who When Progress RAG Continued D Yates Oct Enhanced Recovery uptake with 3 1 Enhanced Formally integrate Enhanced Recovery to all 2013 consultants in colorectal. Plans for Recovery colorectal consultants, one by one. 4th Consultant to adopt in October. integration ER is a turnaround workstream and within Further develop Colorectal care pathway and therefore an ER steering group colorectal launch ERAS branding Trust wide. created to focus on Elective ER in surgery. areas of Urology, Breast and A Gynaecology, Colorectal. Seamless inclusion of End of October will see all colorectal new colorectal surgeons adopting ER surgeon once appointed. Continue Meet with Head of service and clinical leads to D Yates Jan ER in Women’s healthcare; 2 ERAS roll out Identify self as ER lead nurse. 2014 Gynaecology component agreed and A and integration Gain commitment form service. the procedures this will apply to, now within Set meetings and champions identified need to clarify who will take follow up Womens Care pathways calls for these patients. Breast ER Healthcare Business case being considered to ensure will be taken forward by an identified permanent Enhanced recovery involvement. Breast Specialist Nurse as she has previous ER experience. Ward manager To ensure entrenching of Gynae and Brestcare appointed for ERAS M1

Rollout to Initial meeting with breast pathway team. Await

Womens appointment of new nursing staff to support. Healthcare- Breast Roll out ER to Met with head of service. D Yates June Urology ER – first few patients are 3 Urology Miss Lee identified as clinical lead. 2013 starting to go through pathway R Mr Smith updated that a small team have commenced ER meetings to build on experience and expand ER into other services. Roll out ER to Met with Dr Darshan D Yates/Dr Oct ER for #NOF Pilot delayed until 4 MSK, initially # Assessment of how enhanced recovery Darshan/ Mr. 2013 October 2013 due to nurse NOF principles could facilitate better outcomes for # Wykes/ Linda vacancies. NOF patients. Woods/ Julie Pilot on hold until Oct 2013 (due to staffing Pilkington/ Process preparation completed with A issues) Claire Bailey exception of education to new BETTER /Temp starters to be delivered when URGENT Align and comply with national target of ERAS orthogeriatrici appointed. CARE incorporation into #NOF from April 2013 an- name OUTCOMES unknown.

Ortho # NOF ERAS discussion group meetings have finalised process and documentation. SAFER Explore possible use of pre CQUINS D Yates/ Dr Jan Assistance required to move forward 5 ELECTIVE qualification money for purchase of CPEX / Nethercott / 2014 within division to obtain relevant SURGERY- CPET technology to enhance pre op risk Dr Masheter funding to purchase a new CPEX BETTER assessment process. service. OUTCOMES Development Review of equipment requirements of improved ongoing. A pre operative risk assessment methods to bring Trust in

line with peer providers.

Review of Aim to use ODM with all high risk patients to ODM in use for all colorectal majors intra improve outcomes and reduce risk by April and P-Possum score >5% operative 2013.CQUIN award potentially available. assessment technologies to Roll out ODM training to all anaesthetists bring Trust in involved with Colorectal Enhanced Recovery line with peer and high risk patients. providers. Seek board support for formal integration of ODM use within Anaesthetic pathways. - May 2013 7 Use of Risk Formal integration of P-possum assessment in S. Leonard/ Nov Sister Leonard is completing P- Assessments all general surgical in patients (excluding day D.Nethercott/ 2013 possum pre-operatively on colorectal in patients on cases):- S. Corsan patients. This is cross-checked with Elective and Elective - part of pre assessment clinic Anaesthetists. Ready to roll out to A Emergency Agreed with Mr. Varghese that all surgical other pre-assessment nurses. Pathways emergencies (excluding O&G, Orthopaedic and Sometimes definitions of surgical Children) will have a P-possum score. grading and estimated blood loss differ, but otherwise going well.

Agreement reached for a P-possum mortality score for referral to the Anaesthetic Clinic. Suggestion that this should be patients with a mortality risk of 5% that are referred to the Anaesthetic Clinic. 11 Audit and Audit and monitoring P-possum usage J.Varghese/ Oct Dr Bene provided with the data from monitor use Audit tool to be designed, audit to be registered nominated 2013 Mr Varghese on P-possum usage for of P-possum with Clinical Effectiveness and a surgical trainee surgical emergency patients. scoring on to be identified and aligned to the audit. trainee/ A patients clinical effectiveness

12 Explore Emergency Laparotomy Pathway to be created Leads identified - feasibility of and implemented Dr Nov Dr John Roberts(anaesthesia) acute surgical Roberts/Mr. 2013 Mr. Dave Smith (surgery) pathway Register in the National Emergency Laparotomy Smith Audit (NELA) Dr Roberts has created an A emergency laparotomy pathway. Prior to implementation discussions with surgical colleagues to be commenced. Hopeful that only minor adjustments required to pathway before using.

Pathway will support the auditing of emergency laparotomy patients. Registered for NELA – to commence later this year. Mr Smith/Dr Price providing relevant information prior to project commencing.

Work Stream Respiratory Aim Reduce mortality in COPD and Pneumonia Leads Dr Ibrahim/M Bowden

No Key Aims Actions Who When Progress RAG Appropriate Review current practice to include; KI/MB October 2013 Meeting held with Matt Dunn 2 administration of Oxygen prescribing/administration (Advanced Practitioner, GMAS) A Oxygen in during interface/handover from GMAS and concerns expressed in ambulance/ to A/E staff relation to oxygen held in Emergency care Establish a small working group to ambulances. Informed there is no address these issues including GMAS space in ambulances to house any additional clinical equipment therefore an audit will need to gather supporting evidence that a change is required. Most patients in an ambulance receive oxygen at 6 litres as they are given a nebuliser in the vehicle and this is the minimum level required to deliver the nebuliser. Plan to audit patients and provide evidence (if found) that supports type 2 respiratory failure patients are compromised by not having smaller amounts of oxygen delivered during transit in an ambulance. Will also look at auditing oxygen usage once patient arrives in A/E. Additionally are looking into providing travel nebs for CO2 retainers if required in the ambulance. NWAS alert system – taking to clinical governance to

discuss how to incorporate into the alert system a notice to inform ambulance crew that someone from the address is likely to need controlled oxygen in the ambulance. Early Discharge proforma KI/MB October 2013 Meeting held with palliative care 5 identification of Work with palliative care team re best team and respiratory team have A EoLC in COPD/ practice of GSF agreed to use the amber care Respiratory Rapid Assessment tool i.e. COPD bundle. Pilot to start in January disorders admission care bundle 2014 for patients on virtual ward. Recognised trigger point - Implement Following pilot will meet and Amber Care Bundle discuss themes with palliative Virtual ward concept for high risk care team. Dr Ibrahim and patients – bronchiectasis & COPD Michaela Bowden to attend EofLC training for advanced care planning. 6 Aspiration Need to interrogate data on aspiration KI/MB October 2013 Case note review for aspiration Pneumonia pneumonia deaths further. pneumonia; proforma to be used case note Contact Janet Heaton to look at data has been agreed and case notes A review with increased RAMI being pulled with a view to To review case notes of 20 identified starting the audit patients of patients between Dec 12 – Jan 13 7 Reducing Design COPD admission care bundle KI/Tina Nov 2013 Tina Dewhurst leading on this mortality in Pilot bundle with respiratory nurse specialist – Dewhurst piece of work. COPD through once agreed rollout/launch for D1, D2 and A&E A appropriate as affects first few hours of care. Working group convening to use timely care COPD care bundle KEY: Anne Gerrard (AG) Clare Blaydon (CB) Mr. Dave Smith (DS) Dr. John Roberts (JR) Dr Ambar Basu (AB) Dr Brian Bradley (BB) Tina Dewhurst (TD) Dr Kim Steel (KS) Dr Gary Saynor (GS) Dr Jackie Bene (JB) Dr K Ibrahim (KI) Anita Nasser (AN) Dr Karen Lipscomb (DrKL) Dr Kieran Moriarty (KM) Dr Steven Little (SL) Dr Owen McCormack (OM) Kay Lewtas (KL) Dr Power (SP)

Mr. Steve Hodgson (SH) Helen Clarke (HC) Lisa Woods (LiW) Beatrice Fox (BF) Michaela Bowden (MB) Natalie Speakman (NS) Helen Clarke (HC) Linda Woods (LW) Darren Yates (DY)

Completed Actions:

No Key Aims Actions Who When Progress RAG 1 Improve Audit compliance / PDSA improvement AG / BF / annual Completed Feb – ongoing audits compliance with DP linking with Exemplar programme G EWS recording H@N working CB May Nurse Practitioners recruited, waiting vision 2013 start date. Band 3 support worker re- development Recruitment into team advertised and shortlisted for. Work being undertaken with G surgery/orthopaedics regarding level of support required out of hours Development of Escalation Policy to Maria October Agreed at Professional Forum in 1 Optimize trust support Exemplar Programme Sinfield 2012 September 12 the performance chosen `track assurance framework to support G and trigger ` nursing care indicators of which system in line clinical observations are an indicator with national model

Review + implement electronic data/ alert HC / JB Ongoing This piece of work has been systems – iBleep, Extramed, Patient track incorporated into hospital at night/out as feasible of hours review and review relating to hand held devices and completed from this workstream as review occurring in aforementioned meetings

Implement National EWS score / chart JW/AG/BF Jan 2013 National Score/Chart and Local trustwide including A&E (Exceptions Clinical Response Algorithm paediatrics/ maternity) implemented trustwide January 14th 2013 G Agree Clinical response algorithm via MRG MRG Improve compliance with EWS recording/ Mandatory EWS training / awareness at Carol Feb AG /CLB to finalise clinical induction documentation Trust induction LeBlanc 2013 session for NEWS Promote National E- learning package National e- learning training package G trustwide. to be promoted at Clinical Induction for medical and nursing staff

All NEWS training to include reference to E-Learning website 2 Improve / Delivery of study day to support level 1 AG/BF Completed – 1st study day delivered establish robust monitoring Future study days to be delivered as G response level 1 areas identified system to EWS

Repeat annual NICE 50 audit JW Autumn H@N working 2012 G vision

development Review of senior medical input model JB / DS Dec Linked to workshops relating to 2012 hospital at night/out of hours service G review therefore complete from this

workstream

H@N service future model JB/NE Sept Action complete and removed from 2012 workstream as being addressed within G hospital at night/out of hours review 4 Improve Regroup sepsis forum AG Achieved compliance with G Sepsis care bundles Agree action plan to address key themes including: Sepsis - standardising Trust sepsis audit form to Forum help collate numbers Sept - develop and pilot sepsis proforma in 2012 G A&E - Continued delivery of sepsis study day - Increase education / awareness among Next Oct CSQI presentation May 2012 AG-EW senior medical staff 2012 FY1/FY2 session June 2012/ Sept - Develop / offer sepsis education 2012- JW/AG - delivered sessions to individual specialties Ongoing O+G medical staff session Sept 2012- - Engage Director of Medical Education AG/JW – delivered in Sepsis Forum Achieved Next full sepsis study day 18/10/12 Ongoing audits to identify key themes / Sepsis Ongoing Audits to be completed on a quarterly issues impacting on compliance Forum basis and presented to MRG. Audit G form re-designed and circulated for Review new 2013 sepsis guidance comments.

Trustwide generic Sepsis Audit form CW March Results of Audit to be presented at developed and being piloted by Junior MRG in March 2013 Doctors 5 Reduce Trust engagement in National Cardiac Resus Achieved avoidable arrest audit Officer G cardiac arrest

Continue roll out of RCA of cardiac arrests Targets set are: within individual specialties SJT / MT July Reducing avoidable cardiac arrests by Defined need to involve specialty teams in 2013 10% per year and increasing RCA’s addressing the findings – core independent completed for Cardiac Arrests to G team to undertake initial review and hand >80% by June 2014 and >95% by on to teams for emerging themes/ learning 2015. Departmental Governance would be the Dr Thornton to present repeat audit in appropriate forum for this July 2013. CA RCA reviews not SJT to present latest RCA collated embedded into divisions, yet MDT feedback June 2013 MRG review crucial to aid learning. HOD’s to discuss with clinical leads and incorporate RCA reviews within Mortality & Morbidity meetings identify nominated consultants to get behind undertaking CA RCA’s with divisional reviews occurring similar to CDiff/MRSA/HAVTE – currently poor clinician involvement in RCA’s so nominated clinicians to address RCA’s in context to these and not just CA RCA’s. CA review proforma to be circulated via Dr Thornton, but divisional dialogue to run alongside this. Dr Grey suggests that as Mortality and Morbidity reviews occur in all specialties then this is where they could start discussions and undertake reviews. Suggestions include that junior doctors can do a case review and share the learning within specialties.

No Key Aims Actions Who When Progress RAG Develop education for the following staff KL/TG July Education –plans for Friday Develop groups to strengthen knowledge on heart 2012 lunchtime meetings with Elderly education for failure and AQ measures: Care Consultants and junior doctors. staff in Heart Junior doctors (every 4 months) Failure and Consultants Adopting a buddy system whereby associated AQ D1/D2 staff each Cardiologist will ‘buddy’ an measures Nursing (acute adult division) elderly care ward round 2-3 times a Active case managers week. Meeting to finalise the division of elderly care wards amongst cardiologists to buddy.

1 Carmel Wiseman to start GSF G

training for nursing staff. The HF monthly MDT Forum will also help to identify patients reaching ceiling treatment and end of life.

Active case managers attending MDTs with linked person assigned to them. Will repeat this model in elderly care as a rollout.

Develop further and strengthen existing GB/TG Oct Monthly MDT Heart Failure training in key areas to nursing staff 2012 commenced August 2012 (cardiology, assessment areas) for smoking cessation. PJS and Steve Little to validate diagnosis in notes prior to submitting G into AQ

Review clerking proforma in relation to KL/AK May 2013 Smoking cessation screening smoking cessation screening questions questions now formulate part of the nursing and assessment care document G

Review the current system in place for ST June Echo request form re-designed and Effective and accepting and prioritising echo requests for 2012 currently in printing. New forms in 2 timely diagnosis suspected new diagnosis of heart failure with admission areas initially to aid G of Heart Failure detailed capture of clinical information required prioritising echo requests. for decision making and prioritizing requests.

ECHO requests: Timely requests for new TG/ST June New ECHO cards are printed and inpatient diagnosis of heart failure 2012 placed in clinical areas/wards to allow ECHOs to be prioritorised. G

Appropriate and Undertake a service improvement event with KL/TG April-Dec RIE 10-13th April 2012 – action 3 safe BICs department and key staff within specialty 2012 planned developed and in place. G management and treatment of Heart failure pathways created, Heart failure laminated and situated on notes trolleys. Same model will be adopted and go to complex care wards. Re-organise Cardiologists on call schedule to KL April-Dec Monthly Heart Failure MDT meetings allow set time to undertake consultant rounds 2012 for case reviews. Cardiologists will G in the assessment areas to identify and pull buddy wards. through heart failure patients. BICs RIE planned for May 14th to look at KL/TG July 2012 Completed Cardiology Rapid Access Clinics G Monitor Heart failure emergency admission TG April-Dec 48 hour post discharge and rates, re-admission rates and hospital bed day 2012 diagnosis follow up phone call with G occupancy. use of a proforma being trialed to aid avoidance of re-admission.

Established use of patient hand held records with patients being given supported control in condition management. Participate in the National Heart Failure Audit; LW Ongoing Undertaking audit for past 6 weeks commences in April 2012 which is already highlighting where G the problems lie. The themes encourage the continuation of plan to buddy elderly care wards. Has

been helpful in identifying that the primary diagnosis is not HF.

Advancing Quality Heart Failure Audit KL Ongoing Continuation of a perspective and prospective data collection. Awaiting G results. Agree a pathway to support safe removal of an PS/SL August Monthly forum has been launched Raising Implantable Cardioverter Defibrillator (ICD) in 2012 and have an interim arrangement in 4 awareness and heart failure patients when identified as dying place for ICD switch off at end of life. G recognition to and commenced on the Liverpool Care The Cardiac Network ICD End of Life Care Pathway. Deactivation Policy will be formally for Heart Failure endorsed at the Cardiac Network patients Board Meeting on 8th November. Dr Little is a member of the working group and attending the meetings. To take forward High Impact Actions; Important KL/TG/ Nov Choices, identifying End of Life and Palliative 2012 GSF: discussions as part of the communication of this with patient and family care monthly forum re End of Life in and facilitating patients to die at their place of team/JB place, proactive use of Specialist choice. Palliative Care team for end stage heart failure certainly on C1 and recommendations going on ASCRIBE to GPs for GSF. G

Work Stream End of Life Care (EoLC) Aim To support delivery of high quality care in the last year of life, including promoting and enabling patient’s choice and delivering of high quality care of the dying Leads Dr Marion Lieth

No Key Aims Actions Who When Progress RAG

1 Improve Expand membership of ‘Bolton Palliative BD/ML May ‘12 May ’12 - Helen Clarke, Linda Woods Care and EoLC Strategy Group’ to and Anne Cleary now members of engagement and awareness strengthen representation from acute ‘Bolton Palliative Care and EoLC of EoLC within trust at strategic meeting Strategy Group’ G trust Undertake baseline assessment of CW March 13 Baseline assessment completed Earlier practices who have signed up to the Meeting with triple aim completed 4.2.13. identification of campaign

those at the end 1. of life in primary Undertake proactive visits to each GP care by Practice visits have commenced practice SF Jan – Dec 13 supporting GPs G to increase their awareness & Jan-Dec 13 sign up to the Work collaboratively with the Triple Aim BD/CW Earlier identification & 1% campaign is incorporated in Palliative & EoLC training Dying Matters team to support the EoLC project which 1% Campaign incorporates the 1% campaign GP training event to be arranged May 2013 by Triple Aim team

st Explore & Attend regional workshops CW Jan-March 13 1 workshop attended 31.1.13 nd understand 2 workshop attended 21.3.13 further the benefits and resource implications of 2. implementing the Amber Care G Bundle across RBH to improve earlier identification of those at the end of their life in acute hospital Develop EoLC objectives for trust overall ML Mar ‘12 March ’12 – 1st meeting with HC, MS, 2 EoLC AC, LW, CWi, Steve Wilson, ML; agreed developments to develop EoLC objectives for trust to G thoughout support EoLC developments throughout divisions divisions 3. Reduce missing data on LCP and ML/CW Jan 13 Facilitator project till end of Jan 13, 2 ½ G Embed use of improve documentation days per week, extending to 3 further LCP within RBH wards (D1, D2, C1) and continuing B3, B4, C3, D3, D4; final report early 2013 Review action plan for National Care of BD/CW April13 Completed - Meeting with BD & CW 26.4.13. Action plan reviewed. the Dying Audit Acute Hospitals Revised action plan completed G

Register for round 4 of the National LCP JS Sept13 Registration for involvement in the audit National LCP audit completed. Data Entry period opens 1st Sept 2013 Data Entry period closes 30th Nov 2013 Bereaved Relative Survey 28th Feb 2014 G Final Audit report 2014

During the Complete registration on national LCP BD/CW Dec 2013 Registration completed phasing out of /KS the LCP maintain and 7 G monitor standards of care in the last days of life 4. RBH staff Able to report attendance at Pall Care ML/ July ‘12 Attendance database developed and has G appropriately and EoLC training based on divisions/ CW been in use since 1st September 2012 trained in EoLC professional groups Bolton FT to have representation on the CW Feb 13 Completed Develop a Network Education Strategy Group G training & education Cross reference Bolton FT training CW March 13 Completed strategy which programme with network programme G is consistent 4. when final version released with the Network Review priorities for training & education CW May 13 Meeting held 22.5.13 and priorities Education as Palliative & EoLC educator has left agreed until Dec13 G Strategy the organization & agree membership of Education Strategy group meeting a group who will develop a local strategy arranged for 30.7.13 Agree data collection & reporting CW/S June 13 Meeting held 4.6.13 with contracts dept. 5. Support G achievement of requirements W/BD Data collection & reporting requirements

EoLC CQUIN agreed Develop data collection & reporting CW July 13 Data collection & reporting systems systems developed further G

Arrange meeting with DN managers SW/C July 13 Meeting held 10.6.13 & 26.6.13 with CW, W SW & DN managers. Action plan G developed and agreed with the DN teams involved. Deliver training and education for the SF June 13 Training programmed developed and G teams involved delivery dates agreed

Work Stream Enhanced Recovery Aim Integration of Enhanced Recovery as Standard Practice Leads Daren Yates

No Key Aims Actions Who When Progress RAG 5 SAFER Formal integration of anaesthetist assessment D Yates/ S. Ongoing Achieved ELECTIVE and presence as part of pre assessment clinic Leonard G SURGERY- for all colorectal surgery. BETTER Explore assessment tools. Dr Ongoing Compliant with NICE guidelines OUTCOMES Nethercot/ 2003 in pre-assessment clinic – full Explore and review NICE guidelines. Daren 26/06/12 nutrition and skin integrity Development Yates assessment completed so actions of improved can be taken prior to surgery to pre operative optimize patients for surgery. risk assessment Explore NICE guidelines. G methods to bring Trust in line with peer Explore and review professional bodies providers. guidance. Free loan of equipment agreed in Explore and review possible use of pre CQUINS principle. Review of qualification money or other funding sources for intra intra operative technologies support. Regional Innovation fund money operative Increased the use of intra-operative assured to purchase ODM assessment oesophageal doppler monitoring. equipment. technologies to bring Trust in line with peer providers. 6 Use of Risk Possum Scoring – discuss use of possum Daren P-possum incorporated into surgical Assessments scoring with patients for Elective and Non Yates/Mr clerking proforma. Communication

in patients on Elective patients Varghese/ on action being coordinated to Elective and Anaesthetist surgical teams. Agreement reached G Non Elective Creation of a range of risk assessments for use that emergency surgical patients Surgical in surgery with audit and monitoring of their being booked into emergency Pathways usage. theatres provide a P-possom score for patient on booking. 8 Agree a Devise a protocol/flowchart which enables those S. Leonard/ April Team to incorporate into current process to undertaking P-possum scoring to escalate ‘high D.Nethercot 2013 process use of P-Possum. Alerts for ensure all risk patients’ to Anaesthetist. t/S. Corsan high risk patients are now being G high risk Alert of high risk patients to be identified on inputted into LE2.2 by anaesthetic patients are LE2.2 – agreement to highlight who will input the secretaries. alerted to alert onto LE2.2 Anaesthetists 7 Use of Risk Formal integration of P-possum assessment in J.Varghese April Trial of P-possum scoring for all in- Assessments all general surgical in patients:- 2013 patients commenced in January. in patients on Emergency – include into booking process for all Piece of work being led by Surgeons Elective and emergencies who will be completing this Emergency assessment to identify high risk Pathways patients early and refer them as G necessary. P-possum scoring to be included as part of booking process and checked when patients being placed onto emergency theatre list. Dr Corsan updated that since previous update, Mr. Varghese may have altered the remit of patients requiring P-Possum. Nashaba Ellahi to clarify with Mr. Varghese. 9 Improve Include into specialty training programme for J.Varghese April Matron within Elective care (Janet Training and surgical doctors the use of P-possum and 2013 Howarth) is progressing with all Education on relevant understanding of undertaking. surgical PC’s having icon for risk use of P- Encourage use of free website amongst surgical scoring – on target to achieve by possum for teams: riskprediction.org.uk February. Surgical Risk application G surgical Arrange desktop icon for risk scoring tool above to be applied to identified surgical

trainees to be available on PCs on surgical wards for PCs on 18/02/13. Nottingham Hip ease of use by teams Fracture Score apps not required as Mr. Wykes has incorporated an appropriate scoring system into the Hip Fracture Care Pathway. 10 To closely To encourage clinical engagement with coding, J.Varghese April Discussions of all mortalities take observe and reviewing and validating coding of live patients 2013 place in audit meetings. Further align clinical but also of deaths. discussions to take place within G coding of co- To identify a clinical coder and lead surgeon to division to agree a standard to morbidities in take above forward. identify deaths that require further collaboration validation. Mr. Varghese to discuss with coders with Coding and Dr Ibrahim to explore if they can make any improvements.

Work Stream Respiratory Aim Reduce mortality in COPD and Pneumonia Leads Dr Ibrahim/M Bowden

No Key Aims Actions Who When Progress RAG Appropriate Early respiratory assessment KI/MB/HO September Still reviewing risk stratification 3 treatment 7days/week 2012 tools. 7day nursing service G pathway during Risk stratification onwards resumes Nov 2012. Consultant 7 th in-patient stay of COPD care bundle/ICP day working due to start 13 COPD Liaise with palliative care team re early October identification of patients 1 Accurate Audit notes of deaths 2011 KI/MB/HO June 2012 This action to be monitored and G reflection of Live data collection at coding on a onwards tracked in Respiratory current practice weekly basis Governance Meetings with 6 Share information with respiratory team monthly feedback on audit and mortality reduction group findings

Appropriate Early respiratory assessment BB/ October Education tool for pneumonia in 4 treatment 7days/week 2012 place since October 12. Recent G pathway during Risk stratification onwards agreement that specialist nurses in-patient stay of Pneumonia care bundle/ICP will have linked areas/wards Pneumonia Education programme for assessment where they will take forward areas training, education and audit. Education programme for non- respiratory ward areas

Quarterly Mortality Report

Report No. 01

August 2013

Edition prepared for:

Royal Bolton Hospital NHS Foundation Trust

Report prepared for Page 1 of 24 FileName Author:Royal Paul Bolton Hawgood Hospital NHS Version 0.4 Foundation Trust 5th June 2013 Version:by AQu.A 1.1 Analytics

Contents

INTRODUCTION ...... 1

SECTION 1 – The North West ...... 2 1.1 Crude Mortality Rate ...... 2 1.2 SHMI ...... 3 1.3 SHMI – proportion of deaths that occur in-hospital...... 6 1.4 SHMI – diagnosis groups ...... 7

SECTION 2 – Trusts in the North West ...... 8 2.1 Crude Mortality Rate ...... 8 2.2 SHMI ...... 9 2.3 Palliative Care coding ...... 9 2.4 Signs and Symptoms coding ...... 11 2.5 Co-morbidity ...... 13

SECTION 3 – Your Trust ...... 14 3.1 Crude Mortality Rate ...... 14 3.2 SHMI ...... 15 3.3 Palliative Care Coding ...... 15 3.4 Signs and Symptoms coding ...... 17 3.5 Co-morbidity ...... 18

Appendix A: Differences between HSMR, RAMI and SHMI

Appendix B: Metadata

Contents Page AQuA Quarterly Mortality Report Issue 01 Version 1.1 5th September 2013

INTRODUCTION

This is the first quarterly report on Mortality produced by AQuA Analytics for the benefit of its members.

The report provides information on mortality rates, indicators of the quality of care and system/process measures that may affect the quality of care. The report does focus on the data, however, this is only one part of understanding the issues that may affect a Trust’s mortality rate. They are an indicator, a sign-post, a prompt to looking at the wider system issues; these issues and themes are explored in detail in AQuA’s Mortality Lessons Learned publication (May 2013).

Many of the indicators contained within this report relate to Standardised Mortality Ratios. There are several different methodologies available for the calculation of these ratios – see Appendix A for a summary of the differences between the three main methodologies. Throughout this report, data relating to the Summary Hospital-level Mortality Indicator [SHMI] has been used. This is because this is the methodology used and published by the NHS Health and Social Care Information Centre [HSCIC].

This report is set out in three sections:

Section 1 compares the North West with other regions of England. Section 2 looks at the differences in data for the 22 Trusts in the North West for which the NHS HSCIC produces a SHMI. Section 3 provides more detailed information for your trust.

Some inferences and conclusions have been drawn from the data, however, this often needs to be set in the context of the wider health-economy. AQuA has a rolling programme of Mortality Reviews in order to support the understanding of issues surrounding mortality and the quality of care provided in a Trust and the health economy that it serves. Detailed trust- level analysis and inferences are best placed within this programme.

This report has been prepared following the publication of the SHMI for the period January to December 2012; Appendix B details the metadata for the information contained within this report.

Report prepared for Page 1 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

SECTION 1 – The North West

1.1 Crude Mortality Rate

The North West has the fifth lowest crude in-hospital mortality rate in England with a rate that is similar to the overall rate for England – see chart 1. The rates for both England and the North West have been reducing over the past four years – see chart 2.

Chart 1 – crude in-hospital mortality rate

Chart 2 – crude in-hospital mortality rate time series

Report prepared for Page 2 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Across the former SHAs, crude mortality rates for non-elective [NEL] activity are between 5 and ten times higher than for elective [EL] activity; the crude NEL mortality rate for England being 2.7% and the crude EL mortality rate for England being 0.4% (nearly 7 times higher) – see chart 3. A similar pattern is seen for deaths occurring within 30 days of discharge. When reviewing the underlying causes of high(er) mortality rates, it would, therefore, be beneficial to explore pathways relating to emergency care.

Chart 3 – crude in-hospital mortality rate, NEL & EL split

1.2 SHMI

This report does not aim to describe the SHMI methodology in detail, nor to compare the SHMI methodology to other methodologies e.g. HSMR. Appendix A shows a summary of the differences between the three main methodologies and further information is available from AQuA Analytics.

Although the North West has the fifth lowest crude mortality rate in England, it has the highest SHMI – see chart 4. In essence, this means that the low crude mortality rate is to be expected given our demographic make-up, the case-mix that we treat and the other illnesses that our patients have. Indeed, our current SHMI of 1.07 means that it is expected that our crude rate should be lower.

Report prepared for Page 3 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Chart 4 – latest SHMI

The SHMI for the North West has been worsening since the indicator was first published for the period Apr 2010 to Mar 2011. [The HED analytical tool re-creates SHMI to a high degree of accuracy which does, therefore, allow for calculations to be made for periods prior to the first publication – see chart 5.]

Chart 5 – NW SHMI time-series

Report prepared for Page 4 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

As was seen in chart 2, the crude mortality rate for the North West is falling but no faster than it is for England. The SHMI is a relative-risk model centered around England having a value of 1.00 for each publication. The fact that our SHMI is increasing over time [against a back-drop of a reducing crude mortality rate] means that the SHMI-constructed risk model is expecting relatively fewer deaths in the North West each time the SHMI is published and that our reduction in Observed deaths is not keeping pace with this reduction in Expected deaths.

Factors that affect this risk model such as Signs and Symptoms coding and levels of co- morbidity are described later in the report.

The impact of the modelling is illustrated further in chart 6. It shows that, for each SHMI period apart from the latest publication, the number of Expected deaths has reduced. Although our crude mortality rate has also reduced [as supported by the reduced number of Observed deaths], this has not been at the same rate as the reduction in the number of Expected deaths – indeed, there has been a small increase in Observed deaths in the three most recent publications.

Chart 6 – NW SHMI Observed & Expected deaths time-series

Report prepared for Page 5 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

1.3 SHMI – proportion of deaths that occur in-hospital

The SHMI is calculated using deaths that occur in-hospital and those that occur within 30 days of discharge. Chart 7 shows the proportion of the total number of deaths that have occurred in-hospital. Low levels of in-hospital deaths could be due to several factors including patients being discharged too early and high levels of nursing, residential and hospice care. The North West has a similar rate to the England average.

Chart 7 –% deaths in-hospital

Chart 8 – % deaths in-hospital time-series

Report prepared for Page 6 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

1.4 SHMI – diagnosis groups

For the purposes of constructing the SHMI risk model, the thousands of ICD10 codes are grouped into 140 groups of similar conditions – these are known as CCS Groups*. The number of Expected deaths is calculated for each CCS Group, compared to the Observed number of deaths for that CCS Group and hence a SHMI calculated for that Group. CCS Groups that have a high SHMI value may relate to conditions of low volume. It is, therefore, more appropriate to be aware of the conditions that have the highest variance between the number of Observed deaths and the number of Expected deaths (often referred to as the number of Excess deaths) – see chart 9.

Chart 9 – excess deaths in NW by SHMI CCS Group

* CCS stands for Clinical Classification System. Each ICD10 code is mapped to one of 260 CCS Categories; these 260 Categories are then mapped to one of 140 CCS Groups. A full list of the descriptions of each Category, of each Group and the related mapping is available from AQuA Analytics.

Report prepared for Page 7 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

SECTION 2 – Trusts in the North West

2.1 Crude Mortality Rate

Based upon the latest published data, crude in-hospital mortality rates in North West hospitals varies from 1.6% to 3.3% - a two-fold difference – see chart 10.

Chart 10 – crude in-hospital mortality rate by trust

There is a similar degree of variance for in-hospital deaths for non-elective admissions – from 1.9% to 4.0% - see chart 11.

Chart 11 – crude in-hospital NEL mortality rate by trust

Report prepared for Page 8 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

2.2 SHMI

Chart 12 shows the latest SHMI together with the range of the 95% Confidence Interval for the 22 Trusts in the North West of England.

Chart 12 – latest SHMI by trust

2.3 Palliative Care coding

The Health and Social Care Information Centre publishes some contextual information for domains that are not accounted for in the SHMI – one of these domains is Palliative Care. A patient can be deemed to have received Palliative Care by virtue of Specialty Code 314 being present in any other their episodes or by having ICD10 Code Z515 in any diagnosis in any episode. The charts below [13 and 14] show the rate of coding where either the Specialty Code or the Diagnosis Code is present during the Spell; chart 13 is for all patients and chart 14 is where the patient died.

Report prepared for Page 9 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Chart 13 – Palliative Care coding by trust, all patients

Chart 14 – Palliative Care coding by trust, patients died

Report prepared for Page 10 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

2.4 Signs and Symptoms coding

The level of Signs and Symptoms coding [R codes] is important because it has inferences on the quality of care and has an impact on the calculations used to create the SHMI.

High levels of R codes may imply lower access to senior medical opinion and later commencement of appropriate treatment. If R codes remain as the primary diagnosis through the first few episodes of a patient’s pathway then this could be indicative of multiple hand-overs within a short period of time i.e. during the period of diagnostic investigation.

R codes remaining as the primary diagnosis for the first 2 episodes affects the calculation of the SHMI, usually in an adverse way. The SHMI uses the primary diagnosis of the first episode to assign the CCS Group of that admission. If the primary diagnosis of the first episode is an R code then the primary diagnosis of the second episode is used. However, should the diagnosis of the second episode also be an R code then the SHMI will revert back to the first episode’s primary diagnosis.

The CCS groups that R codes map to have relatively low mortality rates and, therefore, low numbers of expected deaths. If a trust has a high level of R coding then it is more likely to have a higher level of deaths with an R code as the primary diagnosis (first and second episode). In turn, this will raise the number of excess deaths for that CCS group and, ultimately, the total for the trust.

Chart 15 shows the general use of R Codes – there is a two-fold difference between the trust with the highest usage of R codes in the primary diagnosis [24.6%] (all episodes of a Spell where the first episode was non-elective) and the trust with the lowest [12.2%].

Chart 15 – Signs & Symptoms coding by trust, NEL, all episodes, all patients

Report prepared for Page 11 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Chart 16 shows the use of R Codes in the first episode – here, there is also a two-fold difference between the trust with the highest usage of R codes in the primary diagnosis [19.9%] and the trust with the lowest [9.7%].

Chart 16 – Signs & Symptoms coding by trust, NEL, first episode, all patients

As outlined above, the impact of high levels of R coding on a trust’s SHMI would be greatest where a patient has died. The patients reported in chart 17 will also have been reported in charts 15 & 16 so chart 17 focuses on the last episode. This highlights the incidence of a definitive diagnosis not having been recorded by the time the patient has died. In this area, a much greater variance between trusts is observed [from 5.5% to 0.4%].

Chart 17 – Signs & Symptoms coding by trust, NEL, patients died

Report prepared for Page 12 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

2.5 Co-morbidity

Levels of coding are important for several reasons. Accurate and comprehensive recording of co-morbidities will better reflect the state of health of the patients that the trust is treating. Lower levels may be due to:

this information not being recorded by the clinician in the patient’s notes this information not being recorded clearly enough this information not being recorded fully on the Trust’s PAS healthier patients

Levels of co-morbidity are used in both the SHMI and HSMR. A relatively high level of co- morbidity increases the expected number of deaths in these calculations and so has the effect of reducing the standardised mortality ratio.

Comparative levels of co-morbidity are arrived at using the Charlson Co-morbidity Index. This Index assigns a weighting to 17 different conditions – the higher the weighting, the higher the perceived impact of that co-morbidity on a patient’s risk of dying. A full list of these conditions, their weighting and the underlying ICD10 codes used are available on request from AQuA Analytics.

For non-elective episodes, there is a fair range of average Charlson values per episode between trusts in the North West [from 3.3 to 5.8] – see chart 18. This may be a reflection of the relative health of the population that each trust serves but it could also reflect more comprehensive coding processes.

Chart 18 – Co-morbidity score by trust, NEL

Report prepared for Page 13 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

SECTION 3 – Your Trust

This section shows information for your Trust. The North West edition of this report is not specific to any particular trust; there is, therefore, no data to show in the “Trust” row of the tables below.

The data relates to the same domains as in Section 2 but shows a time-series in order to show whether areas are showing improvement or deterioration.

Trust Name Royal Bolton Hospital NHS Foundation Trust Trust Code RMC

3.1 Crude Mortality Rate

Fin. Year 2009/10 2010/11 2011/12 2012/13 Trust 2.85% 2.57% 2.39% 2.08% North West 2.68% 2.49% 2.36% 2.34% England 2.65% 2.41% 2.34% 2.28%

Crude in-hospital Mortality Rate 2.9%

2.8% 2.7% 2.6% 2.5% 2.4% 2.3% 2.2%

Percentage ofdischarges 2.1% Source: HED 2.0% 2009/10 2010/11 2011/12 2012/13

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 19 – trust crude in-hospital mortality rate time series

Report prepared for Page 14 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

3.2 SHMI

Period Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Mar 11 Jun 11 Sep 11 Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Trust 1.05 1.05 1.04 1.07 1.06 1.03 1.01 1.01 North West 1.05 1.06 1.06 1.05 1.05 1.06 1.07 1.07

SHMI 1.10

1.05

1.00 Index

0.95

Source: HED 0.90 Apr 10 - Jul 10 - Jun Oct 10 - Jan 11 - Apr 11 - Jul 11 - Jun Oct 11 - Jan 12 - Mar 11 11 Sep 11 Dec 11 Mar 12 12 Sep 12 Dec 12

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 20 – trust SHMI time-series

3.3 Palliative Care Coding

The first table and chart relate to all patients admitted; the second table and chart relate to patients that died.

Period Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Mar 11 Jun 11 Sep 11 Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Trust 0.9% 0.9% 0.9% 1.0% 1.0% 1.0% 1.0% 1.0% North West 0.89% 0.87% 0.88% 0.95% 0.92% 0.95% 1.00% 1.04% England 0.89% 0.88% 0.91% 0.95% 0.99% 1.02% 1.04% 1.06%

Report prepared for Page 15 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Palliative Care Coding: All Patients (Combined: Diagnosis and Specialty)

1.1%

1.0%

0.9%

Percentage ofdischarges Source: HSCIC 0.8% Apr 10 - Jul 10 - Jun Oct 10 - Jan 11 - Apr 11 - Jul 11 - Jun Oct 11 - Jan 12 - Mar 11 11 Sep 11 Dec 11 Mar 12 12 Sep 12 Dec 12

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 21 – trust Palliative Care coding time-series, all patients

Period Apr 10 - Jul 10 - Oct 10 - Jan 11 - Apr 11 - Jul 11 - Oct 11 - Jan 12 - Mar 11 Jun 11 Sep 11 Dec 11 Mar 12 Jun 12 Sep 12 Dec 12 Trust 16.5% 16.8% 17.2% 17.4% 18.9% 19.0% 19.7% 20.3% North West 16.4% 15.9% 15.7% 15.8% 16.7% 17.1% 18.1% 18.7% England 16.6% 16% 16.4% 17.2% 17.9% 18.4% 18.9% 19.1%

Palliative Care Coding: Patient Died

(Combined: Diagnosis and Specialty) 22%

20%

18%

16% Source: HSCIC 14% Apr 10 - Jul 10 - Jun Oct 10 - Jan 11 - Apr 11 - Jul 11 - Jun Oct 11 - Jan 12 -

Percentage ofdeaths [in/outofhospital} Mar 11 11 Sep 11 Dec 11 Mar 12 12 Sep 12 Dec 12

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 22 – trust Palliative Care coding time-series, patients died

Report prepared for Page 16 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

3.4 Signs and Symptoms coding

All non-elective FCEs.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13 Trust 21.1% 15.5% 16.8% 15.9% 13.0% North West 18.6% 18.1% 17.8% 17.3% 16.2% England 16.1% 15.8% 15.6% 15.1% 14.8%

NEL FCEs with an R Code as the primary diagnosis 24%

21%

18% Percentage 15%

Source: HED 12% 2008/09 2009/10 2010/11 2011/12 2012/13

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 23 – trust Signs & Symptoms coding time-series, NEL, all patients

First Episode of the non-elective Spell.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13 Trust 21.3% 16.7% 18.1% 17.1% 13.9% North West 19.4% 19.1% 18.8% 18.4% 17.4% England 17.0% 16.5% 16.5% 16.0% 15.9%

NEL FFCEs with an R Code as the primary diagnosis 22%

20%

18%

16% Percentage 14% Source: HED 12% 2008/09 2009/10 2010/11 2011/12 2012/13

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 24 – trust Signs & Symptoms coding time-series, NEL, all patients Report prepared for Page 17 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Last Episode of the non-elective Spell where the patient has died.

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13 Trust 6.2% 2.2% 1.8% 1.4% 0.7% North West 4.7% 3.3% 2.6% 2.2% 1.8% England 4.1% 3.4% 2.8% 2.3% 2.1%

NEL FFCEs with an R Code as the primary diagnosis of the last Episode - patient died 8%

4% Percentage 2%

Source: HED 0% 2008/09 2009/10 2010/11 2011/12 2012/13

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 25 – trust Signs & Symptoms coding time-series, NEL, patient died

3.5 Co-morbidity

Fin. Year 2008/09 2009/10 2010/11 2011/12 2012/13 Trust 2.5 2.9 3.4 3.3 3.4 North West 3.1 3.4 3.8 3.9 4.1 England 2.9 3.2 3.5 3.8 4.1

Charlson Co-morbidity Index - NEL episodes

3 Average Average ScoreperEpisode Source: HED 2 2008/09 2009/10 2010/11 2011/12 2012/13

Royal Bolton Hospital NHS Foundation Trust North West England

Chart 26 – Charlson Co-Morbidity Index time-series, NEL

Report prepared for Page 18 of 18 AQuA Quarterly Mortality Report Royal Bolton Hospital NHS Issue 01 Foundation Trust Version 1.1 by AQuA Analytics 5th September 2013

Appendix A: Differences between HSMR, RAMI and SHMI

Hospital Standardised Risk Adjusted Mortality Summary Hospital-level Mortality Rate (HSMR) Index (RAMI) Mortality Indicator (SHMI) **

Observed All spells culminating in death Total number of observed in- Number of observed in- at the end of the patient hospital deaths hospital deaths plus deaths pathway, defined by specific out of hospital within 30 days diagnosis codes for the of discharge primary diagnosis of the spell: uses 56 diagnosis groups which contribute to approx. 80% of in hospital deaths in England*

Expected Expected number of deaths Expected number of deaths Expected number of deaths Calculated using a 10 year Calculated using a 36 month data set (as of 2012) to get data set to get the risk the risk estimate estimate Adjustments . Sex . Sex . Sex . Age in bands of five up . Age . Age group to 90+ . Clinical grouping (HRG) . Admission method . Admission method . Primary and secondary . Co-morbidity . Source of admission diagnosis . Year of dataset . History of previous . Primary and secondary . Diagnosis group emergency admissions Procedures in last 12 months . Hospital type . Month of admission . Admission method Details of the categories . Socio economic above can be referenced deprivation quintile from the methodology (using Carstairs) Further detailed methodology specification document at . Primary diagnosis based information is included in http://www.ic.nhs.uk/services/ on the clinical CHKS products, or specific classification system summary-hospital-level- enquiries to CHKS . Diagnosis sub-group mortality-indicator-shmi . Co-morbidities based on www.chks.co.uk Charlson score . Palliative care . Year of discharge Exclusions Excludes day cases and Excludes mental illness, . Specialist, community, regular attendees obstetrics, babies born in or mental health and out of hospital, day cases, independent sector hospitals. and patients admitted as . Stillbirths emergencies with a zero . Day cases, regular day length of stay discharged and night attenders alive and spells coded as palliative care (Z515)

Whose data is All England provider trusts via UK database of Trust data All England non-specialist being compared SUS and HES acute trusts except mental and how much data health, community and is used for Data attributed to all Trusts Data attributed to Trust in independent sector hospitals. comparison e.g. all within a ‘super-spell’ of which patient died trusts or certain activity that ends in death Data attributed to Trust in proportion etc. which patient died or was discharged from

*HSMR does not exclude 20% of deaths, it looks for the diagnosis groups that account for the majority of deaths, and the figure of 80% is quite variable dependent on the case mix of the trust. HSMR could just as easily cover 100% of activity. It covers 80% of activity mostly for historical reasons and the fact that you get little extra value from the other 20%.

** The HSCIC publishes the SHMI indicator as observed, expected, denominator, value, upper control limits, lower control limits and banding. The term numerator is not used in the publication.

Annex B: Metadata

Resource Title Description Coverage Numerator Denominator Date Publisher Source Status type Mortality Charts 1 Crude in- 142 SHMI Discharge Method All discharges Latest published HSCIC HED Published & 10 hospital Trusts = 4 SHMI (12 month mortality rate period) Mortality Charts 2 Crude in- 142 SHMI Discharge Method All discharges 1.4.2009 – HSCIC HED Published & 19 hospital Trusts (22 in = 4 31.1.13 mortality rate North West) Mortality Charts 3 Crude in- 142 SHMI Discharge Method All discharges Latest published HSCIC HED Published & 11 hospital Trusts = 4 SHMI (12 month mortality rate period) Split as per Appendix B.3 of the SHMI Indicator Specification i.e. Elective = Admission Method 11, 12, 13 Acute [NEL] = 21, 22, 23, 24, 28, 31, 32, 81, 82, 83, 84, 89, 98 Mortality Chart 4 SHMI 142 SHMI Observed deaths Expected deaths Latest published HSCIC HED Published Trusts SHMI (12 month period) Mortality Charts 5, NW SHMI 22 Trusts in Observed deaths Expected deaths Latest published HSCIC HED Published 12 & 20 North West SHMI (12 month period) Mortality Chart 6 Observed and 22 Trusts in N/A N/A October 2009 – HSCIC HED Published Expected North West December 2012 deaths

Appendix B - Metadata Page i of iii AQuA Quarterly Mortality Report Issue 01 Version 1.1 5th September 2013

Resource Title Description Coverage Numerator Denominator Date Publisher Source Status type Mortality Chart 7 % Deaths 142 SHMI Discharge Method Discharge Method Latest published HSCIC HED Published occurring in- Trusts = 4 = 4 plus deaths SHMI (12 month ONS hospital from the HES-ONS period) linked mortality data file Mortality Chart 8 % Deaths 142 SHMI Discharge Method Discharge Method October 2009 – HSCIC HED Published occurring in- Trusts (22 in = 4 = 4 plus deaths December 2012 ONS hospital North West) from the HES-ONS linked mortality data file Mortality Chart 9 Excess deaths 22 Trusts in The sum of Observed deaths minus Latest published HSCIC HED Published by CCS Group North West Expected deaths where this is >0 for a SHMI (12 month Trust. period) Clinical Chart 13 Palliative Care 22 Trusts in Patients with All discharges Latest published HSCIC HSCIC Published Coding & 21 coding North West ICD10 Code Z515 SHMI (12 month in any position of period) any episode or Specialty Code 315 in any episode Clinical Chart 14 Palliative Care 22 Trusts in Patients with Discharge Method Latest published HSCIC HSCIC Published Coding & 22 coding North West ICD10 Code Z515 = 4 plus deaths SHMI (12 month in any position of from the HES-ONS period) any episode or linked mortality Specialty Code 315 data file in any episode (where Discharge Method = 4) Clinical Charts Signs & 22 Trusts in ICD10 “R” code in Number of Latest FY for HSCIC HED Published Coding 15 & 23 Symptoms North West primary diagnosis episodes which data has coding of any episode. been published Admission Method Appendix B - Metadata Page ii of iii AQuA Quarterly Mortality Report Issue 01 Version 1.1 5th September 2013

Resource Title Description Coverage Numerator Denominator Date Publisher Source Status type = 21 – 28, 31, 32, 81 – 89, 98. Clinical Charts Signs & 22 Trusts in ICD10 “R” code in Number of first Latest FY for HSCIC HED Published Coding 16 & 24 Symptoms North West primary diagnosis episodes [i.e. which data has coding of the first episode. Spells] been published Admission Method = 21 – 28, 31, 32, 81 – 89, 98 Clinical Charts Signs & 22 Trusts in ICD10 “R” code in Number of last Latest FY for HSCIC HED Published Coding 17 & 25 Symptoms North West primary diagnosis episodes [i.e. which data has coding of last episode. Spells] been published Admission Method = 21 – 28, 31, 32, Discharge Method 81 – 89, 98 = 4 (where Discharge Method = 4) Clinical Chart 18 Charlson Co- 22 Trusts in Total co-morbidity Number of Latest published HSCIC HED Published Coding & 26 morbidity North West score for all episodes SHMI (12 month Index relevant codes in period) Diag02 – Diag20 for each episode

1 See Appendix D.1 of SHMI Methodology

Appendix B - Metadata Page iii of iii AQuA Quarterly Mortality Report Issue 01 Version 1.1 5th September 2013

Agenda Item No: 10

Meeting Trust Board Meeting

Date 31st October 2013

Title Pressure Ulcer Prevention Strategy

Despite pressure ulcer prevention and management being one of the Trusts top three objectives for 2013/14 there is currently no evidence to suggest that the organisation had a systematic approach to understanding why pressure ulcers are still occurring and what standards need to be met to ensure improvement in occurrence happens. Over recent months the clinical and corporate teams have developed an improved and proactive approach to challenging why pressure ulcers are occurring. The attached strategy has been developed to clearly outline the approach the Trust is taking towards the Executive Summary management and prevention of Pressure Ulcers. A zero tolerance of grade 3 and 4 hospital/community Why is this paper acquired pressure ulcers will be enforced through the going to the Board delivery of the strategy. To summarise the main points and key issues that the Board Pressure Ulcer Total (2,3 and 4) should focus on 2013 -2014 (All Areas) including risk, compliance priorities, 35 29 cost and penalty 30 27 implications, KPI’s, 25 Trends and 19 Projections, 20 15 conclusions and 15 12 13 proposals 10 5 0 0 0 0 0 0

NumberofCases 0 Jul

-5 Jan

Jun

Oct

Apr

Feb Sep

Dec

Aug

Nov

Mar May -10

Total Target Linear (Total)

Delivery of the Pressure Ulcer prevention strategy is key for the organisation in its aim to provide Harm Free care, and provide patients with positive experiences of the care delivered.

Next steps/future The Strategy will be launched in November 2013 across actions the organisation.

Clearly identify what will follow a Board decision i.e. future Discuss Receive KPI’s, assurance requirements Approve * Note

Assurance to be provided by:

This Report Covers (please tick relevant boxes)

Strategy * Financial Implications

Performance * Legal Implications

Quality * Regulatory

Workforce Stakeholder implications NHS constitution rights and Equality Impact Assessed pledges For Information Confidential

Beverley Tabernacle, Deputy Director of Trish Armstrong- Nursing. Prepared by Presented by Child, Director of Jacqui Ashton, Nurse Nursing Consultant Tissue Viability

Pressure Ulcer Prevention Strategy

Bolton NHS Foundation Trust October 2013 – October 2014

Contents

1. Executive Summary ………………………………………………………. 4

2. Background ………………………………………………………………... 5

3. Introduction………………………………………………………………… 7

4. Pressure Ulcer Risk……………………………………………………… 8

5. Risk Factors …………………………………………………………………... 8

6. Reduced Mobility/Immobility…………………………………………………. 9

7. Lack of Sensation…………………………………………………………….. 10

8. Skin Marking………………………………………………………………….. 10

9. Compromised Vascular supply……………………………………………… 10

10. Nutritional Status……………………………………………………………... 10

11. Continence…………………………………………………………………… 10

12. Extremes OF Age…………………………………………………………….. 11

13. Patient Refusal……………………………………………………………….. 11

14. End Of Life…………………………………………………………………… 12

15. Communication………………………………………………………………. 12

16. Moving,Handling,Positioning………………………………………………... 12

17. Pressure Ulcer Care Plan…………………………………………………… 13

18. Trust Wide Responsibilities…………………………………………………… 14

19 Holistic Assessment………………………………………………………… 15

19. Incident form completion…………………………………………………… 15

20. Root Cause Analysis (RCA)………………………………………………. 15

21. Dissemination of Learning from RCA panel……………………………… 15

22. Summary ……………………………………………………………………….. 16

23. References……………………………………………………………………… 17

Appendix 1 Waterlow Risk Assessment...... 18

Appendix 2 Community/ Hospital Care Plan...... 19

Appendix 3 Root Cause Analysis Tool...... 20

Appendix 4 Turning Clock...... 21

1. Executive Summary

This strategy will set out the approach that must be taken by all members of Bolton NHS Foundation Trust to undertake effective pressure ulcer prevention in either an in-patient setting or a community setting for patients in receipt of health care.

This strategy underlines the change in culture required to that of zero tolerance and where staff consider pressure ulcer prevention 24 hours a day throughout the care delivery cycle.

Pressure ulcers are rarely due to one factor alone and by considering all possible risk factors and addressing each identified risk for patients via a multidisciplinary approach the patients risk of developing a pressure ulcer can be reduced. Communication of risk to the wider team on a regular basis will ensure that all staff is aware of every patient’s pressure risk.

Figure 1 Classification of Pressure Sores

2. Background

Bolton has a population of approximately 276,800, an increase of 15,763 (6%) from the 2001 census. The most significant change in Bolton’s age structure was the increase in the very elderly (aged 85+).

Bolton continues to have an ageing population, as does the rest of the country as a whole. In particular there has been a significant increase in the population aged 85+, which has increased by 20% in the past years. There are 5,500 over the age of 85 living in Bolton. This is significant as this group has an increased level of social need in areas of health care, accommodation and other types of social care support.

By 2085 it is predicted that there will be 11.5 million people aged 80 or over (ONS, 2012)

With the elderly population growing and life expectancy increasing, many individuals now face the challenge of caring for a growing number of elderly patients who are sick and vulnerable.

The changes in the skin that occur as an individual ages affect the integrity of the skin, making it more vulnerable to damage. The epidermis gradually becomes thinner, making the skin more susceptible to damage from mild mechanical injury forces such as moisture, friction and trauma.

Around 412,000 people in the UK are likely to develop a pressure ulcer (PU) every year (Bennett et al, 2004), including 4-10% of patients admitted to hospital (RCN, 2005).

The financial cost of pressure ulcers cannot be underestimated as they are postulated to be the single most costly chronic wound to the NHS (Posnett and Franks,2008).The cost of treating a category 3 pressure ulcer is between £363,000- £543,000 and a category 4 between £447,000-£668,000 (Department of Health (DOH),2010a).

The large numbers of patients affected and high cost associated with pressure ulcers means that they have become a key quality issue for the NHS.

Zero tolerance to avoidable pressure ulcers is being implemented widely as a Quality of Care indicator.

The main focus of this strategy will therefore be on prevention of pressure ulcers within the in-patient and community environment. Work has already begun with the harm free care panels but the organisation is taking a zero tolerance to pressure ulcers developing in our care setting. Therefore practice has to change immediately for further reduction/prevention of pressure ulcers. This must be achieved and sustained.

Pressure ulcers have a profound negative effect on the physical, social and financial realms of people’s lives and are also distressing for their carers.

Subsequently the National Institute for Clinical Excellence (NICE, 2005) produced clinical guidelines “The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline” (CG7) which set the main aims of:-

“To reduce the occurrence of pressure ulcers by providing guidance on the early identification of at risk patients, the provision of preventative interventions and by identifying practice that may be harmful or ineffective.”

“All individuals on admission to a healthcare setting, hospital should have an appropriate pressure risk assessment within six hours of admission to an acute setting. All individuals admitted onto a community nurse caseload should have a pressure ulcer risk assessment performed at the first visit and at regular intervals thereafter dependent on clinical need”.

Failure to perform an appropriate risk assessment and act to protect a patient constitutes neglect by the omission of care (Nursing and Midwifery Council 2008).

By following these guidelines, adhering to evidence based practice and creating a culture that addresses pressure ulcer prevention all day every day Bolton NHS Foundation trust can successfully achieve a significant reduction in pressure ulcers.

3. Introduction

Pressure ulcer prevention is the responsibility of every member of staff that comes into contact with our patients, from those involved in direct patient care to support staff whose input is more distant.

Figure 2 Key Elements of the Strategy:

• Does the Patient have a pressure sore? • What is the Patients Risk? Assessment

• How, Where and Why did the Pressure ulcer occur? Cause

• Strategy • Training Zero Tolerance • Transparency

This requires the implementation of appropriate screening and assessment of at-risk patient’s (including vulnerable adults).

Protection of the individual patient from pressure damage is a fundamental aspect of nursing care. Pressure ulcer risk assessment using an appropriate tool is intrinsic to that care.

Bolton requires a change in staff culture that considers that all patients to be at risk of pressure damage until deemed otherwise 24 hours/day. This will enable the trust to prevent all avoidable pressure ulcers by considering each individual’s risk within 6 hours of admission or initial admission to caseload.

There is much that can be done to reduce the risk of pressure damage and therefore minimise harm whilst in our care. To achieve this means involvement from a wide range of staff, particularly nurses, doctors, healthcare assistants, therapist and pharmacists.

This strategy therefore outlines the best practice approach to prevent pressure ulcers. The greatest success will be achieved when all aspects are implemented and all staff from management through to support staff are committed to 24 hour pressure ulcer prevention.

4. Pressure Ulcer Risk

Protection of the individual patient from pressure damage is a fundamental aspect of nursing care. Pressure ulcer risk assessment using an appropriate tool is intrinsic to that care.

Healthcare professionals require specific training in pressure ulcer risk assessment appropriate for the group of individuals within their care. Various groups have particular needs which their pressure ulcer risk assessment tool should reflect in order to highlight the risk:

Paediatric patients Orthopaedic patients Older people Adults Adults with mental health issues Critical care patients.

5. Screening and Assessment of Pressure Risk/ Ulcers

For all patients this should begin with a risk assessment. Risk assessment tools have been developed to help identify those patients most at risk (Waterlow). Recognising which patients are at risk of developing pressure ulcers early on is an essential part of the prevention care pathway. However, all risk assessment tools are limited and therefore should be used within the context of a holistic assessment, and include a full skin assessment using the trust risk and skin assessment (Appendix 1).

Waterlow Pressure Ulcer Risk Calculator (Appendix 1)

The Waterlow Pressure Ulcer Risk Calculator and skin assessment should be performed on every individual patient at the initial assessment. Below 10+ = At risk 15+ = High risk 20 + = Very High risk

The Waterlow score and skin assessment combined with clinical judgement should be used to determine the treatment plan for the patient.

All patients should have a pressure ulcer risk assessment immediately upon entry to an episode of care. For all patients identified as ‘at risk’ initial screening should lead to further holistic assessment. Although an assessment may take time to complete, it should be commenced within six hours for ’in-patients’ and during the first visit for patients under the care of the Community Nursing Service.

6. Risk Factors

Risk assessment is not exclusive to the prevention of pressure ulcers, it is used in many aspects of life and healthcare. The Health and Safety Executive (2011) States “that it helps to focus on the risks that have the potential to cause harm”.

These risks need to be identified and processes initiated to reduce the likelihood of harm occurring.

Each identified risk factor needs to be considered. For instance, a patient with dementia may have both an intact sensory pathway and be able to move. What this patient may lack is the cognitive ability to recognise the pain signal associated with the beginnings of pressure damage (EPUAP&NPUAP2009).This would normally trigger movement, sometimes subconsciously. Some patients in pain may stay still because moving increases discomfort, they may be taking analgesics, sometimes opiates. Pain is an early warning signal for pressure damage and the use of strong analgesics may diminish this, which delays a trigger to move.

7. How do Pressure Ulcers develop?

Pressure ulcers normally occur due to a combination of extrinsic and intrinsic factors. Extrinsic factors are those that can be controlled or altered by clinicians.

Intrinsic factors include those inherent patient-related features that may predispose them to developing pressure ulcers, such as previous or chronic conditions that may leave them susceptible to injury.

8. Reduced Mobility or Immobility (Appendix 4 Turning Clock)

The longer pressure is exerted over a bony prominence, the higher that pressure will become. This results in an increased period of reduced or occluded blood flow to the tissue, which results in tissue hypoxia leading to tissue death.

Pressure ulcers may first present with blue/black or purple discolouration of intact skin this is often a sign of deeper tissue damage.

Patients who are undergoing surgery requiring them to be immobile for long periods may be at increased risk of pressure damage therefore preventative measures should include actions that can be taken to reduce pressure, shear, friction and moisture build-up. Assessment of mobility should include all aspects of independent movement including walking, ability to reposition, bed to chair. All patients at risk of pressure damage need to reviewed minimum every six hours within the acute setting and at each domiciliary visit.

Figure 3 Actions that can be taken to reduce pressure, shear, friction and moisture build-up

•shearing refers to the pulling of the skeleton (normally by gravity) downwards, while the skin adheres to the surface of the bed, trolley or chair. This results in the tearing of capillaries and can increase the severity of pressure ulcer when shear and pressure forces are Shear present. During surgery, certain positions that are necessary in order to gain access to the affected area may also leave the patient at risk of shearing forces.

•Describes the forces at play when two surfaces rub across one another. If this persists, patients can develop friction ulcers. Friction Friction may compound the effects of pressure and shearing and potentially lead to loss of dermis.

•moisture is implicated in the development of some pressure ulcers due to the effect of the skin being over-hydrated, whether due to

incontinence, excessive perspiration and/or wound exudate. If the Damage skin is excessively moist, the epidermis becomes weaker and more Moisture fragile. This can lead to skin breakdown in the presence of pressure, shear and/or friction.

9. Lack of sensation

If pain signals are absent because of a lack of sensation, patients will not be aware that damage is occurring and will not realise they should move. This increases the risk of pressure ulcer development in those with, cerebrovascular accident, multiple sclerosis, spinal cord injury and neuropathy. Health professionals should consider other medical conditions that may impair sensation, as well as temporary sensory loss due to unconsciousness, spinal anaesthesia or analgesia, or alcohol or substance use. A source of pain elsewhere may distract from the pain associated with pressure, reducing the likelihood of the patient responding to this pain trigger.

10. Skin marking

The change of colour in the skin associated with pressure damage is an early warning sign of risk. In pale skin a visible circular pink/red blanching mark known as blanching erythema (the area of redness blanches white when pressed lightly with a finger),over a bony prominence is an indication that pressure is starting. If this is not noticed and continued pressure is sustained, the discolouration will become darker until it is purple/black.

Identifying skin colour changes can be difficult in patients with darker skin colours, as areas of redness are neither visible nor blanch white. This means these patients may be at increased risk of pressure damage. It is essential that the pressure is removed and the skin is inspected at regular intervals.

Erythema may also be masked by physiological illnesses that alter the skin colour. This includes cellulitis, necrotising skin infections, bruising disorders and incontinence-dermatitis.

11. Compromised vascular supply

An already compromised vascular supply will be further hampered by pressure, resulting in a more rapid deterioration of skin. Patients with peripheral arterial disease may be at risk of damage to their heels. Patients who experience events such as cardiac arrest or hypovolaemic shock may be at increased risk of skin damage because the blood supply to the skin is diminished by a sudden drop in blood pressure.

12. Nutritional status

There is a significant link between poor nutritional status and pressure ulcer risk. Undernourished people are at increased risk of pressure ulcer development (EPUAP and NPUAP(2009)Patients who have chronic disease prior to surgery may be at risk of malnutrition and this risk could be reduced with appropriate preoperative nutrition. Also consider hydration. Nutritional support should be given to patients with an identified nutritional deficiency. Nutritional support/supplementation for the treatment of patients with pressure ulcers should be based on:

Nutritional assessment (MUST Tool 1999) General health status Patient preference Expert in put supporting decision-making (dietician or specialist). Professional judgement

13. Continence

Urinary and faecal incontinence can have a detrimental effect on skin integrity and are considered to be a risk for pressure ulcer development. The cause of the

continence problem must be explored, for e.g. factors such as Chron’s disease, ulcerative colitis, impacted faecal load, antibiotic use and bacterial infection should be considered. In urinary incontinence, the ammonia produced by the urine raises the pH balance of the skin on contact, making it permeable. It is essential that the underlying cause of the urinary incontinence is explored to prevent skin breakdown.

14. Extremes of age

Neonates and very elderly people have more fragile skin. In the elderly, several changes occur in the skin and its supporting structures, which may predispose their skin to pressure, shearing and friction related ulcers. Pruritus is common in the older person. Dry skin is itchy skin. Once identified patients should have a frequent skin assessment to prevent breakdown. Neonates are a group vulnerable to pressure ulcer risk given the immaturity and underdevelopment of the epidermis and the dermis of a baby born before 28 weeks of gestation (McGurk 2004).For children who are at risk of developing pressure ulcer they require vigilant regular monitoring.

15. Patient refusal

On occasion, patients may not wish to change their position as often as needed to protect their skin, or they may refuse to use a pressure-relieving mattress/cushion. In such instances, nurses should first consider patients’ mental capacity) Mental Capacity act, 2005). If they are deemed to have capacity then the patients decision must be respected and documented. Some patient’s may have fluctuating capacity and this must be taken into consideration when the patient is refusing to change position. Some-times the explanation given to the patient is not always fully understood, therefore the nurse/health professional must ensure that they have explored every avenue to explain how important pressure relief would be of benefit. Review of the patient is essential, if the patients risk of pressure damage is high the review gives the health care professional the opportunity to explore why the patient is refusing equipment.

16. End of life

The dying process compromises the homeostatic mechanism of the body, which may lead to a number of vital organs becoming compromised. This can lead to skin complications, including gangrene, infection and pressure ulceration. Specific attention should be given to bony prominences and skin areas with underlying cartilage. When delivering care to patients on the end of care pathway it is essential that pressure care is maintained. The patient should be kept comfortable and pain free when repositioning, pressure areas and skin changes must be monitored closely. Skin changes at life’s end may well be an inevitable event that cannot be averted despite all preventative measures being implemented.

17. Communication

Good communication between healthcare professionals and patients and carers is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given

about it, should be culturally appropriate. It should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

Moving,Handling,Positioning and Re-Positioning Skin damage can be minimised by using correct positioning, transferring and repositioning techniques and the use of aids. Hoist slings and sliding sheets should be removed from underneath the patient after repositioning. Where possible patients should be taught to reposition themselves and carers should be shown how to assist. Repositioning should be performed in such a way as to minimise the impact on bony prominence. Whenever possible avoid positioning patients directly on a pressure ulcer or directly on a bony prominence unless this is contra-indicated by the general treatment objectives. Using the 30 degree tilt can increase the range of positions available (Appendix 2) Moving and handling should be in accordance with European and trust manual handling regulations. The patient’s need for repositioning should be assessed, planned, auctioned, evaluated and documented with evidence of ongoing re-assessment. The frequency of repositioning is determined from individual assessment. A repositioning plan should take into consideration, existing/potential tissue damage, medical condition, comfort, patient preference, support services and overall plan of care.

18. Pressure ulcer and risk care plan (Appendix 2)

This should be completed as soon as a pressure ulcer is identified. Whilst the pressure ulcer care plan may be initiated by nursing staff, all staff involved with the patient should be aware of its individualised content. If the patient transfers ward/unit the pressure ulcer must be re-assessed and have regular on going assessments.

Figure 4 Key Assessment Priorities for Care plan must include:

•Cause of ulcer •Site/location •Dimensions of ulcer •Depth of pressure ulcer is measured by identifying the category of the ulcer using the EPUAP tool. •Level of risk –from holistic assessment •Previous pressure damage •Exudate amount and type •Local signs of infection •Pain •Wound appearance in the ulcer i.e black, grey, yellow, red, pink or green. •Surrounding skin Assessment •Undermining/tracking(sinus or fistula) •Smell/odour •Tracing and or photography(calibrated with a ruler) •Pressure relieving support surface/cushion •Re-positioning regime using Bolton Turning Clock •Monitor closely skin changes 14

The ward/unit/caseload teams Must involve the clinical specialist - Tissue Viability Team if a pressure ulcer is failing to improve.

Pressure ulcers should not be reverse graded (retrograding).A category 4 pressure ulcer does not become a category 3 as it heals. As the ulcer heals it should be described as a healing category 4 pressure ulcer showing signs of granulation tissue at base/edges of wound etc.

19. Education & Training

All staff who care for patients with or ‘at risk’ of developing a pressure ulcer Must ensure that their knowledge is current and evidence based. All staff must attend a yearly pressure ulcer prevention and management course. This will be held by the tissue viability service and will cover: Pathophysiology of pressure ulcer development Risk factors and risk assessment tools Positioning/repositioning Selection, use and maintenance of support surfaces and equipment Incident reporting Pressure classification

Please contact the Tissue Viability Service for further details 01204 463823/9.

20. Trust wide responsibilities

The following points are the responsibility of the Foundation Trust and all staff working with patients at risk of pressure damage.

All staff in regular contact with patients should undertake pressure ulcer prevention training, to ensure all are familiar with risk factors and their role in prevention.

All clinical staff must re-assess and evaluate effectiveness of interventions at specified intervals to identify any potential changes in risk.

Pressure relieving equipment should be provided appropriate to the individuals’ needs without delay.

Adequate staffing levels should be provided at all times to meet the number and level of dependent patients at any point. Unfilled shifts are not acceptable and should be escalated immediately.

21. Trust acquired pressure ulcers

All preventable pressure ulcers acquired in Bolton must be reduced to zero. If a pressure ulcer occurs we should learn from it and the following measures should be taken and evidence of such recorded.

Pressure ulcer acquired protocol

Full holistic clinical assessment, when the pressure ulcer developed, risk of patient, type of pressure relieving equipment.

Complete on line incident form and include any actions taken. The relevant manager must be informed immediately of all pressure ulcers acquired within the trust. All category 3 and 4 pressure ulcers acquired in hospital or community ensure the Tissue Viability Consultant Nurse is made aware of the incident at the earliest available opportunity. All category 2, 3, and 4 pressure ulcers acquired within Bolton will be subjected to a full Root Cause Analysis.

Review pressure ulcer care plan to reduce the risk of further deterioration.

If the patients pressure ulcer deteriorates seek advice/review from Tissue Viability Team, Medical / Surgical review.

22. Incident Form Completion

When completing the incident form give as much detail as possible about the development of the pressure ulcer.

When the pressure ulcer developed and in which environment, home, ward A&E, theatre, residential home or nursing home. Give details of pressure ulcer wound assessment, size, depth, position and details of frequency of treatment. Document any issues that may have significantly contributed to the patient developing the pressure ulcer.

If the patient developed the pressure ulcer having sustained a fall document how they fell and if found on the floor how long the patient was on the floor. Include the patient’s opinion regarding what happened and record their answer. Include any contributing factors, general health condition, environmental factors.

23. Root Cause analysis (RCA) (Appendix 3)

As indicated in the pressure ulcer protocol all pressure ulcers should have a RCA completed whereby the staff member(s) involved and the manager should look at the pressure ulcer(s) in detail considering all factors that may have contributed to the pressure ulcer developing and whether or not sufficient measures had been taken to pre-empt and prevent the pressure ulcer. It may be beneficial to bring fresh eyes in to help complete the RCA. Details of the RCA should be communicated to the wider

team, in particular any lessons learned and recommendations as a result. The RCA will then be discussed at the next harm free care panel when other areas can also learn from the outcome and prevent further pressure ulcers in other areas.

24. Dissemination of learning from RCA panel

The learning gained from all cases discussed at the Pressure Ulcer RCA panel must be cascaded to staff from the same and other areas to ensure any measures identified that may prevent future pressure ulcers are shared. This can be done by staff involved feeding back directly to the rest of the MDT in the area.

The pressure ulcer RCA panel should be seen by all staff as an opportunity to learn, to enable improved patient care across the organisation. This can only be achieved if the learning at the panel is disseminated effectively.

25. Summary

Figure 2 MDT Collaborative approach

Pressure ulcer prevention is everyone’s job and should be considered 24 hrs a day for all patients. Preventing pressure ulcers in patients at risk requires a multidisciplinary collaborative approach from many members of the multidisciplinary team and only when this is executed correctly and efficiently will pressure ulcers be reduced to zero. Patients and their relatives also have a responsibility to work with health professionals to minimise the risk ensure of pressure ulcer damage when in our care.

References

Department of Health (2011) Safe care.

Department of Health undated defining avoidable and unavoidable pressure ulcers.

Health and Safety Executive (2011) Five steps to Risk Assessment.

McGurk V et al (2004) Skin Integrity assessment in neonates and children,Paediatric nursing,16,3,15-18.

Mental capacity Act (2005) Mental capacity.

Moore Z,Van Ettan M (2011) repositioning and pressure ulcer prevention in the seated individual. Wounds UK 7 (3):34-40.

National In statute for Health and Clinical Excellence (2008a) Surgical site infection. Prevention and treatment of surgical site infection. NICE, London. Available at:www.nice.org.uk/CG74.

National Institute for Health and Clinical Excellence (2005) CG29 Pressure ulcer management: Quick reference guide. NICE, London. Available on line at htpp://guidance.nice.org.uk/CG29/QuickRefGuide/pdf/English.

National pressure Ulcer Advisory panel (2010) Not All pressure Ulcers are Avoidable. Washington, DC: NPUAP.

North West Tissue Viability Nurses.Guidelines for classification of pressure ulcers (Adapted from EPUAP 2009)

Nursing and Midwifery Council (2008) The Code: Standards of conduct, Performance and Ethics for Nurses and Midwives. NMC. London.

Office of National Statistics (2012) Results, 201-based NPP reference Volume. Available from:www.ons.gov/ons/dcp 171776_253934.pdf.

Posnett j,Franks p (2007) The Costs of Skin Breakdown and Ulceration In the UK.In Pownall M (ed|) Skin breakdown:the silent epidemic.London.Smith&Nephew.

Royal College of Nursing (RCN) (2005) The management of pressure ulcers in primary and secondary care. A Clinical Practice Guideline. Available from: http: /www.rcn.org.uk.

Appendix 1 WATERLOW ASSESSMENT (J. Waterlow 2005)

Date Date Date Date Date Date Score Build/ Weight for Height Average (BMI = 20 - 24.9) 0 Above average (BMI = 25 – 29.9) 1 Obese (BMI = > 30) 2 Below average (BMI= < 20) 3 Continence Complete/ Catheterised 0 Urinary incontinence 1 Faecal incontinence 2 Urinary and faecal incontinent 3 Risk area, visual skin type Tissue paper/ Dry/ Oedematous/ Clammy, pyrexia (score 1 for each) 1 Discoloured (grade 1) 2 Broken/spots (grade 2 – 4) 3 Mobility Fully 0 Restless / Fidgety 1 Apathetic 2 Restricted 3 Bedbound / Traction 4 Chairbound e.g. wheelchair 5 Sex Male 1 Female 2 Age 14 - 49 1 50 - 64 2 65 - 74 3 75 - 80 4 81+ 5 Appetite Patient eating poorly or lack of appetite 1 Has patient lost weight, if yes weight loss score: 0.5 - 5kg 1 5 - 10 kg 2 10 - 15 kg 3 > 15 4 Unsure 2 Tissue Malnutrition Terminal Cachexia 8 Multiple organ failure 8 Single organ failure (respiratory, renal, cardiac) 5 Peripheral vascular disease 5 Anaemia (Haemoglobin < 8) 2 Smoking 1 Neurological Deficit Diabetes, MS (Mulitiple Sclorosis), CVA (Cerebral Vascular Accident) 4-6 Motor/ Sensory 4-6 Paraplegic (max of 6) 4-6 Major Surgery or Trauma Orthopaedic/ Spinal 5 On table > 2 hours 5 On table > 6 hours 8 Medication 19 Cytotoxics, long term high dose steroids, anti- inflammatory (max of 4) 1-4 Total Score

Risk Level

Signature

Appendix 2 Care Plan – Hospital

Score Risk Actions Level Provide patient information leaflet and commence repositioning chart. 10 + Implement Advise patient to move from side to side in bed and stand every 15-20 minutes when sitting out. If unable to alter position for ALL independently reposition the patient at regular intervals in accordance with response to pressure. risk Reassess Waterlow score in accordance with the patient’s individual needs or as changes to clinical condition. groups below All grade 2 pressures sores must be recorded as a clinical incident. Skin intact/ grade 1 or 2 and good mobility – Static cushion and pressure reducing static mattress 10+ At risk Grade 3/4 pressure ulcer and average or poor mobility – Dynamic cushion and dynamic mattress

Skin intact & good mobility - Static cushion and pressure reducing static mattress 15+ High Risk Skin intact or grade 1 or 2 & poor mobility - Static cushion and dynamic overlay

Grade 3 or 4 and poor mobility – Dynamic cushion and dynamic mattress replacement Skin intact & good mobility - Static cushion and pressure reducing static mattress 20+ Very High Skin intact, grade 1 – 4 & poor mobility - Dynamic cushion and dynamic mattress Risk CARE PLAN NUMBER …………….. BOLTON NHS Foundation Trust CARE PLAN TITLE: Patient at Risk of Developing Pressure Ulcers

PATIENT’S NAME ………………………………………………RMC/ NHS NUMBER…………………….. WARD ………

Plan commenced by ………………………………………… Date…………………………………….

Problem: Patient is at risk of developing skin / tissue damage.

Goal (s): To prevent tissue damage.

Summary of problems in relation to Waterlow assessment:

Provide patient / carer with a copy of pressure ulcer prevention information / Date Signature leaflet

Assess following risk factors and devise individual plan of care Assess if patient needs assistance to alter position and frequency of position changes State frequency of Waterlow assessment as an intervention below

Date: Signature Individual Interventions: Date: Signature Intervention Intervention commenced Discontinued

Document date of discontinuation of plan and rationale for discontinuing Date: Signature

Community CARE PLAN NUMBER ……………..CARE PLAN TITLE: Patient with Pressure Ulcer BOLTON NHS Foundation Trust

PATIENT’S NAME ………………………………………………RMC/ NHS NUMBER…………………….. Date Of Birth ………

Plan commenced by ………………………………………… Date…………………………………….

Problem: Patient has a pressure ulcer on ------category ------

Goal (s): To facilitate healing and minimise risk of infection and further tissue damage.

Pressure Ulcer History: Hospital Acquired (3 days after admission) Community Acquired (on admission or within 3 days)

District nurse input Nursing home Residential Home

Provide patient / carer with a copy of pressure ulcer prevention information / Date Signature leaflet

Assess following risk factors and devise individual plan of care Surface: Need for pressure relieving equipment Skin: Frequency of skin inspection

Keep Moving: If patient needs assistance to alter position and frequency of position changes Incontinence: Urinary / faecal incontinence Nutrition: Nutrition and hydration needs

Date: Signature Individual Interventions: Date: Signature Intervention Intervention commenced Discontinued

Community: Plan of care discussed and agreed with patient Patients Signature

Document date of discontinuation of plan and rationale for discontinuing Date: Signature

Appendix 3 RCA Tool

Pressure Ulcer Root Cause Analysis (RCA) Data Gathering Tool (For patients who acquire category 2/ 3/ 4 Trust acquired pressure ulcer complete within 5 working days) Stage 1: React – What were the critical problems Patient Name: RMC/NHS Number: DOB: RCA Completed by: Designation: Date : Date Incident Reported Incident Number Past Medical History: Current Medical History:

Date and time admitted to hospital/Dept /DN Were there any transfers/moves after admission? Caseload: Give details: Date pressure ulcer was identified: Category of Pressure Ulcer:

Site of pressure ulcer/s please state category and  Sacrum site of each pressure ulcer?  Left heel  Right heel  Right ischium  Left ischium  Left hip  Right hip  Other (Specify) Where did pressure ulcer develop? Give Details (ward name/district nurse team/other)

Was patient identified as at risk of pressure ulcers Was the six hour skin inspection completed Yes/No on admission Yes /No Date & Time: Completed on transfer Yes/No Date &Time What was the Waterlow score on admission(i.e. to List all dates and scores of completed Waterlow ward/District Nurse Team)

Was the patient incontinent Yes/No Was the patient immobile describe

Bed Bound Yes/No Chair Bound Yes/No

Was the patient meeting their nutritional needs What pressure relieving equipment is in place? Yes/No (E.g. Mattress and/or cushion).

What was the nutritional score? Date Implemented

Reposition chart commenced Is this completed appropriately Yes No Date: Yes No Date care plan commenced Is this completed appropriately Yes No Pressure Ulcer Photographed Yes/No Patient informed and given explanation Yes/No.

Patient Consent sought Yes/No If so, state date. (check if information leaflet given) Who has the pressure ulcer been reported to(i.e. Date: TVN/Matron) Any Vulnerable Adult Concerns: Describe: Stage 2: Record - Complete a timeline from the patient’s records review What actually happened (timeline of events What should have happened include dates & frequency of skin inspections)

Stage 3: Respond – What needs to be done to reduce the chance of another pressure ulcer developing? Recommendations: Actions to be taken By who and by when

RCA Panel Review Meeting Date: Recommendations from Panel & Outcome:

Appendix 4 New Turning Clock Documentation

TRUST WINTER PLAN

2013/2014

CONTENTS

Page

1. Introduction 3

2. Learning from Previous Years 3

3. Capacity 2013/14 5

4. Planned Demand (RTT) 6

5. Norovirus and Infections 6

6. Social Marketing 7

7. Risks 7

8. Hospital Plan 8 8.1 Emergency Demand/Capacity Modelling 8.2 Using Planned Capacity to Meet Demand 8.3 Improved Discharge Policy 8.4 Weekend Discharge Team 8.5 7-day Woking 8.6 CDU 8.7 BCU 8.8 Winter Ward B1 Ward 8.9 Surgical 8.10 Elective Bed Capacity 8.11 Families 8.12 Integrated Rapid Response Team and A&E 8.13 Intermediate Care 8.14 3rd Party Providers 8.15 Impact of Actions taken to Meet Demand

9. Workforce Issues 11

10. Escalation Process 12

Appendices 14 Health Economy Plan Trust Escalation Plan Critical Care Escalation Plan NHS North West – Major Contingencies – Guidance for Critical Care Escalation

1. INTRODUCTION

The Trust Winter Plan addresses specific conditions related to winter which impact on:

Emergency Department capacity Bed capacity Critical care services Communications including cross-party working with partnership agencies Business continuity, ensuring that the Trust maintains essential services and, where relevant, returns to normal operating capacity as quickly as possible Ambulance turnaround times

The plan outlines the principles of response to be adhered to when pressures are identified which are likely to put at risk the Trust’s ability to deliver acceptable levels of patient care and services.

There are a number of factors that are particular to winter and which result in increased demand for healthcare services:

Length of stay for many patients increases, driven by increased acuity and more complex needs. This is particularly relevant in the care of the elderly and respiratory patients. Closure of capacity due to infection which limits the supply of usable beds. Norovirus is significantly more prevalent in winter and this can result in temporary closure of affected wards thus reducing bed capacity. Intermediate care capacity comes under increased pressure during winter, with demands from both the community and primary care as well as “step-down” patients from hospital. This can contribute to increased lengths of stay in hospital, leading to challenges regarding staffing in all areas. Unplanned staff absence increases in winter months, particularly due to increased infections, leading to challenges regarding staffing in all areas.

The Winter Plan aims to meet the need of the Trust during these pressures as it is essential that the Trust is able to continue to provide high quality, safe and effective patient care throughout the winter period. It is also important that care is delivered in a timely manner so that the Trust continues to achieve against performance measures in both urgent and elective care.

2. LEARNING FROM PREVIOUS YEARS

Winter 2012/13

Last winter the Trust increased the medical bed base to 362, by opening 14 beds on CDU on 26th November 2012 and 25 beds on B1 on 3rd December. The beds on B1 were not fully utilised until after Christmas, due to staffing shortages.

Accident & Emergency Type 1 performance against the 4-hour target was above 95% every month between November 12 and March 13, with the exception of January when it was 94.5%.

Attendances at Accident & Emergency for the period Nov-Mar 12/13 were 46,857 compared to 46,591 (+0.6%) the previous year. Emergency admissions were 14,550 and 14,145 (+2.9%) for the same period. In January, emergency admissions were 10.5% higher than the previous year.

Acute Adult non-elective admissions

2000 1800 1600 1400 1200 1000 2011/12 800 2012/13 600 400 2013/14 200 0

Acute Adult Non-elective LOS 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 0.00

2011/12 2012/13 2013/14

Occupied bed days - Acute Adult - Available Against Actual 12000

10000

8000

6000

4000

2000

0 41000 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 41365 May Jun Jul

Available Actual

Daily conference calls with the PCT and Social Services were instigated in December and continued throughout the winter months. This assisted in identifying any delayed discharges and where possible these were expedited with the support of other agencies.

The following areas of focus that in previous years have been beneficial to this and other organisations: Expanding bed complement from November 13 Introduction of a weekend discharge team Increased medical cover in A&E during peak times Additional 15 bed capacity in Intermediate Care (Darley Court = 5 & Laburnum = 10) Maximising the efficiency of bed utilisation 7-day working across medical specialties in order to increase weekend discharges and give earlier senior review to optimise the length of stay Daily liaison with Social Services to expedite discharge where social care is indicated Ensuring prompt discharge before 10:00am wherever possible Patient flow meetings are held at least four times per day, enabling close monitoring, real-time communications and assisting decision making Measurement of daily discharges by ward to involve clinicians Conference calls with CCG to ensure delays in transfer of care and escalated to start in November 13 Infection Control measures

3. CAPACITY 2013/14

3.1 During 2013-14 the number of attendances at A&E has reduced by 1,714 from April to September. However, the number of majors patients rose by 1,028 in the same period. Majors patients are more likely to require beds than other A&E patients. Admissions via A&E for the period increased by 1,496 whilst ALOS reduced from an average of 4.9 to an average of 4.5 days.

3.2 Medical beds & Clinical Decisions Unit (CDU) The medical bed base usually stands at 305 plus 14 CDU beds; the CDU beds will support avoidance of admissions.

3.3 Surgical beds Surgery has 176 beds excluding Day Care and Critical Care beds

3.4 Paediatrics There are 38 Paediatric beds which include 7 beds dedicated to assessment and observation and 3 beds dedicated for High Dependency.

3.5 Gynaecology Ward M1 There are 15 beds on this ward and 2 assessment areas.

3.6 Intermediate Care Beds There are 30 beds at Darley Court, which are for patients requiring rehabilitation or sub-acute nursing care. In addition Labernum lodge provide capacity for intermediate care patients.

4. PLANNED DEMAND (RTT)

Planned patient activity (daycase procedures) will be delivered alongside RTT activity. Private providers and LLP will be utilised if necessary.

5. NOROVIRUS ANDINFECTIONS

The Trust has developed robust plans to deal with infection control and is mindful of the likelihood of increased prevalence of Norovirus, Clostridium Difficile and flu in the coming months.

The Trust is proactively promoting flu vaccinations for staff as well as at risk groups in the community.

5.1 Norovirus

Norovirus is highly infectious and spreads easily from person to person. It is the most common cause of infectious diarrhoea and vomiting in the UK. It is also known as winter vomiting disease. It can be spread by contact with an infected person, consuming contaminated food or water or by contact with contaminated surface of objects. The virus can survive in the environment for many days.

Washing hands with soap and water, prompt disinfection of contaminated areas and isolation of those infected for 48 hours after their symptoms have ceased can minimise transmission. There is no specific treatment for Norovirus apart from letting the illness run its course and drinking plenty of fluids to prevent dehydration.

To ensure staff comply with hand washing standards, hand washing audits are carried out in clinical areas on a weekly basis and compliance is also recorded with Exemplar reporting. Performance is currently at 85% with actions to improve and this will be maintained during the winter period.

Vigilance on the part of nursing, medical and other staff can lead to early identification of a problem. The Norovirus Policy details control measures to be taken within affected clinical areas, dealing with prevention of spread to unaffected area and environmental decontamination during and post outbreak.

As Norovirus is often brought into the hospital environment by someone incubating the infection, the No to Noro campaign/Norovirus-Stop the Spread is being run throughout the whole health economy. The infection Prevention & Control Team (IPCT) have designed posters to distribute throughout the Trust and in the community and GP premises to raise awareness about the dangers of the spread of Norovirus to patients and staff.

The IPCT include Norovirus in mandatory training sessions and the Norovirus policy is available on the Trust Intranet. Further information/leaflets can be obtained from the HPA website. Hospital is closed to visiting during periods of infection outbreak. Ward A4 will be available to decant wards for fogging during the winter period.

5.2 Seasonal Flu

The Trust takes the prevention of seasonal flu very seriously. There is a Flu Strategy in place and the Steering group meets on a monthly basis the whole year round in order to plan, deliver and review the Flu Programme. The programme reflects a whole systems approach to planning and delivery of the programme – everything from ordering vaccine, training staff, promoting the campaign, undertaking the vaccinating and reviewing the programme prior to planning for the next season.

Promotion will be ongoing and this will include informing staff how and when they can access their jab, success stories and stories and news articles to generate interest and motivate staff to attend.

There is potential for an infectious disease outbreak affecting patient care and Trust operations in a similar way to the pandemic influenza outbreak. The health response to such an outbreak would be led nationally and via the regional / local command and control mechanisms. The Trust maintains a strategic plan outlining the process and actions to be taken in the event of this type of outbreak.

This plan is held in readiness by the Emergency Planning department.

6. SOCIAL MARKETING

The Trust will work with the CCG and Local Authority on any Social Marketing campaign which aims at reducing pressure on acute hospital beds.

7. RISKS

The key risk that the Trust will face over winter is greater demand on critical services leading to reduced capacity. This will arise from:

Increased emergency patient admissions

Longer length of stay due to increased complexity and acuity

Increased demand for intermediate and other care outside the hospital

Higher levels of infection resulting in closed wards

Staff absence through sickness, including seasonal flu and norovirus

Reduced staff attendance due to adverse weather

BCU patient pathways are being redesigned at present with plans for closure. Therefore, dependant on the success of these pathways and the impact of winter pressures, for approximately 3 months during the winter months there will be no BCU for admissions.

Risks associated with the above are: a small number of sub-acute patients who cannot be turned around by the rapid response team at the front door will have to be admitted. This has been calculated at about 3-4 patients per month.

8. HOSPITAL PLAN

8.1 Emergency Demand/Capacity Modelling The Trust has commissioned a bed modelling exercise for the last 2 years. This gives an analysis of the number of inpatients in hospital throughout the year by specialty. From this bed model, demand can be estimated using this historic data. The following key points have been drawn:

350-360 acute medical beds are needed in the winter months Surgical bed capacity is adequate to meet elective and non-elective demand

8.2 Using Planned Capacity to meet demand The Trust uses a predictor tool which compares predicated admissions against current admissions, planned discharges and bed availability. The outcome of this is then fed into an escalation tool with 16 other metrics and then informs level of escalation.

Escalation triggers are in place and discussions are taking place to agree more explicit thresholds for incorporation in to the revised escalation plan.

Bed meetings are held at least 4 times per day. Capacity Management systems data is also in place. The HERD data will also be used at bed meetings to understand the whole health economy pressures and support predicted demands on the whole system.

The Trust has used the predictive tool to anticipate demand on a daily basis. This is largely reliable and generally predicated activity is manageable. Surges of activity are dealt with in specialties’ escalation plans. There is some flexibility between surgical and medical beds depending upon demand. Extramed is used on a daily basis.

8.3 Improved Discharge Policy In preparation for the winter the Joint Trust and Bolton Council Adult Hospital Discharge and Transfer of Care Policy has been updated and following final approval on 13th December 2012 will be implemented across hospital wards, intermediate care facilities and community services.

A weekly Delayed Transfer of Care meeting will be held with Council representatives from Bolton, Wigan and Salford to performance manage and improve the discharge process for patients.

Information will be given to patients and/or relatives/carers to ensure they are clear about discharge dates and expectations to avoid undue-delays in choice and decision making which may include interim alternative places of care if necessary.

Matrons will review any delays in their areas daily and take actions to mitigate the delays and ensure that patients are discharged before lunch. If appropriate actions for discharge are not being processed this will be escalated to the Director of Operations or the COO of the relevant organisation.

8.4 Weekend Discharge Team During the winter period an additional weekend discharge team will be available. This team made up of physician, therapy, pharmacy and discharge co-ordinator will focus on discharging patients during the winter period to prevent delays and contribute to better bed utilisation.

8.5 7 Day Working From October 1st 2012 a new structure of weekend working for consultant physicians commenced. In November 13 the weekend discharge team will be in place junior doctors, physiotherapists, occupational therapists and pharmacists to support the consultant to prevent delays for those patients who are medically fit for discharge. The discharge team will be reviewing patients to ensure decision for discharge has been determined and all the actions required to enable the patient to be discharged will be put in place.. There will be a consultant rota in place to manage the winter ward.

8.6 CDU/ Integrated Rapid Response Team The Clinical Decisions Unit (CDU) opened on 26th November 2012. The unit comprises 14 beds and this, along with regular attendance in A&E by acute physicians will support admission avoidance wherever possible. The working day of acute physicians has been extended to cover 8.00am to 8.00pm to increase senior review of medical admissions. It is anticipated that the CDU will negate the need for 14 patients per day to be admitted to assessment wards within the hospital, freeing up capacity on wards D1 and D2.

8.7 BCU Plans are in place for BCU patients to have alternative pathways. Eventually some patients will be diverted to CDU, others to F3 and all sub-acute patients will be turned around from A&E by the Acute Rapid Response team into the care of Community rapid response team. Currently BCU is used as destination for patients who are awaiting transport etc. to support A&E flow. Due to the risk to winter capacity it is not expected that BCU will reduce capacity until April 2014..

8.8 Winter Ward The Trust will open winter ward to provide additional capacity. This will be B1 with 26 beds and will be opened in November 13.

8.9 Surgical The Elective Care Division currently has 9 beds on F5. It is intended that these beds will be transferred to the Family Division for Elective Paediatric Surgery. (please see 3.3.)

F6 will be used flexibly and will convert to male or female as demand requires.

A pilot study is underway to facilitate rapid assessment of Gynaecology patients presenting at A&E or referred from their GP. This pathway enables patient’s attendance at the ward where assessment by a specialty doctor will be undertaken to determine the best course of action for these patients. This will be under constant review during the winter. It is envisaged that if successful this will reduce the number of admissions to M1.

8.10 Elective Bed Capacity Review and balance elective and urgent bed demands. Will create additional paediatric capacity between Oct 13 to Mar 14. Build flexibility around trauma capacity. Trial SAU beds in F3 to improve flow. Open additional beds to cope with winter pressure.

8.11 Families There is capacity to increase 9 beds in Ward F5 to help manage a peak in paediatric attendance over the winter period to reduce the likelihood of cancellation of paediatric elective surgery cases when paediatric medical activity is high. The 9 beds on Ward F5 will assist in managing the continued flow of paediatric elective surgery patients at times of high paediatric medical demand. This will reduce the likelihood of treat and transfer for children being initiated and help keep paediatric A&E breaches to a minimum.

8.12 Integrated Rapid Response Team & Additional A&E Senior Staffing This year there will be a front end rapid response team delivering assessment and admission avoidance or early supported discharge to medical patients in the sub-acute phase. This will be delivered by an MDT team of nursing and therapy staff with the support of social workers where required. This rapid response will act to avoid admission and to also support early discharge from D1 and D2 the medical assessment bedded area by signposting to, arranging for, or delivering, care in the community. There will be an increase in support in the referral and assessment team and core districting nursing services to support these patients at home.

In addition to this front end team there will be increased medical cover at consultant and middle grade level to support times of increased demand in A&E during this winter period. This will also be supported by senior advanced nursing both for adult and paediatric patients in A&E.

8.13 Intermediate Care As last year demonstrated, increased intermediate and community bed capacity supports patient flow through the acute hospital. Darely Court capacity will be expanded by additional 5 beds with 10 beds additional beds at Laburnum Lodge from November to March.

8.14 3rd Party Providers Capacity at 3rd party providers such as the Beaumont and the Spire Manchester Hospitals will be utilised to reduce the impact of required RTT activity. The Elective Care Division has arrangements in place to utilise capacity at the BMI Beaumont Hospital and Spire Manchester Hospital. Where possible this capacity will be utilised to deliver planned care for patients both on the RTT pathway and those awaiting repeat procedures.

If cancellation of elective work at the RBH site is necessitated due to winter pressures all attempts should be made to provide this activity elsewhere within the 18 week RTT pathway.

Bolton NHS FT has an agreement with N.W.S.S. (North West Surgical Solutions). Member consultants access the Beaumont Hospital, Spire Manchester Hospital and Bolton NHS FT. The Elective Care Division will seek to utilise this company to deliver planned orthopaedic surgery both at a 3rd party provider or at weekends at the RBH site in order to deliver to the 18 week RTT standards.

8.15 Impact of the Actions Taken to Meet Demand The Trust has a medical bed base of 305 beds and 14 CDU. The following actions have been implemented in order to meet the expected demand based on the bed modelling described above.

Medical bed base 305 beds

CDU opened 26th November 14 beds

Winter ward capacity opened 2nd December 26

Darley Court additional step down beds (to open December) 5 beds

Laburnum Lodge 10 beds ______

Total 360 beds ______

In winter a small percentage of beds are frequently unavailable because of infection control measures. Given the above capacity it is anticipated that the 360 beds estimated to be needed in the winter months will be available in order to maintain occupancy at appropriate levels and thus facilitate effective patient flow.

9. WORKFORCE ISSUES

9.1 Adverse Weather Conditions

Adverse weather conditions may make it difficult for staff to attend work as normal due to school closures, poor driving condition etc.

In the event of adverse weather conditions, the following provisions should be adhered to:

All user email Staff should make contact with their ward/department as soon as possible if they are experiencing difficulty. Staff who are delayed or need to leave earlier than normal will be required to make up the lost time as agreed with their line managers. Staff who are unable to attend work at all may take annual leave, accrued flexi-leave or unpaid leave. Staff who live within a reasonable distance and safe walking distance from the hospital are expected to make their journey to work on foot. Staff should only leave their shift with the agreement of their manager after a handover has taken place to ensure patient care is not compromised. All staff and managers are requested to be as flexible as possible in order to ensure that essential services are delivered and maintained during such unusual circumstances.

9.2 Access to Trust and Non-Trust 4x4 Vehicles/Drivers

During severe weather, in order to maintain patient care to vulnerable patients in the community it is sometimes necessary to request the services of a voluntary team within the North West who can provide drivers with 4x4 vehicles as well as considering Trust staff who have offered their services as owners of 4x4 vehicles.

If deemed necessary by service managers, access to the North West 4x4 service is achieved by contacting a designated number which is on constant relay and will divert to all members of the group until answered. It should be noted however there is likely to be a high demand for this service should the severe weather be spread across a large area or for a prolonged period.

The service is voluntary, will have operational limitations and will require mileage to be covered at a rate of 65p per mile. When requesting assistance contact details must be provided for the correct person to receive the invoice from North West 4x4 – such invoices should receive prompt attention to reflect the fact that this is a voluntary service and reliant upon goodwill and reimbursement. The service should only be considered for critical staff and services in adverse conditions and it must not be advertised in any way outside of the normal command and control structures.

The contact details for the North West 4x4 service and a list of Trust staff with 4x4 vehicles plus additional information are available to all senior managers on call via the Network Drive (J:) – Major Incident – Majax Control – Winter Plans.

10 ESCALATION PROCESS 10.1 Response Flow Chart

Winter Related Service Delivery Issue

Local/Service Winter Trust Wide Winter Business Continuity Issue? Service Delivery Issue? Minimum Impact Serious Impact

Resolve Issue at service level C.O.O.

using exiting winter Business Set up Control to manage

Continuity procedures response at Trust

Report/Update using existing Report Actions/Requests to divisional structure Commissioners and Health Economy partners

Return to Normal Service Provision Continued Monitoring at Service Level

CMS – updated 2-4 hourly by Emergency Department and Bed Management teams to reflect current capacity status Unify 2 – Winter reported mechanism compiled by Trust informatics teams to indicate to commissioners overall Trust status across a number of data sets Exception Reporting – required by SHA (NHS North West) in event of Trust experiencing serious operational difficulties Emergency Planning Generic In-Box – e-mail in box accessible by all senior managers on call, used by Greater Manchester NHS Resilience Team to notify Trust of key information out of hours.

10.2 Command and Control:

The suggested Command and Control structure for the Trust when responding to incidents during winter is outlined below.

“Gold Control” will consist of the Chief Executive Officer, the Chairman and Medical Director. They will co-ordinate the Trust’s strategic Gold Control: response to winter pressures.

Silver Control: “Silver Control” will be provided by the “Operational Control Group” Operational Control (O.C.G). This group made up of senior managers and matrons and bed Group managers and clinicians will convene as a response to the Trust experiencing winter pressures that cannot be addressed at service level using existing operational Business Continuity arrangements

Bronze Control: “Bronze Control” will be provided by Service Level operational and

Service Level Managers clinical staff. This group of staff will lead the operational response to

and Teams winter pressures using identified Business Continuity arrangements

As identified in the command and control structure above, most incidents resulting from winter pressures i.e. patient care issues, reduced staffing numbers, short term loss of supplies etc. will be managed at service level using existing resources policies and business continuity procedures.

Wider ranging, serious or protracted incidents that may affect patient care, service delivery or have a negative effect on performance targets will need to be managed via an Operational Control Group. The group, chaired by the Chief Operating Office, with representation from all affected services and all staff that will be required to respond will be required to attend the meetings to discuss immediate priorities and allocate appropriate actions.

Liaison with all health economy stakeholders should be initiated in line with the current Borough Escalation Plan.

APPENDICES

Bolton Health Economy and Social Care Resilience Plan

The Health Economy Escalation Plan has been produced to assist in the management of the health and social care economy across Bolton during periods of surge or pressure.

The Bolton Health Economy and Social Care Resilience Plan is separate from each organisation’s Major Incident Policy.

Trust Escalation Plan

The Urgent Care Escalation plan has been designed to reflect the needs of Bolton Foundation NHS Trust and the fluctuating demands frequently seen in such a busy general hospital.

Critical Care Escalation Plan

NHS North West – Major Contingencies – Guidance for Critical Care Escalation

The Trust has drawn up contingency plans for its response to a possible influenza pandemic but the actions and principles contained in the Critical Care Escalation Plan are appropriate for any emergency surge in critical care capacity regardless of cause.

Additionally, the Major Contingencies – Guidance for Critical Care Escalation document provides a framework for the development and implementation of the critical care response to contingencies, including influenza or mass causality events, within the North West.

BOLTON HEALTH & SOCIAL CARE ECONOMY RESILIENCE PLAN 2013/14

CONTENTS

Introduction……………………………………………………………………………………………………………………………………………. 3

Planning Assumptions and System Capacity …………………………………………………………………………………………….. 4

Information Management ………………………………………………………………………………………………………………………. 6

Communications ……………………………………………………………………………………………………………………………………. 8

Delegated Authority ………………………………………………………………………………………………………………………………. 8

Awareness Training ………………………………………………………………………………………………………………………………… 9

Health Economy Resilience Leads ………………………………………………………………………………………………………….. 9

Escalation Plan ………………………………………………………………………………………………………………………………………. 11

Appendices ……………………………………………………………………………………………………………………………………………. 23

Signed Agreement …………………………………………………………………………………………………………………………………. 24

INTRODUCTION

This document has been produced to assist in the management of the health and social care economy across Bolton during periods of surge or pressure.

The document has been branded as a Bolton Health Economy and Social Care Resilience Plan and is separate from each organisation’s Major Incident Policy.

The document and plan are subject to continuous improvement and evaluation and as such is a ‘working document’.

This 2013/14 plan builds on the 2012/13 plan and sets out the steps to be taken across the Bolton Health and Social Care Economy to ensure that appropriate arrangements are in place to provide a high quality and responsive service through the winter period and beyond.

A system was established in 2011/12 to provide daily capacity and performance monitoring of providers and this will continue in winter 2013/14.

Significant changes for 2013/2014 to be acknowledged as part of this plan are: The establishment of Bolton Clinical Commissioning Group

Risk sharing agreements between the FT, Bolton Council and Bolton CCG for additional Intermediate Care bed costs over Winter 13/14

Integration of the hospital discharge team and the Intermediate Tier Home Services

The monitoring of capacity and demand for 2013/2014 will continue to be through the Bolton NHS Foundation Trust Urgent Care Group, which has the remit to develop robust demand management strategies, promote best practice and ensure that the whole system is aware of changes to the levels of predicted activity, enabling the system to respond accordingly. A key element of this plan is each organisations response to escalation. An escalation plan has been developed to align partner agency trigger points and action plans.

The Borough-wide resilience planning approach builds on the whole system approach, which acknowledges the usual peaks in demand over the Christmas and New Year period, plus unusual peaks in demand for other reasons, eg., as a result of adverse weather conditions. Our commitment is to ensure that we have an adequate ‘system wide’ resilience plan, to respond to operational pressures in parts of the system, such as delayed transfers of care, waits for Intermediate Care, waiting times in accident and emergency, ambulance delays, unplanned ward or nursing/residential care home closures.

The resilience plan seeks to ensure: Clear identification of the escalation process with defined escalation levels and triggers;

That key organisational contacts are identified;

Potential risks have been identified and contingencies have been put in place;

That the provision of high quality services are maintained through periods of pressure;

That the impact of pressures on the levels of service, national targets and finance are managed;

That process is in place to meet the winter reporting requirements of appropriate Boards and the GM Cluster; 17

This escalation process defines stages of potential increasing pressure that would trigger defined actions so the ability of the BNHSFT, Adult Social Care services and Practices within the Borough to manage patients / service users in a timely manner.

Winter 2013/2014

Additional anticipated pressures:

ANTICIPATED ADDITIONAL PRESSURES/RISKS SYSTEM IMPACT

Seasonal holiday and spread of seasonal holiday - Increased pressure on GP Out Of Hours, ED services

Patients not accessing timely care/crash-landing

Increasing number of patients presenting with drug/alcohol related conditions

Potential industrial action Insufficient resource to provide all services

Workforce, it is as crucial as ever for employer Robust locality sickness management/prevention organisations to offer and promote the seasonal flu strategy in place vaccine to their frontline healthcare workers and eligible patients

Adverse weather Rise in specific conditions, falls, COPD etc. Transport/mobility restrictions.

Rising fuel costs and changes to eligibility criteria for Older, frail and elderly may be affected. Impoverished patient transport families, and people with one or more long term condition may struggle to fund the cost of keeping sufficiently warm/attend appointments.

1. PLANNING ASSUMPTIONS AND SYSTEM CAPACITY Each Health and Social Care organisation in Bolton has its own internal arrangements for capacity management and escalation to meet surges in demand. This is a contractual requirement. This plan recognises the need for capacity management as a co-ordinated model across the Health and Social Care economy.

NHS Bolton, BNHSFT, GMW and Bolton Council continue to work jointly to review, co-ordinate; monitor and update resilience plans.

A Winter Assurance Checklist has been completed and provided the GM Cluster (September 2013), which illustrates our level of preparedness across a number of areas. It will be the responsibility of Bolton Clinical Commissioning Group as the lead commissioner to ‘declare’ the health and social care economy status.

It is an inherent understanding in this plan that no action should be undertaken by one constituent part of the system, which may undermine the ability of other parts of the system to manage their core business, without prior consultation / discussion.

1.1 BOLTON NHS ACUTE FOUNDATION TRUST As part of resilience planning BNHSFT has its own detailed plans for service development plan and capacity. This includes details of inpatient beds required during the year, associated theatre sessions and outpatient capacity. When bed occupancy exceeds normal operational levels, timely, daily discharges procedures will be in place to maintain system safety and efficiency. The system will increase or re-allocate staff to key areas to ensure that the daily discharge targets are achieved.

2013/14 DEVELOPMENTS to strengthen Winter Plans:

Escalation plans have been further developed for 2013/14 based on those of 2012/13. Services within the scope of the escalation plan include:

Intermediate Care services, providing both increased bed based and integrated domiciliary care directly from the community and the acute trust; an increased emphasis on home based reablement.

Develop a “Take Home and Tuck Up” service

An Active case management service targeting very high intensity users of unscheduled care services in conjunction with primary care clinicians and the NHS Bolton Clinical dashboard; this is aimed to reduce admission or expedite the discharge process.

A Rapid Response team (to include a Social Worker) with a 1 hour response, managing patients in the community from primary care, nursing and therapy services.

Bolton Community Unit, providing step up care for community patients to assist avoiding acute admissions and enhancing the flow of patients through the A+E department at RBHFT

Acute medical Consultants are providing a rapid assessment to support GP’s in managing Care closer to home. They are also in-reaching very frequently into the A&E dept to ensure that high level assessment is given early in the patient’s journey. This is aimed to reduce admission and shorten length of hospital stay.

1.2 PRIMARY CARE 46 practices offer extended hours opening for access to GP appointments in the Borough equating to 92% of all practices. Risk stratification in liaison with practices will identify vulnerable patients who may be at risk to co- ordinate any additional support, care plans will be developed in liaison with community services.

2013/14 DEVELOPMENTS to strengthen Winter Plans:

For Primary Care, these include: The development of a data set to monitor urgent care in general practices thereby enabling the health economy to have advanced warning of surges in demand in practices which would alert to potential surges across the system and allow time to plan for this

Continued development of the QBiT (Quality Business Information Tool) and HERD (Health Economy Resilience Dashboard) to support Primary, Secondary and Intermediate care. (see attachment for details of QBiT and HERD)

1048_systems_over view.docx

A step up over the winter months in the regularity of communications to practices to keep them informed on changes in system pressures – weekly newsletter escalating to daily related to alert status

Under QOF Quality and Productivity initiative, practices will carry out a pre-winter review of all COPD Severe and very severe and all Heart Failure on the QoF registers. The review will include proactive review, meds review, flu vaccination, care planning including a self-care plan/ rescue meds / education.

Project work with Practices to improve individual practice management of demands for urgent care.

1.3 SOCIAL CARE –

2013/14 DEVELOPMENTS to strengthen Winter Plans: Social worker to be integral part of Integrated Discharge Team

Altered working patterns of staff to ensure cover from 8am to 7pm

Integrate social worker into the Rapid Response Team

Refocused all social work and Reablement services to prioritise BCU, Hospital and Intermediate Care Discharges

Integrate Home Support Reablement team with Intermediate Care at Home team

Specific project work with care homes

Jointly funded Intermediate Tier Service Manager post

1.4 MENTAL HEALTH

Jointly funded Intermediate Tier Service Manager post 2013/14 DEVELOPMENTS to strengthen Winter Plans: RAID to be fully staffed and operationalised Section 136 Suite opened and fully staffed Integrate member of RAID team into Integrated Discharge Team Return Crisis team to community to prevent known individuals in crisis getting to A&E

1.5 AMBULANCE TRUST (NWAS) NWAS has its own escalation plan including Resource Escalation Action Plan (REAP) arrangements currently under review) and Clinical Escalation Plan all underpinned by Major Incident Plan and On Call Procedures and Deployment Plan, Regional Operational Coordination Centre and Urgent Care Desk monitoring activity and performance.

The REAP, is an integral part of the NWAS Business Continuity management strategy and is in operation at all times. It enables NWAS to ensure that its service can respond to challenges in the local environment, such as increased activity, significant loss of staff, buildings and resources, or pressures within the wider NHS.

The health economy will continue to work with the NWAS in reporting escalation and local pressure status on the Capacity Management System and working to the Gold Control and SHA diversion process and policy.

To meet national indicators for the Ambulance Service patient response and turnaround times, standard operational guidelines are in place to support minimal delays in emergency response times and hospital turnaround times.

2. INFORMATION MANAGEMENT All Provider organisations are responsible for reporting their performance through various systems. These include a Capacity Management System and ExtraMed which provide operational information systems that supply information to the CCG Data Warehouse that “feeds” the Health Economy Resilience Dashboard (HERD).

Emergency Pressures Reporting: This is managed by the GMCSU Utilisation Management Team (UMT). This report is provided by all acute trusts and collaboratively provides the UMT with a region wide picture of demand/capacity and this is fed into the GM Gold Command emergency planning process.

Information provided by the Bolton NHS Foundation Trust will be used by commissioners to gain assurance that all effective measures are being implemented. Where assurance cannot be provided, or actions are not resulting in solutions, then the Urgent Care Operational Board will open communication channels to co-ordinate a solution. Escalation and reporting timescales are as figure 1.

2.1 ESCALATION

For 2013/14, escalation will monitored daily through local HERD report and a minimum of twice weekly health economy conference calls, operational intelligence, SIT REP and breach reports. HERD details differing levels of capacity availability and trigger indicators. Operational intelligence will be provided by senior managers and clinicians involved in the delivery of day to day services and members of the BNHSFT Urgent Care Group. Below is a list of the escalation levels to be adopted; for the purposes of this plan taken from the Greater Manchester Command and Control Framework;

Fig 1. Levels of Escalation for Winter Plans

Level(s) Colour Level Characteristics Impact Reporting Timescales

1 Green Individual organisations No impact on service Monday – Friday only by 1030 manage their own pressures delivery daily across 5 days within normal capacity planning parameters, liaison between commissioners and providers, and provider to provider within the economy will be standard practice 2 Yellow Low surge effect activity increasing impacting Monday – Friday only by 1030 daily on service delivery across 5 days

3 Amber Medium surge effect moderate to severe All Health Economies reporting effects on services across 7 days, real time information.

delivery

4 & 5 Red Major disruption to services high impact on service All Health Economies reporting 7 delivery days as required by DH/ NHS NW.

The Escalation Plan is at section 7 of this plan.

3. COMMUNICATIONS During usual daytime working hours each organisation will have communication arrangements in place, (both internal and external) to manage escalation within and across the health and care economy.

Out of hours the Bolton CCG Director on-call arrangements will have responsibility for leading escalation and necessary communications including declaring the health economy status with NHS England and provider organisations.

During winter and other pressure periods communications will be mobilised appropriate to the level of escalation. See attached Winter Escalation plan.

4. DELEGATED AUTHORITY

This Resilience Plan will be taken for agreement through NHS Bolton and partner organisations as follows: Bolton CCG Urgent Care Operations Board August 2013 Bolton CCG Executive September 2013

RBHFT Executive Board October 2013

Bolton Council Portfolio Board October 2013 Executive Briefing October 2013 Committee Admin October 2013

GMW Executive Board October 2013

Bolton CCG is the lead for managing the Bolton health economy alert status. In alert status individual organisations will be responsible for cascading and managing internal processes.

The BNHSFT Urgent Care Group will meet weekly and more frequently when necessary to monitor and identify capacity/demand and ensure the appropriate escalation level is recommended and activated as appropriate, within agreed timescales and triggers of Escalation.

In the event that any pressures identified outside of the routine winter monitoring arrangements, the BNHSFT Urgent Care Group will be an informing and co-ordinating group (as indicated by the Tactical Response plan appendix F) responsible for the activation of escalation, de-escalation and lead communications between the Health Economy organisations. The BNHSFT Urgent Care Group reports to the Urgent Care Operational Board which has overall accountability for delivering resilience.

The use of trigger indicators to activate actions across organisations, as set out in the plan will, to an extent, result in ‘automatic’ corrective action being undertaken to respond to pressures in one or more parts of the system. However, individual resilience leads with delegated authority will be provided with the necessary information set out within the Borough-wide escalation plan, in order to respond appropriately to escalation or alerts. All provider organisations will ensure the explicit responsibility for who can decide on a change of escalation level in an organisation is in place, this is evidenced in the individual’s plans and on call responsibilities. Our system ensures that organisations do not automatically escalate if just one trigger is tripped, and therefore it has been agreed that the duty manager or director on call for the individual organisation will consider triggers and issues pertinent at the time to inform the escalation alert status.

5. AWARENESS RAISING AND TRAINING

A programme of training and development is in place to ensure individuals, departments and organisations are aware of obligations, processes and individual responsibilities regarding the escalation process.

Desktop exercises have been undertaken throughout 2013; including Winter Debrief, Winter Planning, Resilience Testing due on the 9th of October 2013.

6. HEALTH ECONOMY RESILIENCE LEADS

The following is a list of those personnel from the principal members of Bolton’s health economy who would input to and aid the tactical support function of the Urgent Care Operational Group in the decision process.

Bolton Clinical Commissioning Group

TITLE NAME CONTACT DETAILS

Clinical Director Barry Silvert 01204 462012

Chief Executive Officer Su Long 01204 462110

Major Incident Planning Peter Heijstraten 0161 212 4834

Greater Manchester Gold Emergency 07749684166 Planning (emergency only)

Head of Communications Lucy Ettridge 01204 462026

Senior Commissioner Jackie Bell 01204 432100

Bolton NHS Foundation Trust TITLE NAME CONTACT DETAILS

Chief Executive Officer Jackie Bene 01204 390808

Director of Operations Jon Scott 01204 390390 x3803

Clinical Lead Acute Adult Division Adam Robinson 01204 390390 x3726

A&E Clinical Lead Owen McCormack 01204 390381

Director of Nursing, Patient Safety and Trish Armstrong-Childs 01204 390390 x3650 Infection Control

Divisional Director of Operations for Michelle Redgard 01204 390822 Acute Adult Care Division

Bolton Council – Social Services TITLE NAME CONTACT DETAILS

Director of Adult and Children’s Margaret Asquith 01204 ****** Services

Assistant Director Rachel Tanner 01204 ********

Assistant Director of Health and Adult Adrian Crook 01204 334175 Social Care, Integration and Providers Services

Infection Control Nurse Julie O’Malley 01204 462538

07918619122 (emergency only)

Director of Public Health Wendy Meredith 01204 462009

Greater Manchester West TITLE NAME CONTACT DETAILS

7. ESCALATION PLAN 2011/2012

Area Bolton Clinical Foundation Trust Primary care (FHS Adult Social Care Commissioning Contractors) Group

Volume & Monitoring and Bed availability within normal range GP Activity /Consultations Referrals for assessments and unscheduled reviews are Capacity and spotter practices within within are at or below 10% of hospital population. responding to Clinical activity within normal range Urgent Care normal range. No delays in assessments. Referrals to Reablement dashboard, GM National bed utilisation optimal threshold Seasonal influenza Home Support Team are within normal seasonal levels Gold command 85% vaccinations proceeding and there is capacity to meet demand from assessment and NHS NW as Intermediate bed utilisation at normal against plan areas and complex ward(s).Referrals to Independent required. level of 89% sector Domiciliary Home Care Services are within normal seasonal levels and there is capacity No weather 12 spare beds out of 80 available in IMC

alerts. Capacity available in 24 hour care including residential, GP Out of Hours demand as predicted for EMI and nursing sectors. time of year. All providers have Requests for admissions to permanent residential care BCUs in place DISCHARGES WITHIN EXPECTED RANGES within normal seasonal levels. (NEED TO AGREE THRESHOLDS)

Staffing Staff absence levels normal across the organisations

Infection Infection control status normal (no significant containment issues) management

Critical Care Availability / Capacity within Unit and / or North West Critical Care Network

ACTIONS L1 GREEN

Bolton Clinical Commissioning Foundation Trust Primary care (FHS Contractors) Adult Social Care Group Communications Normal local admission criteria apply Primary Care Usual Business processes apply

1 PCT lead communicators Monitoring against 2 /2-hour internal Practices on a day to day basis flex capacity Hospital and Intermediate care discharges identified and trained in targets - Monitoring of trigger measures to meet peaks in demands GPC01 prioritised GLA01 resilience planning and at Bed Meetings. GHOS01 Business continuity plans (BCP) are in place Routine monitoring of activity in the escalation processes GBCCG01 Ward managers identifying and reporting with triggers alerting the PCT of any independent domiciliary home care sector Monitoring and responding to gaps in staff cover; unplanned reductions in service (or GLA02 Urgent Care dashboard, GM Gold undefined timescale) GPC02 command and NHS NW as Hospital data reporting through SITREPS Weekly monitoring of capacity in the Since 2011/12 winter period, daily required. GBCCG02 and CMS. GHOS02 Residential/Nursing Care Home sector GLA03 monitoring of demands for urgent care Maintain daily monitoring using HR / WorkforceNormal monitoring have been in place, to prompt advance activities in relation to staff attendance CMS/HERD/Sit Reps/GM warning to other parts of the Health and Daily communication of status to partner Weekly Acute/non acute care SITREP Utilisation reports/Breach Social Care Economy GPC03 reporting to monitor and respond to Analysis and 2 weekly Health organisations. Vaccination programmes have commenced blockages in the system. GLA04 Economy conference calls Business continuity plans are in place and for staff and patients GPC04 GBCCGO3 tested. GHOS03

Normal local admission and referral Business Continuity Plans in place GLA05 criteria apply. GHOS04 HR/Workforce

Co-ordinate established whole system Flu vaccines available for staff GLA06 approach through weekly sit-rep reporting agreed across all providers. Infection control risk assessments in place for GHOS05 staff working in high risk areas. GLA07

Vaccination programmes have Routine monitoring activities and protocols in commenced for staff GHOS06Infection place in relation to staff attendance. GLA08 notifications levels manageable

If capacity or operational effectiveness is being stretched beyond existing capability out lined above consider this a trigger INFORM PARTNER ORGANISATIONS26 to move to next level.

WINTER ESCALATION PLAN 2011/2012

L2 YELLOW Description

Low surge effect – activity increasing impacting on service delivery

Area Bolton Clinical Foundation Trust (including the new Primary care (FHS Adult Social Care Commissioning integrated PCT Provider Arm) Contractors) Group

Volume & Dashboard Bed availability issues but within Increasing activity in Referrals for assessments and unscheduled reviews are Capacity monitoring acceptable limits practices with low surge in slightly above normal seasonal levels and are 11% or identifies Adult consultations within normal above of the hospital population Social Care or Clinical activity increased in ED/D1/D2 range – external reports and No delays in assessments. Acute Trust or Demand for community services beginning spotter practices Primary Care to out strip capacity in CRT / RRT / IC / Number of all GP contacts Increase above anticipated seasonal levels of referrals escalating beyond Nursing beds/ IC@home / to independent sector domiciliary care Green increasing IMC Bed utilisation now at 95% (only 4 of Additional capacity planned to be provided by

the 80 beds vacant) Independent sector Domiciliary Care Services

Increasing activity OOH showing increasing activity – Requests for admission to permanent residential care in practices and thresholds to be identified within seasonal levels consultations Some delays accessing social care Temporary residential/nursing homes affected by Weather alerts packages infection and not able to accept new placements. reported DISCHARGES WITHIN EXPECTED RANGES (NEED TO AGREE THRESHOLDS)

Staffing Staff absence levels have exceeded normal levels and managers are reporting staff shortages impacting on services. Flu vaccination rates not being achieved Put in %. All data too retrospective and there are no systems in place to reflect real time status Infection Infection control outbreaks causing concern and impacting on transfer issues and are just containable within increased Infection

management control measures operating procedures daily IC report required Flu vaccination rates below plan -

Critical Care Capacity within critical care / regional availability may be compromised. Regional escalation may be actioned.

ACTIONS L2 YELLOW

Bolton Clinical Commissioning Foundation Trust Primary Care (FHS Contractors) Adult Social Care Group IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO YELLOW MUST INFORM TACTICAL RESPONSE GROUP BY E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS

PCT consolidates plans to identify a Continue with normal local admission criteria Practices continue to flex capacity to Create capacity in Reablement Home pool of GP locums; nurse and admin or review with the potential to fast-track meet peaks in demand. YPC01 Support to support prioritisation of staff for access by Practices as admissions and investigations YHOS01 Hospital and Intermediate Care necessary for maintenance of core discharge. YLA01 Emergency Department services YBCCGO1 Identify patients with chronic problems Continue routine monitoring of activity 1 PCT trouble shooting team identified Monitoring against 2 /2-hour internal targets – for review. YPC02 in the independent domiciliary home Monitoring of trigger measures at Bed in readiness to mobilise on Amber care sector YLA02 Meetings x 5 daily. YHOS02 alert YBCCGO2 Reinforce messages on self-care, PCT lead communicators sends alert HR / Workforce supported by PCT borough wide Double the levels of weekly monitoring to partner agency leads of change in Ward managers identifying and reporting gaps communications plan YPC03 of capacity in the Residential/Nursing status YBCCGO3 in staff cover; YHOS03 Care Home sector Mondays and Fridays Public/patient communications re- Normal protocols in place around sickness mornings YLA03 enforced on self care and advice on Identify at risk patients cared for in reporting/agency/bank staffTrust wide skills Continue weekly Acute/non acute care health protection/promotion community and ensure care plans are in audit refreshedReview workforce business SITREP reporting to monitor and delivered through media, practices continuity plans including collation of place YPC04 respond to blockages in the system. and pharmacies. YBCCGO4 volunteer lists YHOS04 YLA04

Information Elective Services Consider pooling of GP locums YPC05 Business Continuity Plans in place YLA05

Monitor and responding to Urgent Consider/review suspension of elective major ACM/DN. In liaison with Practices start HR/WorkforceFlu vaccines available for Care dashboard, GM Gold command adult non-oncology surgery Consider to identify vulnerable patients in staff YLA06 and NHS NW as required. identifying patients with chronic problems for readiness to mobilise emergency care review in collaboration with GPs Low plans in case of transition to amber alert Infection control risk assessments in PCT to respond to queries and DISCHARGES (NEED TO AGREE THRESHOLDS) YPC06 place for staff working in high risk areas. report YBCCGO5 YHOS05 Continue Routine monitoring activities

and protocols in place in relation to staff

attendance. YLA07

If capacity or operational effectiveness is being stretched beyond existing capability outlined above. Regional response would be implemented. INFORM PARTNER ORGANISATIONS

L3 AMBER Description: Medium surge effect –

Moderate to severe effects on services

Area Bolton Clinical Commissioning Foundation Trust Primary care (FHS Contractors) Adult Social Care Group

Volume & Capacity In a defined geographical area, Bed availability minimal put in % Increasing GP Activity Referrals for new /Consultations outside normal assessments/unscheduled reviews 25% of the practice(s) have Low DISCHARGES (NEED TO range. well above normal seasonal levels 15% alerted the PCT that part of AGREE THRESHOLDS) their BCP has failed e.g. owing or >15% Serious delays accessing social to inability to secure locum or Significant reliance on GP Out of care packages Delays in new assessments/ staff cover and inability to Hours & NHS Direct services. (OOH plan at appendix G) unscheduled reviews being completed. mobilise buddying

arrangements Severe delays in non urgent new Clinical activity disrupted. Increasing Urgent Care activity assessments/unscheduled reviews Demand for provider services across the system being completed. has out striped capacity in CRT /

Increased reliance on Out Of RRT / IC / Nursing beds/ Some independent Domiciliary Care Hours GP Service & NHS Direct IC@home Services no longer able to accept referrals IMC Bed utilisation now at 100% Weather alerts (No beds available] and zero Delays in transferring work from home patients waiting support reablement to the independent sector due to the above. Serious delays accessing social Home support escalation plan on care packages amber.

Some problems with capacity in the residential/nursing home sector

Requests for admissions to residential care for permanent and emergency short term care are well above normal seasonal levels.

Some problems making placements.

Staffing Staff absence levels across the organisations beginning to place a strain on service delivery Data is too retrospective to establish – need to identify proxy to measure Infection management Infection control issues escalating and requiring implementation of special measures

Critical Care Critical care capacity compromised. Local / Network escalation required

ACTIONS L3 AMBER

Bolton Clinical Foundation Trust Primary Care (FHS Contractors) Adult Social Care Commissioning Group IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO AMBER MUST INFORM TACTICAL RESPONSE GROUP BY E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS

Team mobilised to support Normal local admission criteria still apply Practices, in accordance with their BCP, Continue to create capacity in Reablement practices approval/advice on AHOS01 defer non essential tasks and mobilises Home Support to support prioritisation of temporary suspensions Hospital and Intermediate Care discharge. Bed Management workforce plans. APC01 ABCCGO1 ALA01 Identify/expedite potential discharges;Review Sit Reps from Practices at critical status Continue routine monitoring of activity in Co-ordinated comms with all patients for Rehab / home; Review co-ordinated with other parts of the the independent domiciliary home care public/patients, LA and health sector ALA02 system eg OOHs/walk in centre APCO2 partners ABCCGO2 diagnostic delays; AHOS02 ACM/DN’s in liaison with Practices Co-ordinated plans for media Prepare bed escalation capacity; AHOS03 management ABCCGO3 develop emergency care plans for Consultant review of all patients; AHOS04 identified vulnerable patients APC03 Information to practices from Review elective priority list; AHOS05 Urgent Care Clinical Lead on alert status to activate plans Constant monitoring and increased as necessary ABCCGO4 assessment of demand AHOS06

Liaise with identified Bolton Council Senior Manager over escalating planned discharges. AHOS07

Start deferral of non-essential or elective work to generate staff capacity for re- location. AHOS0

The Response to notification Community services Continue weekly monitoring of capacity in with demand reduction the Residential/Nursing Care Home sector Infection Prevention Senior Manager to attend weekly measures includes: acute/non acute SITREPS to monitor and Reinforce infection control Reinforce Infection prevention advice respond to delays/blockages in the system advice and procedures in Reviewing threshold on Emergency ALA03 consultation with health Admissions criteria because trolley waits will Suspend routine review activities, identify departments of the devolved increase due to patient acuity and an increase in clinical exceptions. AHOS09 staff to transfer to manage areas of high administrations ABCCGO5 demand specifically BCU, hospital and Reinforce self-care and how to Increased reliance on Out Of Hours GP Service Intermediate Care discharges. ALA04 protect and look after yourself & NHS Direct services. See GPOOH plan Notify all independent sector providers ABCCGO6 appendix G. regarding escalation status. ALA05

Co-ordinate established whole Liaise with Bolton Council Senior Managers to Escalate planned discharges system approach through weekly request action to prioritise support through HR/Workforce Urgent Care ops meetings/ home care services to the BCU and IC Nursing increasing the frequency beds in order to escalate appropriate Non mandatory staff training cancelled. including meeting face to face discharges. AHOS10 ALA06 ABCCGO7 Review at risk patient emergency care plans ready Offer part time staff extra hours ALA07 to implement if needed. AHOS11 Review Infection control risk assessments Weekly sickness absence monitoring to move to ALA08 daily AHOS12 Senior management on call arrangements in place, ALA09

L4/RED Desctipgtion Major disruption to services – high impact on service delivery

Area Bolton Clinical Commissioning Foundation Trust Primary care (FHS Contractors) Adult Social Care Group

Volume & Capacity In a defined geographic area, Bed availability – None Increasing urgent care activity in Referrals for urgent new assessments 50% of the practice(s) have practices surged to the extent of /unscheduled reviews severely above Low DISCHARGES (NEED TO alerted the PCT that part of major disruption to the service normal seasonal limits. their BCP has failed e.g. owing AGREE THRESHOLDS) requiring advice/support from Severe delays in completing urgent to inability to secure locum or Significant reliance on GP Out the PT C Troubleshooting team assessments staff cover and inability to of Hours & NHS Direct

mobilise buddying services. (OOH plan at No routine assessments being done arrangements and 25% of appendix G) practices at risk of temporary No capacity in Reablement home support closure or suspension of Clinical activity – Severely Limited capacity in the independent services disrupted domiciliary care sector serious delays in accepting work.

No IMC beds available and Severely limited capacity in the patients waiting Residential Nursing care Home sector. Weather alerts Some homes closed to admissions. (eg. due to Noro virus)

Severe problems making placements for permanent and emergency short term care.

Staffing Serious Staff absence levels creating service delivery issues Economy-wide Demand for support is outstripping capacity. Practices alert NHS Bolton of specific difficulties in accessing

other patient support and treatment services et access to community/inpatient services

Infection management further escalation of infection control issues implementation of special measures

Critical Care No Availability / Capacity. Full local escalation required

ACTIONS L 4/5 RED

PCT Bolton Clinical Foundation Trust (includes the Primary Care (FHS Contractors) Adult Social Care Commissioning Group Integrated PCT Provider Arm) IN LINE WITH GM GUIDANCE REQUEST INFORM TACTICAL RESPONSE GROUP. ANY ORGANISATION MOVING TO YELLOW MUST INFORM TACTICAL RESPONSE GROUP BY E-MAIL TO TRIGGER APPROPRIATE LEVEL OF CROSS DEPARTMENTAL OR CROSS ORGANISATIONAL DISCUSSIONS Notification of demand At the earlier stage of the surge: Defined non-essential services suspended across Suspend all non urgent work and reduction measures by the practices (within DH guidelines – Aug ’09) ensuring undertake only urgent/emergency work Tactical Response Group Staffing Business continuity plans continuity of care for vulnerable patients and that contributes to an agreed system wide activated. RHOS01 includes: RBCCGO1 essential screening/patient reviews maintained approach to manage demand and capacity RPC01 across the whole system.RLA01 Ensure all provider BCPs are Cancel clinics, elective surgery and inpatient admissions where no severe activated including FHS Suspend services where appropriate RLA02 contractors RBCCGO2 adverse effect anticipated RHOS02 Practices co-operate with process for phased Suspend any non urgent activity and Increase frequency of co- Essential care only when required response to demands for access to secondary care transfer staff to areas of high demand. ordinated pandemic As the surge increases: (new integrated provider) balance of probability RLA03 conferences both telephone for urgent referrals shifts from possible to Escalate planned discharges form Hospital and face to fact RBCCGO3 Defer some services/treatment for non- probable eg overt cancer signs RPC02 life threatening conditions RHOS03 and Intermediate Care. RLA04 Anti-viral collection centres End of Life care services continue to be supported Operate at critical FACs criteria only. open and fully operational Clinical care practices to maximise and expanded if possible and feasible RPC03 capacity RLA05 Joint working to minimise Practices support secondary care plan to manage

referrals and maintain Ensure rapid discharge RHOS04 patients where possible in community settings Continue to create capacity in Reablement patients in a community RPC04 Home Support to support prioritisation of setting across all services, eg, ED/Medicine Hospital and Intermediate Care discharge. Practices support plans for managed early GPs, Intermediate Care at Consultant recall to wards; RHOS05 RLA06 Home and Referral and discharges RPC05 Opening available escalation capacity Advise independent sector organisations of Assessment teams to prevent Manage patients within the community setting escalation status. RLA07 admission i.e. use of Out patients RHOS06 including: RPC06 Notifications to GPs/PCT/Social Continue routine monitoring of activity in Increase BCU capacity with Trauma cases additional beds/ chairs Services; RHOS07 the independent domiciliary home care sector RLA08 RBCCGO4 Cardiac arrest – not responsive to electrical Start implementation of plans around therapy Twice weekly monitoring of capacity in patient classification of emergency management priorities RHOS08 Known severe, progressive baseline cognitive independent residential/nursing care impairment requiring respiratory support home sector RLA09 Critical Care/Paediatrics known advanced, untreatable neuromuscular HR and Workforce SHA May implement of NHS North disease requiring respiratory support West Critical Care Operational Policy Advise trade unions of escalation status. Use alternative settings for critical care Known advanced metastatic malignant disease RLA010 Increase stringent criteria for critical Known advanced, irreversible Senior management on call arrangements care beds immunocompromised requiring respiratory in place, RLA11 Restrict treatment options in ICU support Offer staff additional hours to facilitate 7 RHOS09 Severe & irreversible neurological event or day services in high demand areas and all Consider implementation of the reverse condition staff training cancelled RLA12 triage methodology RHOS10 Elective palliative surgery Paediatric referrals for critical care

should follow current practice e.g. Paediatric ICUs. if not possible Paediatrics may have to be cared for on 35

adult wards RHOS11

Elective Services

Gradual increasing suspension of all elective major adult surgery RHOS12

Infection Control

To increase their level of input, focussing on limiting the spread of infection within wards and more generally across the hospital RHOS013

HR / Workforce

Implement plans to transfer staff into non-specialist areas (created through closure of Out patient services, wards and other non-essential corporate services) RHOS14

Clinical care practices maximised – removal of all non-essential clinical involvement across the Trust RHOS15

Senior manager to attend RBH bed meetings RHOS16

Senior manager included in RBH control Team RHOS17

Referral and assessment team member

based in BCU RHOS18

Deploy consultant of the day to BCU RHOS19

L 4/5 RED If capacity or operational effectiveness across the health and social care economy (ie there is a risk to borough wide provision of care) this should be escalated to GM Gold Command so that a regional response could be implemented. INFORM PARTNER ORGANISATIONS

7. APENDICES

Appendix A: Bolton Health and Social Care Economy Organisational Response Pathway

Appendix A operational reponse pathway.doc

Appendix B: Winter Assurance Checklist, providing a Summary of readiness of components of the Borough health economy providers

Appendix C: Emergency Pressures Health & Social Care Tactical Group Terms of Reference

appendix C tactical response.doc

Appendix D: NWAS Winter capacity plan 2013/2014

NWAS Strategic NWAS Winter Winter Capacity Plan 2011Assurance 12 .pdf Checklist 2013 (FINAL inc NHSE REVISIONS 2013-09-19).docx

Appendix E: NWAS Hospital Arrivals policy 2011/2012

Appendix E Hospital Arrivals Policy 2011 12.doc

Appendix F: Greater Manchester Command and Control Framework 2011/ 2012

FINAL - GM NHS CCFramework Winter 2011-12 (2).doc

Appendix G: Arriva Winter Plan

ATSL Winter Plan .docx

Bolton Health and Social Care Economy Resilience Plan - AGREEMENT

This joint plan has been produced by the Health and Social Care Economy. Individual organisations are responsible for ensuring that appropriate training and communications systems are in place to deliver the actions required in the Resilience Plan and in particular the Escalation Plan at Section 7.

Name: Su Long

Signature: …………………………..

Organisation: BOLTON CLINICAL COMMISSIONING GROUP Date: ………………………………..

Name: Margaret Asquith

Signature: …………………………..

Organisation: Bolton Council Date: …………………………………

Name: Jackie Bene

Signature: ………………………….

Organisation: Bolton NHS Foundation Trust Date: ………………………………..

Name: Bev Humphrey

Signature: ………………………….

Organisation: Greater Manchester West Mental Health NHS FT Date: ………………………………..

Agenda Item No : 12

Meeting Board of Directors

Date 31st October 2013

Title Phase 2 Transparency Project NHS England

Executive Summary

Why is this paper • “Transparency in Care” aims to be a programme of going to the Board improvement in culture and care. To summarise the main points and key • Publishing data on harm, experience and staffing that issues that the Board supports patient choice and enhances staff knowledge, should focus on leading to empowerment to change practice. including risk, • By participating in “Transparency of Care”, the Board of compliance priorities, cost and penalty Directors is agreeing to the Compact agreement and implications, KPI’s, ownership of the ‘concept’ Trends and Projections, conclusions and proposals

Next steps/future actions

Clearly identify what will follow a Board decision i.e. future Discuss Receive KPI’s, assurance requirements Approve Note

Assurance to be Bev Tabernacle, Deputy Director of Nursing provided by:

This Report Covers (please tick relevant boxes)

Strategy * Financial Implications

Performance Legal Implications

Quality * Regulatory

Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Trish Armstrong- Bev Tabernacle, Deputy Prepared by Presented by Child, Director of Director of Nursing Nursing

BOARD – 31st October 2013

Phase 2 Transparency Project NHS England

1. PURPOSE Inform the Board of the organisation involvement in the Phase 2 of the NHS North Transparency project and to present the Board Compact which has been issued through the Chief Nurse for the North of England.

2. BACKGROUND In September 2011 Nursing Leaders from 8 Acute NHS Trust in the North West came together as members of the “Transparency Project” to see if they could learn more about the PU and Fall harms that occur in their Organisations. They jointly had a shared passion to progress and improve the experience of both patient and staff and to work closely with patients to learn what needs to change in order to improve future patient care.

This work was completed with a view to the expansion of the project to include further indicators, and enable roll out across all areas of the NHS. Phase 2 of this work began in August 2013 with 35 organisations being invited to participate in the further development of the work completed in 2012.

The Phase 2 Transparency data will be undertaken in the following areas;

1. Classic Safety Thermometer results

2. Friends and Family Test

3. Pressure Ulcers grade 2-4 and unclassifiable ( pre and post 72 hour)

4. Falls moderate harm and above

5. Staffing levels/skill mix (when harm occurred)

6. Staff and Patient Experience information

7. Patient story of harm

8. Improvement story

Bolton Royal NHS Foundation Trust is one of the 35 organisations involved in the Phase 2 Transparency project. 3. CURRENT POSITION Bolton Royal FT was involved in the Phase one work in relation to transparency, currently data is not being submitted. A review of the process used will be undertaken by the Deputy Director of Nursing to ensure that the system going forward is inclusive of the new areas of information and fit for purpose.

4. PROPOSAL The Board Compact is outlined in Appendix 1. The Transparency project working group have agreed the following measures, and upload of this information is supported by a purpose built web module to enable easy upload of the information required. 1. Trust level data on MRSA, C Diff, Safety Thermometer and FFT ( NHS North are currently working on a solution that will extract this data from the current systems) 2. Pressure Ulcers (2 and above) and Falls (moderate and above) – Actual numbers for each month and a trend line of rates/1000 occupied bed days. PUs by pre 72 and post 72hr. 3. Staffing levels, this will have to be at ward level for each harm. So will look like: PU or fall, the shift on which it was identified (E, L or N) then the preceding 3 shifts: Planned RN vs. Actual RN, Planned Non-RN vs. Actual Non-RN for each shift. 4. The mini RCAs will be completed electronically BUT will not be displayed on the front page for publication – that information is for the Trust to use. 5. Staff experience – 3 questions to be asked at the time or the harm to 5 staff members (a range of staff). The results will be displayed as a net promoter score. 6. Patient experience questions – 7 questions; to be included as part of the Trust monthly survey, not specifically patients who have been harmed. Again, the results will be presented as a net promoter score. For those trusts that cannot include them in their regular surveys, for whatever reason, this section will be left blank. 7. A patient story 8. The improvement story – this is what you have seen from the month’s data and what improvements you are making, written in language that the public and all staff groups will understand.

5. CONCLUSION Although some of this data collection and publication will be challenging, it is important that the organisation continues to participate in the Transparency work in a shared learning environment with other organisations. The publication dates for this information are yet to be confirmed, however currently the project is looking to publish in the New Year. Work will be done between now and the first data collection to ensure that processes are in place to support this work in the long term.

6. RECOMMENDATIONS The Board are asked to agree with the ongoing participation in this work and endorse the Board Compact in Appendix 1. Transparency in Care

The Board Compact

September 2013

1 NHS | Presentation to [XXXX Company] | [Type Date] Transparency in Care

• “Transparency in Care” aims to be a programme of improvement in culture and care.

• Publishing data on harm, experience and staffing that supports patient choice and enhances staff knowledge, leading to empowerment to change practice.

• By participating in “Transparency of Care”, the Board of Directors is agreeing to the Compact agreement and ownership of the ‘concept’ Transparency in Care – Background & Context

• Phase one: 8 Trusts in NW agreed and started to publish harm and experience data in February 2011. (Pressure ulcers, falls, patient and staff experience)

• There were two key principles: to improve experience and reduce harm; to be open and honest with the public.

• The programme was not formally evaluated; however the majority of Trusts did demonstrate improvements and have continued to publish their data and information.

• So why spread the programme further?

Compassion in Practice

Francis Report: “Duty of Candour” and “Openness”

Keogh Reviews: Ambition Two and Three

Berwick Report

The Board Compact

• Board endorsement of organisation’s involvement and commitment to openness

• Utilisation of common data definitions, reporting templates, PR/media etc. Trusts can add to the data set if they so wish, but the core must be agreed.

• Publication of data in agreed formats at agreed times and proactively shared with stakeholders (internal and external). Will form part of routine quality reporting in Part One of Board of Directors.

• Commitment to publish further metrics as developed and agreed

• Focus on the capacity and capability for improvement, not to apportion blame

• Mentoring organisations new to transparency as their own experience and confidence grows

Metrics and narrative for publication

The metrics for publication will grow over time. In the first instance, we will publish actual numbers and trends (annotated with improvement work):

1. Classic Safety Thermometer results

2. Friends and Family Test

3. Pressure Ulcers grade 2-4 and unclassifiable ( pre and post 72 hour)

4. Falls moderate harm and above

5. Staffing levels/skill mix (when harm occurred)

6. Staff and Patient Experience information

7. Patient story of harm

8. Improvement story

Publication

• The metrics and narrative will be published monthly on the Trust internet and intranet (within two clicks) and on NHS Choices. Internally, wards and teams will be able to view both their local data and Trust data.

• Trusts will establish a regular feedback mechanism with staff, patients and families to ensure the publication is understandable and meaningful.

Agenda Item No : 15

Meeting Board of Directors

Date 31st October 2013

Title Board Assurance Framework (BAF)

Executive Summary

Why is this paper going to the The BAF is designed to focus the Board on controlling principal risks Committee threatening the delivery of objectives. The BAF aligns principal risks, key To summarise the controls and assurances on controls alongside each objective. Gaps are main points and key issues that identified where key controls and assurances are insufficient to reduce the the Committee risk of non-delivery of objectives. should focus on Board members are asked to note the significant risks to the achievement including risk, of the Trust’s objectives and consider the mitigations and assurances. We compliance priorities, cost and are continuing to review and refine the BAF to ensure it best meets the penalty needs of the organisation. implications, KPI’s, Trends and Projections, conclusions and proposals

Next steps/future actions The development of the BAF will continue with oversight from the Risk Management Committee

Clearly identify what will follow i.e. future KPI’s, Discuss  Receive  assurance requirements Approve Note 

This Report Covers (please tick relevant boxes)  Strategy  Financial Implications   Performance Legal Implications   Quality Regulatory   Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Esther Steel Esther Steel Prepared by Presented by Trust Secretary Trust Secretary BOARD ASSURANCE FRAMEWORK

1. INTRODUCTION The Board Assurance Framework (BAF) is a tool which sets out the significant risks for each strategic objective, along with the controls in place and assurances on their operation. The BAF is used by the Board of Directors to ensure that all significant risks have been identified; information on control, performance and assurance is timely and relevant; and to provide leadership on risk management.

2. DEVELOPMENT OF A NEW BOARD ASSURANCE FRAMEWORK Although the format previously used for the BAF was in line with Department of Health guidance it was felt that the format and content could be improved to provide a more effective framework. In developing the new BAF advice has been sought from other Trusts and companies recognised for their expertise in this area. The BAF policy is being updated to reflect the changes.

2. 2013/14 ASSURANCE FRAMEWORK The Board of Directors agreed the following corporate objectives in March 2013: Improved care To be financially strong To be well governed To be a great place to work To be fit for the future The BAF sets out the significant risks to the achievement of these objectives as agreed at the Risk Management Committee (October 16th 2013)

3. NEXT STEPS The new BAF is still a work in progress and will be subject to further review and refinement before being presented to the Audit Committee on 21st November 2013.

Summary of Risks October 2013 Likelihood Impact score

A1 Failure to reduce the number of cases of CDT 4 5 20

A2 Failure to provide appropriate skill mix 3 4 12

A3 Failure to provide timely response to deteriorating patient 4 4 16

A4 Failure to comply with CQC standards 4 4 16

A5 Failure to meet the criteria for meeting needs of people with learning disability 3 2 6

A6 Failure to continue to meet the A&E target 4 4 16

A7 Failure to continue to meet the RTT target 4 4 16

B1 Failure to achieve the planned deficit 5 3 15

B2 Failure to achieve run rate balance 5 4 20

C1 Failure to address compliance requirements 5 2 10

C2 Failure to ensure safe management and learning from incidents 4 4 16

C3 Failure to comply with information governance 3 3 9

D1 Failure to reduce sickness absence 4 4 16

D2 Failure to strengthen communication and engagement 4 4 16

E1 Healthier Together 5 3 15

E2 Failure to achieve integrated care

E3 Failure to provide adequate IT infrastructure 20

E4 Failure to provide an efficient fit for purpose estate 4 4 16

 = risk increased  = risk decreased = new risk = no change

Risk Assessment Process RISK = Impact x Likelihood A simple approach to quantifying risk is to define measures of the Impact and Likelihood should an identified hazard materialize as an accident/ incident. Examples of qualitative measures of Impact

Level Descriptor Examples of the Impact of outcome/s

1 Insignificant Unsatisfactory patient experience not related to patient care. Short term low staffing with no effect on service. No obvious/small financial loss.

2 Minor Unsatisfactory patient experience related to patient care but readily resolvable. Ongoing staff shortage reduces service. Minor environmental implications. Minor financial loss (<0.1%). Local media short term interest.

3 Moderate Some short term physical harm. Mis management of patient care leads to short term effects. Lack of staff leads to late delivery of service. Moderate financial loss (0.1%- 0.5%). Long term local media attention. Moderate business interruption up to 2 days

4 Major Major injuries or long term incapacity. Uncertain delivery of service due to staff shortage. National adverse publicity. Major financial loss (over 0.5% of turnover loss).

5 Catastrophic Death caused by accident, exposure to toxic substance or through serious unsatisfactory patient care and outcome. None delivery of key services due to lack of staff. Over 1% of turnover loss. International media interest. Major loss of life/property after fire.

Examples of qualitative measures of Likelihood

Level Descriptor Examples of how often it may occur.

1 Rare Will only occur in exceptional circumstances

2 Unlikely Unlikely to occur in most circumstances.

3 Possible Reasonable chance of occurring.

4 Likely Likely to occur under most circumstances.

5 Certain More likely to occur than not.

QUALITATIVE RISK ASSESSMENT MATRIX –

Impact Likelihood

Rare 1 Unlikely 2 Possible 3 Likely 4 Certain 5

Insignificant – 1 1 2 3 4 5

Minor – 2 2 4 6 8 10

Moderate – 3 3 6 9 12 15

Major – 4 4 8 12 16 20

Catastrophic -5 5 10 15 20 25

Low Moderate Significant High

Strategic Objective A Improved Care – improved outcomes for patients – Reduction of C Difficile cases Lead Director Director of Nursing st Risk to achieving Failure to reduce the number of cases of CDT caused by inadequate compliance and/or insufficient Date added to BAF 1 April 2013 objective operational control could lead to harm to patients. Extended stay, financial penalty and further th 1 Date of last update 16 October 2013 intervention by Monitor Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to assist Where we can gain evidence that our Where are we failing to put controls /systems in current in securing delivery of objective and control/systems, on which we are placing place? Where are we failing in making them I L managing principal risks? reliance are effective effective?

• Ratification and launch of new C • Cases reducing month by month • Inappropriate testing 4 5 20 • On-going upgrading works. Difficile policy • More divisional accountability • Antibiotic management • Development of diarrhoea assessment • Improved staff awareness around CDT • Handwashing • C Difficile action plan developed for 12 months (need to embed). • • tool Improved attendance at strategic reviews Gaps in environmental audits • New policy and assessment tool • External reviews note tangible improvements • Linked resource within IPC team and • incorporated into all training • Infection Control Committee microbiology Function of antimicrobial stewardship committee. Timescale – • Weekly CDT RCA strategic reviews November 2013. • IPCT close monitoring of admission areas for patients admitted with • Review current antibiotic policy. Timescale – December 2013. diarrhoea • Alerts implementation on Extramed for • Develop business case for increased IPC support. Timescale – patients previously identified with CDT December 2013. and risk assessed. • Monthly divisional report sent out to divisions • CDT workshops held across Trust for Staff • Trust wide mattress audit – replacement of mattresses • Introduction of sporicidal wipes for CDT/GDH cases • New handwashing posters launched • Commode audit • Introduction of hydrogen peroxide fogging of all side rooms after CDT cases • Upgrading estates programme to improve facilities (floor signs, doors on bays, sinks at ward entrances) • External follow up review requested by Trust to provide assurance. • Trialling of ATP machine to identify areas to be cleaned • Two permanent Microbiologists employed by Trust

Position at date: Comments I L Comments Currently on 25 cases against an annual trajectory of 28 cases for acute Trust (therefore likely to go over trajectory in the financial year). Severe implications for quality of patient care and also financially due to penalties imposed on Trust for exceeding trajectory.

Strategic Objective A Improved Care Lead Director Director of Nursing st Risk to achieving Failure to provide the appropriate skill mix and establishment for “safe and suitable staffing” Date added to BAF 1 April 2013 objective could lead to compromised patient safety and patient experience leading to potential adverse th 2 Date of last update 16 October 2013 incidents and complaints and potential regulatory or reputational damage Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Ward staffing establishments • Rostering KPIs • Recruitment process not yet 3 4 12 • Review current rostering policy . Timescale – November agreed at July Board of completed 2013. • Incident reporting of unsafe staffing Directors meeting levels • Ward managers need to be • Establish monthly e rostering forum to review current levels. • Recruitment to agreed staffing empowered to sign off rosters that • CQC Inspection Reports Timescale – November 2013. levels prioritise patient safety at all times

ensuring school holidays and • Implementation of E-Rostering • Explore upgrade of e rostering software. Timescale – unpopular shifts are covered first system to facilitate monitoring December 2013. of KPIs for safe staff Rostering • Timeliness and senior level scrutiny of Roster sign-off needs to be • Development of the integrated pathways that will include • Rostering Policy developed strengthened staffing and skill mix. To ensure services are fit for purpose. incorporating escalation Timescale – commenced December 2013 process for unsafe staffing incidents • Safety walk rounds provide the • Staff encouraged to use opportunity to triangulate incident reporting system to • Work to date has mainly focussed highlight incidences of unsafe on ward nurse staffing-further work staffing-exception reports to needed to look at the wider Board when number of workforce, including Community incidents exceeds agreed Nursing teams , AHPs and medical threshold staff.

Position at date: Actions taken I L Comments Strategic Objective Improved Care – improved outcomes for patients – recognising and responding to the Lead Director Medical Director A deteriorating patient st Risk to achieving A failure to provide an adequate timely response to the deteriorating patient could impact on mortality Date added to BAF 1 April 2013 objective and length of stay th 3 Date of last update 16 October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to assist Where we can gain evidence that our Where are we failing to put controls /systems in current in securing delivery of objective and control/systems, on which we are placing place? Where are we failing in making them I L managing principal risks? reliance are effective effective?

• Yearly NEWS audit • Benchmark mortality data with peers via • Using the NEWS system and following the 4 4 16 Much work been completed to date and this continues to remain a top Mortality Board Report/CHKS data graded response algorithm • priority within the mortality reduction group. There is a workstream Monthly Audit via Nursing care (Crude/RAMI/SHMI) Indicators (NCI’s); section criteria – • Escalation process for wards not achieving which forms part of the mortality 5 point plan; the leads track and ’Patient Observations’ • Monthly audit of NCI’s Green RAG rating on NCI’s not yet agreed monitor movement against key actions and report into the mortality reduction group bi-monthly. • • • Expansion to the Nurse Practitioner and Cardiac arrest reviews – data shows year on Critical Care Outreach team yet to recruit to Critical Care Outreach Teams year reduction capacity. • iBleep cover on days and nights each • Annual NEWS audit – 2013 compliance of • No iBleep surgical cover for bank holidays Wednesday and at weekends 61.5% • Shortfall in funding to ensure consistent 7 • Critical Care outreach response day dovetailing with hospital at night; dovetailing with the hospital at night limited critical outreach medical cover (only team 5 mornings) • Planned introduction of level 1 care • Funding to rollout level 1 care areas • Shortfall in provision of resuscitation • Limited resuscitation service training • Advanced Nurse Practitioners • Need for an operationally closed unit for augmenting senior review critical care • Divisional Action plans for aiding • Advanced Nurse Practitioner are limited in improvement in NEWS in place - for Surgery divisions to take appropriate ownership • of the issues faced and report/update Divisional Action plans may not be reviewed at the Trust Mortality Reduction Group frequently at Divisional Board Meetings. • • Minimum yearly presentation of Lack of on site senior surgical, orthopaedic & Cardiac Arrest reviews sharing findings medical personnel out of hours and themes from RCA’s to act upon • Educational initiatives – AIM, Sepsis, • Ownership at a divisional , ward and team Junior doctor rolling programme level for monitoring improvement over time and acting on findings.

Position at date: Actions taken I L Comments Strategic Objective A Improved Care Lead Director Director of Nursing st Risk to achieving Non-compliance with CQC standards could lead to poor patient care and poor patient experience and Date added to BAF 1 April 2013 objective could affect Monitor compliance rating; CCG contract; Trust reputation and NHSLA cover. th 4 Date of last update 16 October 2013

Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to assist Where we can gain evidence that our Where are we failing to put controls /systems in current in securing delivery of objective and control/systems, on which we are placing place? Where are we failing in making them I L managing principal risks? reliance are effective effective?

• regular monitoring of the CQC • Excellent QRP. • poor implementation of learning 4 4 16 • New complaints policy. Timescale – launch October 2013. quality and risk profile at the from incidents. • Internal audit reports. QAC. • Develop patient experience strategy. Timescale – launch November • poor response to patient • Dashboard performance 2013. • monthly meetings with the CQC complaints. monitoring. local inspector. • Review current incident reporting policy to include process and • Feedback from divisions on • No enforcement action by CQC. audit. Timescale – draft November 2013. • early reporting of SUI’s to CQC implementation of learning from and CCG. • significant assurance on QRP SUI’s and Divisional reviews to • Develop and introduce ward risk registers. Timescale launch report. QAC. December 2013. • reporting to the Board of all

CQC inspection visits. • significant assurance on CQC • Monthly incident reporting of • Launch of falls strategy. Timescale November 2013. process. category 3 and 4 pressure ulcers • learning from incidents/SUI’s • and reviews. • mid table performance when • Reduction in falls but not harms Develop PO strategy. Timescale launch October 2013. from falls • benchmarked against other trusts in • NRLS report.

Position at date: Actions taken I L Comments Need to embed new complaints policy, falls strategy, pressure ulcer strategy. Strategic Objective A Improved Care Lead Director Director of Nursing st Risk to achieving Failure to comply with the six criteria for meeting the needs of people with a learning Date added to BAF 1 April 2013 objective disability, based on recommendations set out in Healthcare for All (DH, 2008) as a result of lack th Date of last update 16 October 2013 5 of cover for the service during long term absence of the LD nurse could lead to poor patient experience and impact on the Monitor RAF rating Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • All patients admitted with LD • LD Nurse aware of patients and can • Cover for absence of LD Nurse 3 2 6 LD Nurse has developed a matrix to evidence how are seen by the LD Liaison evidence seeing them reasonable adjustments have been made. • No cover when the LD Nurse is on Nurse if necessary. Ward staff • The quarterly Safeguarding Adults leave or off sick. Community LD are all aware of how to contact report presented to Clinical Nurses can help with complex the nurse if required. Governance provides updates on problems but are not able to cover • Community teams contact LD national reports and all the work during periods Nurse to inform her of any recommendations in relation to LD. • No cover at week ends and out of admission. • From Complaints from families and hours. • Information page on the Trust patients not aware that patients intranet provide guide for staff with LD are not do not feature. to identify patients who may • One recent clinical incident have LD, with a variety of identified issue with patient not accessible information on having nutritional needs managed various procedures which staff over a week end. can download. • LD Nurse has developed a matrix to evidence how reasonable adjustments have been made.

Position at date: Actions taken I L Comments Strategic Objective A Improve care - Improved patient experience Lead Director COO st Risk to achieving A failure to continue meeting the A&E target caused by increased attendances or insufficient Date added to BAF 1 April 2013 objective operational control could lead to poor patient experience and escalation of intervention by th 6 Date of last update 16 October 2013 Monitor Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective?

• Weekly SITREP • ECIST • CHC process 4 4 16 • Sign off and funding of Winter Plan • Urgent care board • PAF • GP referrals to A&E for primary care • Development of Primary Care treatment on site for GP referrals for • Bed flow meetings (4 * daily) • Reports to Board issues primary care treatment. • Analysis of breaches • CCG contract monitoring • OOH primary care patients attending • Co-location of GPOOH service under discussion with CCG • Winter plan • LOS in medical wards A&E • Discharge planning • Delayed discharges below 20 a month • Trust Board sign off of Winter Plan • CCG agreement for co-location of GPOOHs

• There has been a sustained rise in admissions since July which is affecting bed capacity – analysis is being undertaken to determine the root cause.

Position at date: Actions taken I L Comments Strategic Objective A Improve Care - Improved patient experience Lead Director COO st Risk to achieving A failure to continue meeting the RTT access targets as a result of increased referrals or Date added to BAF 1 April 2013 objective insufficient operational control could lead to poor patient experience and experience and th 7 Date of last update 16 October 2013 escalation of intervention by Monitor Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • PTL • Sustainability tool • Demand management 4 4 16 Develop plan for trauma patients to be treated outside of • Daily monitoring • Reporting to Monitor • Trauma capacity required elective care capacity • Sustainability tool • Performance report • Plan for management of trauma to • Elective care programme board • PAF ensure sufficient theatre and bed performance management • Reports to Board capacity to deliver 18 weeks RTT • Reduction in new to follow up • CCG contract monitoring ratios

Position at date: Actions taken I L Comments Strategic Objective B Be financially viable Lead Director DoF st Risk to achieving Failure to achieve the planned deficit of £7.8m for 2013/14 Date added to BAF 1 April 2013 objective th 1 Date of last update 16 October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Finance Improvement Plan (FIP) • Reports to Executive Team and Audit 5 3 15 • Implement 2014/15 income and cost improvements before 31st • Divisional Financial Management Committee on FIP progress Match 2014 Framework (DFMF) • Revised arrangements are being put in • Patch Financial Management • Monthly finance reporting to the place to improve grip and reduce the Framework (PFMF) organisation (Budget, actual and transactional burden of the programme • Budgetary control system (Budgets, forecast) management. actuals and forecasts) • Divisional self certification outputs • Programme controls on 2013/14 • Reports on DFMF and PFMF to Finance • The first year of the FIP is about income and cost improvements committee embedding basic financial controls. • Reports on income and costs Until this happens there remains a risk improvements of gaps in assurance on finance.

• Internal Audit Reports on the • As noted above a revised process is budgetary control system being put in place improve assurance. • External assurance on the financial plan This will be fully operational in October.

Position at date: Actions taken I L Comments Strategic Objective B To be financially viable Lead Director Director of Finance st st Risk to achieving Failure to achieve to achieve run rate balance by the 1 April 2014 resulting in liquidity issue in Date added to BAF 1 April 2013 objective quarter one of the 2014/15 financial year. th 2 Date of last update 16 October 2013

• Long Term Financial Plan (LTFP) • Reports to Finance Committee and • SLM being developed, the Board will be 5 4 20 • The detailed financial planning process for 2014/15 is scheduled to • Service Line Management Process Board on the development on the LTFP briefed on this in October 2013 be concluded by the end of February 2014. At that point will need • Shadow Service Line Management to make the decision as to whether the Trust will be able to operate • Process to identify and implement 2014/15 income and cost reporting in Quarter one of 2014/15 without cash support from the DoH. • Assurance reports to be in place from improvements • Specific reports to finance committee November 2013 • Process to agree budget control on run rate balance from 1st April • The 2014/15 budget setting process will be presented for approval

totals for 2014/15 • Reports on 2014/15 Budget setting at the November finance committee

process to Finance Committee • The 2014/15 contracting strategy will be presented for approval at • 2014/15 Contracting Strategy • Reports on 2014/15 Contracting the November finance committee process to Finance Committee • The 2014/15 cash management plan will be presented for approval at the November finance committee • 2014/15 Cash management plan • Reports on 2014/15 Cash management to Finance Committee • The gaps in control and assurance noted are expected at this stage of the planning cycle given the Trusts financial position. All the actions noted have been programmed in the Finance Improvement Plan since April 13.

Position at date: Actions taken I L Comments Strategic Objective C Be well governed Lead Director CEO st Risk to achieving Failure to address the compliance requirements and enforcement undertakings caused by Date added to BAF 1 April 2013 objective inadequate governance could lead to escalation by Monitor and further intervention th 1 Date of last update 16 October 2013

Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • An action plan has been • The Governance action plan is • Although progress has been made 5 2 10 Actions have been agreed to address the following areas agreed with Monitor to routinely monitored by the CEO in some areas there is still a identified in the KPMG and Deloitte reports address the 200+ and at the Board of Directors. significant amount of work to do • Board Assurance Framework and risk management – recommendations in the with regard to risk management escalation and reporting of risks external reports, this is • Regular feedback following PRM processes • Performance Reports and Information supported by more detailed meetings with Monitor • Data Quality action plans responding to • Assurance and Escalation • Review of Board and Committee effectiveness each recommendation. Framework not yet developed • Requirement for an assurance and escalation framework • Requirement for a single overarching Quality Strategy • Communication and Engagement

• PwC will review the implementation of these recommendations to assure Monitor and the Board – the review on the KPMG report will be completed by 31/12/13; the review of Deloitte recommendations will be

conducted by 31/01/14

Position at date: Actions taken I L Comments Strategic Objective C Well governed Lead Director Director of Nursing st Risk to achieving Failure to ensure the safe management, statutory reporting, internal reporting and learning from Date added to BAF 1 April 2013 objective incidents will lead to inadequate safety management systems leading to compromised patient safety th 2 Date of last update 16 October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to assist Where we can gain evidence that our Where are we failing to put controls /systems in current in securing delivery of objective and control/systems, on which we are placing place? Where are we failing in making them I L managing principal risks? reliance are effective effective?

• reporting all incidents on-line via • Internal audit reports. • Poor governance controls within divisions. 4 4 16 • Review the current incident reporting policy and framework. safeguard system within 24 hours. • Dashboards. • delays in divisions signing off incidents Timescale – November 2013, launch December 2013. • monitoring and validating of all within 72 hours. • incidents before reporting to NRLS. No RIDDORs/HSE prosecutions or • Development of risk assurance framework. Timescale – December • External financial risks from clinical • 2013. • daily incident reporting to managers enforcement notices. incident claims will impact on future NHSLA and directors. • NRLS mid-table performer on • premiums when this changes to a claims • learning from incidents • incident reporting against 45 acute performance model, current value of communicated to divisions. • trusts in cluster. • clinical claims in system is circa £38m, • dashboard reporting of volumes; premium is circa £10m presenting a themes; numbers to the board monthly. • reduction in certain incident • significant financial risk to the trust, hence • RIDDOR reporting on-line to HSE. • categories & claims. the score of 25 (RAG=red) • CAS alerts circulated; recorded and • significant assurance on reporting. • Feedback from divisions on implementation monitored on safeguard system. of learning from SUI’s and Divisional • Red rated incidents subject to • Harm free care data reported via • reviews to QAC. • exception reporting to the Board. safety thermometer and on board • Compliance reporting from divisions on dashboard. • Exceptional performance managers signing off completed • Significant harm/never events, dealt • benchmarked against other trusts. • with as SUI’s and reported to QAC incidents on safeguard within 72 hours. • 8,000 incidents will be reported on monthly. • Compliance with all other non CAS alerts to • safeguard in 2013/2014. be reported to QAC. • improved falls and reduced OL/EL • claims.

Position at date: Actions taken I L Comments Strategic Objective C Well Governed Lead Director COO st Risk to achieving A failure to comply with standards for Information Governance as a result of paper based Date added to BAF 1 April 2013 objective systems and failure to adhere to policies and protocols could result in a breach of information th 3 Date of last update 16 October 2013 security leading to breach of confidentiality, potential fines and reputational damage Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Access Controls for systems • Reduction in incidents/complaints • Access controls not applied 3 3 9 • Apply access controls to all systems managed by Bolton FT • Information Governance • Compliance with IG Toolkit – universally across • Review and audit staff training re: IG, information (IG)Training internal/external audit Acute/Community security/confidentiality – achieve at least 95% of all staff • Policies and Procedures • Third party contracts – suppliers • PIAs not applied to all new • Audit third party contracts and obligations projects/service changes • Privacy Impact Assessments and temporary staff • Planning for Electronic Patient record/Electronic document (PIA) • Information Governance group • Paper-based information – management system. continued incidents • Encryption standards for email review and reporting • Promote use of PIAs • Trust not yet achieving its target and laptops • Achievement against target levels • Implement recommendations from SUI – (Handover Notes levels of mandatory training in IG • Audits – external/internal of IG training incident) • Staff awareness of procedures and • IT Contingency Plans • Internal/external audit of records • Plan to achieve target level of IG training. management standards • Training for staff • Formal training in defensible documentation for staff • Reduction of reported incidents • Health records filing – non- • Regular audits of tracking • Integrate community/acute records off site e.g. missing notes, misfiled notes, compliance with standards wrong patient record etc. • Inadequate tracking • Move towards electronic document management systems • NHSLA standards

Position at date: Actions taken I L Comments Strategic Objective D Be a great place to work Lead Director Director of Nursing st Risk to achieving A failure to reduce sickness absence and improve staff health and wellbeing would have Date added to BAF 1 April 2013 objective implications for the quality of care and staff morale alongside the financial implications of th 1 Date of last update 16 October 2013 providing cover for absent staff Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Consistent application of • Workforce committee reports • Managers failing to apply policies 4 4 16 • Integration of all attendance management policies by end of attendance management policy • Workforce dashboard reported to consistently. December 2013 • Focused review and discussion Executive Board and Workforce • Divisional Action Plans reviewed monthly by Deputy Director at workforce committee Committee • Different policies for managing of Workforce with escalation to Workforce Committee as including focus on Divisional • Audit of performance reports attendance following appropriate. Performance against Divisional • Regular benchmarking with other integration/TUPE transfer under • Meeting with OH Physician to discuss long term sickness Attendance Management NHS Trusts MiB cases and management of going forward – October 2013 Action Plans overseen • Regular audit of Return to work

interviews and application of the consistent application of the appropriate policy.

Position at date: Actions taken I L Comments Strategic Objective D To be a great place to work Lead Director Dir Workforce and OD st Risk to achieving A failure to strengthen communication and engagement with staff throughout the integrated Date added to BAF 1 April 2013 objective organisation during organisational change could lead to increased turnover, increased sickness th Date of last update 16 October 2013 2 and a failure to address other issues within the Trust and a loss of discretionary effort and potential employee relations issues. Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Organisational Change Policy in 4 4 16 • Reflection and learning session with staff side colleagues on place for all staff relating to implementation of organisational change and lessons learnt • Workforce reports to Board /Exec • Impact of turnaround/CIP and loss framework for organisational • As a result of the above review of organisational change Board of discretionary effort change policy and guidance including training for managers • Workforce Committee reports • Staff engagement action plan in • Continue to run the Engaging Manager Programme

place to continue proactive • Staff survey supporting managers in engaging skills including the LMSQ engagement with staff. • Staff quarterly temperature check (Leadership Management Styles Questionnaire) which • Leadership development • Leadership Management Styles provides 180 feedback on how the manager is engaging with programmes focus on Questionnaire (LMSQ) the team. importance of communication • Continued regular dialogue with staff side representatives. and engagement during organisational change

Position at date: Actions taken I L Comments Strategic Objective E Fit for the Future Lead Director CEO st Risk to achieving If the Healthier Together exercise downgrades the RBH scope of service this will threaten the Date added to BAF 1 April 2013 objective financial and clinical viability of the organisation th 1 Date of last update 16 October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Clinicians and other staff will be • Healthier Together publications and • The Trust has limited influence on 5 3 15 Continued engagement in Healthier Together supported to make the case meetings the outcomes of the Healthier clearly for the service strategy Together exercise • Clinicians and other staff will attend planning forums and contribute to the anticipated consultation process • The Trust will continue to work with other providers in the NW sector of G Manchester • Arrangements are in place to work closely with the commissioners to secure the changes needed in the local model of care

Position at date: Actions taken I L Comments Strategic Objective E Fit for the Future Lead Director CEO st Risk to achieving Failure to achieve integrated care in Bolton will lead to escalating demand on hospital Date added to BAF 1 April 2013 objective services and increasing pressure on the achievement of financial stability for the Health th 2 Date of last update 16 October 2013 Economy Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? • Full engagement with partners in • Trial of integrated care between CCG, Development of workforce capacity and capability to ensure primary and social care in the FT and social care the Trust realises the full benefits of integrated services within planning and delivery of the vision the organisation for integrated care in Bolton

• Regular meetings with Health Economy partners

Position at date: Actions taken I L Comments Strategic Objective E Fit for purpose supportable community IM&T Infrastructure Lead Director COO Risk to achieving Failure to secure funding for the upgrade and on going support of legacy community IT Date added to BAF May 2013 objective infrastructure will lead to loss of IT access in the community setting. 3 Date of last update 22nd October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective?

Required capital investment of £1.6M Effective financial planning for 2014/15 4 5 Implementation of the IM&T Investment Strategy in 2014/15. incorporated into the IM&T investment including the integration of legacy plans for 2014/15. Community systems.

Investment strategy for IT and community shared with Monitor. Risk review at the Informatics Finance exploring the flow down of committee. 480k former PCT funds which was used to support the community infrastructure which has not been transferred to the Trust budget.

Position at date: Actions taken I L Comments Strategic Objective E Fit for the Future Lead Director COO st Risk to achieving Failure to provide an efficient fit for purpose estate may restrict the implementation of Date added to BAF 1 April 2013 objective service plans and lead to an adverse impact on financial and quality indicators th 4 Date of last update 16 October 2013 Key Controls Assurance on controls Gaps in Control and or Assurance Risk Score Action/Plans & timescales What controls/systems are in place to Where we can gain evidence that our Where are we failing to put controls current assist in securing delivery of objective control/systems, on which we are placing /systems in place? Where are we failing in I L and managing principal risks? reliance are effective making them effective? Estates Committee 4 4 16 Implementation of the agreed Estates strategy

Position at date: Actions taken I L Comments . Agenda Item No 16

Meeting Board of Directors

Date 31st October

Title Quarter 2 submission to Monitor

As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance. These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets. The governance and target templates will be uploaded with the Executive Summary monthly financial templates by the close of play on October 31st 2013.

The Trust will remain red rated until Monitor are satisfied that actions taken have led to a sustained improvement and compliance with the Provider Licence

In April 2013 the “Terms of Authorisation” for Foundation Trusts were replaced by a Provider Licence; from October 1st the Compliance Framework has been replaced by the Risk Assessment Framework.

This paper includes a briefing note outlining the new Risk Assessment Framework process

Directors are asked to approve signing of the proposed Q2 declaration to Monitor. Next steps/future actions Following analysis of the Trust’s Q2 data, Monitor will publish a shadow Risk Assessment Framework rating.

Discuss Receive Approve Note This Report Covers (please tick relevant boxes) Strategy Financial Implications Performance Legal Implications Quality Regulatory Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

Esther Steel Esther Steel Prepared by Presented by Trust Secretary Trust Secretary

Compliance Declaration Q2 2013/14

1. PURPOSE The purpose of this paper is to inform the Board’s consideration of the quarter two submission to Monitor.

2. BACKGROUND As a Foundation Trust regular declarations are required with regard to compliance with targets and financial performance. These declarations are made on a template provided by Monitor which includes worksheets for financial performance, governance declarations and performance against targets.

3. CURRENT POSITION An update on the current position with regard to operational performance, quality and finance is included on the Board agenda.

4. RECOMMENDATIONS Board members are asked to agree that the following statements are signed for submission to Monitor for the Q2 return.

The Continuity of Service risk rating replaces the FRR – this remains at 1 – response must therefore be “not confirmed”

Compliance with targets is included in the performance report – the Trust has breached the Q2 target for C. difficile and must therefore respond “not confirmed”

During quarter 2 exception reports on SUIs and the outcome of the CQC review were provided to Monitor in line with the requirements of the Risk Assessment Framework.

Diagram 6 from the RAF is included for information.

Election Results

During Quarter 2 elections for Foundation Trust Governors were conducted. The outcome of these elections is also reported through the quarterly submission

Risk Assessment Framework Monitor has issued a Provider License to the Trust which replaces its Terms of Authorisation. Compliance will be overseen by Monitor using its new Risk Assessment Framework (August 2013) and enforced using its Enforcement Guidance (March 2013). The Monitor Risk Assessment Framework came into full effect from 1st October 2013, replacing the outgoing Compliance Framework. 1. The process. Monitor will broadly follow a four-step process to oversee the Trust’s compliance with its provider license:

2. Submission of information and reports. Monitor requires the Trust to make annual and in year information submissions, together with exception reports and additional reports to assess its risk to compliance. The frequency of in-year submissions will depend on the risk ratings assigned to the trust. 3. Assessing risk to continuity of services and financial risk. Monitor will assess this risk and apply a new Continuity of Services Risk Rating to the Trust. This risk rating will be derived from two metrics, Liquidity and Capital Servicing Capacity, resulting in a rating of 1-4 (with a rating of 1 showing significant risk to the Trust). 4. Assessing risk to governance. Monitor will assess this risk and apply a new Governance Rating to the Trust. This will be derived from a number of metrics including CQC judgements, access and outcomes targets, third party reports, quality governance indicators and financial risk. Of particular note in relation to this rating is the following: a) The majority of the access and outcome metrics are the same as those in the outgoing compliance framework (e.g. 18 week referral to treatment times, cancer waits and C.Diff. Incidence). However, the MRSA target, seen in the outgoing Compliance Framework, is no longer included. b) Quality governance Indicators will also be used by Monitor in calculating the governance risk rating. Such indicators include patient satisfaction, staff metrics (e.g. staff satisfaction, sickness/absence rates, staff turnover and proportion of temporary staff), and use of aggressive cost reduction plans c) Monitor requires the Trust to commission an external review of its governance at least once every three years. Such a review must include at least one of the following: board governance, quality governance, organisational oversight and board capability. Monitor will use this review to inform the Trust’s governance risk rating. d) Monitor will no longer assign a colour risk rating to any grading between green and red (e.g. no amber/green, amber or amber/red ratings will be given). Instead, where a Trust is categorised as falling between a green and red rating for governance, a description of the status will be given together with any issued identified. 5. Investigating actual or potential breaches. If, following assessment, Monitor identifies an actual or potential breach in the Trust’s provider license conditions, it will initiate an investigation. The steps taken to fulfil this are discussed further in the accompanying paper. 6. Enforcement powers. If, following investigation, Monitor finds a Trust in breach of its Provider License, Monitor has powers under the Health and Social Care Act (2012) and competition law to initiate enforcement action against the trust using its Enforcement Guidance.

Next steps The Trust’s new Governance and Continuity of Services risk ratings will be updated and applied by Monitor as follows: Monitor have assigned the Trust a Governance Risk Rating, based on its new Risk Assessment Framework (appendix 1) Following its analysis of the Trust’s Q2 13/14 data, Monitor will publish both the outgoing Compliance Framework Financial Risk Rating alongside the new Risk Assessment Framework Continuity of Services Risk Rating which will be identified as a ‘shadow’ rating. The Continuity of Services Risk Rating will be the only financial rating published following Monitor’s analysis of Q3 13/14 data.

17 September 2013

Ms Jackie Bene 4 Matthew Parker Street Interim CEO and Medical Director London SW1H 9NP Bolton NHS Foundation Trust Royal Bolton Hospital T: 020 7340 2400 Minerva Road F: 020 7340 2401 W: www.monitor-nhsft.gov.uk Farnworth Bolton BL4 0JR

Dear Ms Bene

Introduction of Risk Assessment Framework risk ratings

As you are aware, from 1 October 2013 the Risk Assessment Framework (‘RAF’) will replace the Compliance Framework as Monitor’s approach to overseeing foundation trusts. A key part of this new framework is the new risk rating methodology, as set out in the RAF.

The role of ratings is to indicate when there is a cause for concern at a provider. It is important to note that they will not automatically indicate a breach of its licence or trigger regulatory action. Rather, they will prompt us to consider where a more detailed investigation may be necessary to establish the scale and scope of any risk.

Monitor will assign foundation trusts a governance risk rating based on the RAF on or shortly after 1 October. This will appear on our website shortly afterwards, replacing the Compliance Framework governance rating. This reflects that the governance risk rating represents Monitor’s current view of governance at foundation trusts.

In advance of introducing the new governance rating, Monitor’s relationship teams will assess which ratings are appropriate for each foundation trust in accordance with the criteria set out in the RAF. Trusts will be informed of their governance rating before publication.

Following the conclusion of our analysis of Q2 13/14, Monitor will publish both the Compliance Framework financial risk rating and the RAF continuity of services risk rating, which will be identified as a ‘shadow’ rating. This dual publication reflects that the Q2 performance data on which these ratings are based relates to a period when the Compliance Framework was in force, while the RAF will be in force at the time of publication. The continuity of services risk rating will be the only financial rating published following our analysis of Q3 13/14.

If you have any queries relating to the above, please contact me by telephone on 020-7340- 2519 or by email ([email protected]).

Yours sincerely

Kate Sutherland Senior Regional Manager cc: Mr David Wakefield Chairman Mr Simon Worthington Director of Finance

Agenda Item No : 18

Meeting Board of Directors

Date 31st October 2013

Academic Health Science Network (AHSN) – Update Title

The Board has received previous reports on the establishment of a Greater Manchester Academic Health Science Network and, in April, formally approved the Trust’s participation. Executive Summary The GM AHSN is now coming into place, with a confirmed funding settlement and key appointments, including Raj Jain who has now joined the AHSN as Managing Director. In April the Board asked for a six-month update on the benefits of AHSN Membership. Raj has kindly agreed to attend the meeting to provide an update and a look forward, including opportunities for Trusts like BFT to be involved.

Identify key workstreams for Trust involvement. Next steps/future actions Ensure related CQUIN requirements are met.

Discuss  Receive Approve Note 

Assurance to be provided by:

This Report Covers (please tick relevant boxes)

Strategy  Financial Implications 

Performance Legal Implications

Quality  Regulatory

Workforce Stakeholder implications NHS constitution rights and pledges Equality Impact Assessed For Information Confidential

A Schenk, Director of Strategy & A Schenk, Director of Strategy Prepared by Presented by Improvement & Improvement

BoD Meeting – 31st October 2013

Academic Health Science Network (AHSN) – Update

Background

The Board will recall earlier items on Board agendas relating to the national policy paper “Innovation, Health and Wealth” and the related commitment to establish a series of Academic Health Science Networks (AHSNs) across the country.

In order to encourage the uptake and development of specific innovations and improvements highlighted in “Innovation, Health and Wealth”, there is a schedule of developments now linked to CQUINS payments for all providers.

In February, the Board received an outline of the proposed governance arrangements for the Greater Manchester AHSN, and, in April, the Board formalised its commitment to participation in the GM ASHN and asked for a six-month update, focussing the benefits of membership.

The AHSN is now approved and established. The attached “Senior Leaders’ Update” was circulated in June, reaffirming the proposals and priorities of the AHSN and confirming senior appointments.

The newly appointed Lead for the AHSN, Raj Jain has kindly agreed to attend the Board meeting to outline progress and next steps and answer any questions from the Board.

Ann Schenk Director of Strategy & Improvement

Senior Leaders Update

Edition 2 – 3 June 2013

1. Licence agreement update On 20 May, 2013 a small subgroup of the Steering Board attended a meeting with Rachel Cashman at NHS England. Rachel outlined the next steps for AHSN authorisation, apologised for the delays and gave feedback from the Interview with Sir John Bell, Sir Alan Langland’s and Sir Ian Carruthers on GM AHSN’s plan. Full details are available in the appendix to this document but in summary the application and interview were considered strong. The focus on informatics was seen as unique and of potential benefit to clinical outcomes improvement, research and interactions with industry. These strengths placed GM AHSN in the first cohort of funded networks and enables us to negotiate our position as the lead AHSN for informatics and information.

2. Funding NHS England has allocated the GM AHSN £4.63m in FY 2013-14 which will be available for release in July 2013 based on satisfactory licence negotiations. The planning cycle for FY 2014-15 will begin in September 2013 and deliverables in year 1 will be negotiated alongside the licence. See the Business planning section about our plans to reflect the smaller resource envelope.

3. Draft licence On 23 May, 2013, the draft Five Year Licence Agreement between the Academic Health Science Networks and NHS England was issued. The licence is available in the appendix to this document. NHS England have asked all AHSN’s to comment on the licence and to look at how it might need to be modified to account for local innovation. The response from Greater Manchester will be available in June 2013.

3. Business planning At the May steering board of the AHSN the programme leads for Innovation and Research (Keith Chantler), Health and Implementation (Maxine Power), Wealth and Investment (Martin Gibson) and Education and Capability (Maxine Power – acting) were asked to review their business plans and make suggestions about how the work plan could be delivered with a smaller resource envelope. Since then, work has been underway on reformatting. This work now needs to accelerate and partners have been invited to participate in the revision of plans under the work stream leads. Leads have been asked to address the elements of their work streams that map directly onto the licence requirements. From this reconciliation process gaps will be identified and addressed in the next stage of the planning.

4. Establishment milestones The Steering Board have approved a number of appointments:

 Peter Ellington as interim Chair for a 6 month period. Peter is the Chief Executive of the Association of British Healthcare Industries and he will start with us on 28 June 2013. A short bio is available in Appendix 2.  Raj Jain has accepted the role of Managing Director. He is on 3 months’ notice and during this period will be working 2 days a week on GM AHSN establishment and connecting with the membership. Raj is currently Chief Executive at Liverpool Heart and Chest Hospital NHS Foundation Trust.

The Board are meeting monthly and have been reconstituted to include broader representation from the Higher Education Establishments and the LETB. An industry advisory committee will provide a single point of entry to

2 Edition 2 – 3 June 2013

the sector for the Academic health Science Centre and network. We have been working with Finnamore as our management consultants to finalise the business plan and will be advertising for an operations lead within the next 2-3 weeks.

5. Next steps In the coming weeks, we will be focusing on:

 The establishment of new governance arrangements  Getting boards that have not already done so signed up to the new AHSN

Sent by

Ian Wilkinson David Dalton Clinical Lead Chief Executive Oldham CCG Salford Royal NHS Foundation Trust GM AHSN Steering Group Chair GM AHSN acting Accountable Officer

Appendix

1. NHS England GM AHSN Feedback 2. Peter Ellingworth biography 3. Appendix 3, Raj Jain biography

3 Edition 2 – 3 June 2013

Appendix 1 - NHS England GM AHSN Designation Interview Feedback NHS England recognises the huge amount of interest and commitment that has gone into making the fifteen AHSN applications across the country. The application teams have marshalled an impressive range of leaders from the NHS and universities and some application teams had senior and experienced colleagues from industry integrated into the application. There had been only 6 or 7 months between the publication of the national guidance and the panel interview during which all the teams had produced a prospectus, a draft business plan and a 100 day delivery plan.

Building on the guidance published in summer 2012, the designation interview and designation feedback each AHSN should describe their ambition setting out the 2 or 3 service areas where they will have a significant national impact in its first five years. All AHSNs will have an agenda to drive adoption and spread of innovation across all areas of healthcare provision and population health but they also need to have a small number of areas where each AHSN will bring together the resources and assets in their geography to create a synergy between researchers in universities, industry and entrepreneurs, and the local NHS to identify, exploit and commercialise innovations that will have national and international significance. AHSNs need to be focused as trying to achieve this in too many areas will not deliver the necessary impact.

All applications need to undertake further work to translate their work plan into agreed, measurable deliverables and milestones that the AHSN commits to and crucially work on how these commitments will be delivered through the network’s systems and processes.

The AHSN is based on a membership model with a wide range of partners holding each other to account. All application teams need to continue to build their leadership teams with people who have the personal qualities to be effective in leading networks, the vision for the future, and the knowledge of the NHS-industry-academic interface. Most of the applications need to develop a governance structure that industry can understand and engage with.

The dual purpose of AHSNs to improve health and create wealth was recognised in all applications but the maturity of the thinking and the specificity of the proposed actions on the wealth creation agenda varied greatly across the fifteen applications. All teams need to accelerate their work in this area and put in place the infrastructure to effectively bring together industry, the NHS and universities to focus on delivering specific projects and partnerships. All AHSNs need a quantified plan for wealth creation and to create a single technology transfer mechanism across the whole network, ideally integrated with the research infrastructure.

AHSNs should be thinking of and demonstrating industry collaboration that focuses on adoption and spread of innovative treatment, technology and models of care delivery and AHSNs should be demonstrating how they are developing their commercial acumen in order to demonstrate ROI and match funding requirements.

Most applications recognised the key role that their AHSN will play in promoting and supporting research in the NHS across their geography, working alongside NIHR research infrastructure. However, they varied significantly in the extent to which they had clear, robust plans to make this a reality. NHS England hope that AHSNs will work in alignment with Strategic Clinical Research Networks and not seek to replicate or duplicate. It is for the local AHSN and the Strategic Clinical Research Networks to identify how best to work together. Similarly AHSNS should work with and build upon existing research structures and not seek to duplicate or replicate. AHSNs may

4 Edition 2 – 3 June 2013

choose to fund CLARHCS if they feel by doing so it will enable the AHSN to deliver the outcomes set out in its business plan and agreed in the Licence. It is not an expectation or requirement from NHS England that AHSNs should use their funding allocation in this way.

Improved integrated information shared between primary & hospital care and linking research, evaluation and clinical practice will be at the heart of the successful AHSN. Those licenced with immediate effect provided evidence that this was a central part of their application and proposed work plan and all teams need to develop the detailed mechanisms so that members can effectively collaborate in network-wide sharing and analysis of data.

Although most AHSNs had some discussions with their Local Education and Training Boards and had input from a range of universities, the depth of these relationships varied greatly. Only in a few applications was there evidence of a sophisticated shared vision and proposals for common approaches about how education would support the collaboration between industry, academia and the NHS on innovation and adoption.

Applications teams all included strong representation from NHS providers and universities. The contribution of clinical commissioning groups, industry, local government and public health was variable with some application teams including experts in each of these areas but others not even evidencing an active input from these stakeholders beyond the statements in the written application.

All AHSNs would benefit from support in continuing their development, especially in how they developed their governance and in working with industry partners. As part of the Organisational Development of AHSNs in the new system we will ask all to attend a Kick-starter event in July 2013 and to participate in an Organisational Development process that will be co-designed between NHS England, NHS Improving Quality and each individual AHSN.

Greater Manchester

Potential specialist area(s): e-health and patient safety.

AHSN Total funding 2013/14 First Second allocation allocation

Greater £4.63m £3.2m £1.43m Manchester

The application reflected the large volume of work that has been undertaken by the partners in developing a distinctive model for innovation and knowledge transfer in the Greater Manchester area. The application builds on the strengths of the Manchester AHSC, but the separate approach to the Network demonstrates a good grasp of the specific expectations for a successful AHSN, focusing on the wider engagement with industry and on the adoption and spread of innovations. The work on the digital economy and the creation of shared data sets that can be used to measure clinical benefit and outcomes and inform commercial opportunities came through clearly in the presentation and documents. Although the document highlights the need for collective working across the AHSN, there needs to be more detailed work about this will actually happen in practice

Recognise the request for designation with specific “Leadership” for E-Health on behalf of the whole system NHS England is giving active consideration to this and will feedback in due course. NHs

5 Edition 2 – 3 June 2013

England will also welcome a proposal from Greater Manchester AHSN on a single model of VC and Angel investor funding for AHSNs led by a single AHSN.

Appendix 2, Peter Ellingworth Peter is Chief Executive of the Association of British Healthcare Industries (ABHI), the industry association for the UK medical device sector. ABHI work with government and NHS England to improve patient outcomes and deliver more cost efficient healthcare through the uptake of innovative medical technologies. Under Peter’s leadership the association has become a key government partner, supporting NHS England in its work to improve patient access to innovation.

Peter has built strong links with NHS leaders and currently represents industry on the Implementation Board of the ‘Innovation Health and Wealth Report’, the NHS Chief Executive’s report focussed on improving the uptake of innovative technology.

Peter leads the industry secretariat for the Ministerial Medical Technology Strategy Group, is the Chair of MATCH and a Trustee and Vice Chair of the Thackray Museum, which houses the world’s largest collection of medical trade literature. Peter sits on the board of the Health Tech and Medicines Knowledge Transfer Network. He is also a member of the EPSRC Strategic Advisory Network and the Eucomed National Association Network.

Peter has 30 years of experience in sales, marketing and general management in the UK & Ireland and across Europe.

Appendix 3, Raj Jain Since 2008, Raj has been Chief Executive at Liverpool Heart and Chest Hospital NHS Foundation Trust (LHCH), one of the largest cardiothoracic specialist hospitals in Europe. LHCH was named HSJ Provider of the Year in 2012, which recognised its continuing work to establish the Trust as a world class organisation. Raj is Board Director at the Institute of Cardiovascular Medicine and Science and Liverpool Health Partners. He is a board member of NIHR Cheshire and Merseyside CLRN and the North West Coast AHSN. Raj started in the NHS 18 years ago after spending 10 years in the oil and gas industry. He was an Executive Director at Salford Royal NHS Foundation Trust for 5 years prior to his appointment at LHCH.

During his time as CEO and Executive Director Raj has led a number of regional programmes including QIPP Lead for Workforce for the Northwest Region and Workforce lead for Merseyside.

6 Edition 2 – 3 June 2013

Agenda Item No : 19

Meeting Board of Directors

Date 31st October 2013

Title Finance & Activity Report Month 6

Please find attached the monthly Financial Board Reporting pack

The key points to note are:-

• The financial position for month 6 was a deficit of £(0.7)m which is Executive Summary £(0.1)m worse than planned. • The year to date position was a deficit of £(5.4)m deficit compared to • Why is this paper going to the the planned £(6.3)m. Board • Income is £(0.1m) below plan this month but remains favourable by • To summarise the main points £0.8m YTD. and key issues that the Board • Pay costs have now been static at £16.6m per month for the last four should focus on including risk, months. compliance priorities, cost and • Income and cost improvement are below plan year to date. It is penalty implications, KPI’s, forecast that there will be a shortfall in CIP’s of £3.2m for this financial Trends and Projections, year. conclusions and proposals • The forecast shows that the Trust’s plan deficit of £7.8m is still achievable by not utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes to offset recurrent shortfalls. The Trust has a range of actions in place to secure run rate balance by the year end but there is delivery risk associated with these actions.

Next steps/future actions

Clearly identify what will follow a Board decision i.e. future KPI’s, assurance Discuss 9 Receive requirements Approve Note 9

Assurance to be provided by:

This Report Covers (please tick relevant boxes)

Strategy Financial Implications 9

Performance 9 Legal Implications

Quality Regulatory 9

Workforce Stakeholder implications 9

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Andrea Bennett Simon Worthington Prepared by Presented by Deputy Director of Finance Director of Finance

Finance Report for the year to the end of September 2013 (Mth 6)

1. Introduction

1.1 This report is intended to update the committee and provide more information on the financial position of the Trust as at month 6 and to provide further detail on the forecast for the remainder of the financial year.

1.2 The Trust is ahead of plan year to date and is forecasting to deliver the planned deficit of £(7.8)m by the end of the year.

1.3 There is a plan in place to achieve run rate balance by the end of the financial year but there is delivery risk associated with this.

2. Month 6 Financial position

2.1 The financial position for month 6 was a deficit of £(0.7)m which is worse than the £(0.6m) deficit planned. The year to date position is a deficit of £(5.4)m which is £0.9m better than the planned deficit of £(6.3)m. 2.2 Income is £(0.1M) below plan mainly this month but remains £0.8m better than plan YTD.

2.3 Pay costs are static for the fourth month running and continue to show good cost control within the divisions. However, an under-delivery of CIP schemes produces an overspend of £0.4m on pay (2.5%). Some of the overspend on pay has produced an over-delivery in income

2.4 Non Pay expenditure is significantly lower this month. This is due to a number of reasons. In particular pass through drugs and estates costs are lower than last month.

2.5 The financial plan included PDC funding of £11.7m to the end of quarter 2. The improved financial position in the first six months and the revised phasing of planned restructuring costs indicates that the Trust will only need to request £5.75m to the end of November.

3. Cost improvements

3.1 Income and cost improvements year to date are now behind plan due to the Board decision to reinvest nursing savings on the wards and lower delivery rates some other workstreams than planned at the start of the financial year. This is being mitigated by additional CIP plans which are in place in the divisions and are part of the divisions’ financial recovery plans. 3.2 The Trust currently forecasts an under-delivery of £3.2 on income and cost improvements as shown below

Plan Forecast Diff £,000 £,000 £,000 CIP ‐ Recurrent 14,600 8,731 ‐5,869 CIP ‐ Non Recurrent 0 2,669 2,669 Income 1,575 1,575 0 Turnaround – Total 16,175 12,975 ‐3,200

Financed by £,000 Risk Reserve 2,200 Non Recurrent 1,000 Total 3,200

3.3 It is planned to use the risk reserve of £2.2m and non- recurrent items of £1m to offset the under achievement on income and cost improvements.

3.4 The actual / forecast performance by work stream compared to plan is contained within the body of the report.

4. Forecast for the Financial Year 2013/14

4.1 The forecast deficit for the financial year 2013/14 remains unchanged from last month. This is based on bottom up forecasts signed off by the Divisions which have then been adjusted for forecasting risk. The forecasting method used is primarily a ‘run rate plus’ type approach which looks at the run rate in each area and then adjusts for known changes

4.2 The forecast shows that the Trust’s plan deficit of £7.8m is achievable by utilising the £2.2m risk reserve that was set aside in the plan and by using non recurrent schemes to offset recurrent shortfalls.

4.3 Action is being taken to secure run rate balance by the year end. The actions are as follows:

• Bringing forward of the corporate directorate CIP requirement for 2014/15 into 2013/14.

• Work with Bolton CCG the community service model. £1.2m non recurrent support to community services has been allocated by the CCG in this financial year.

• Work with Bolton CCG on the “Making it Better” service specification

• Other improvements in the clinical divisions cost improvement programmes.

• Divisions with forecast underspends are being required to maintain these. 4.4 Progress is being made on the actions set out in in paragraph 4.3 however their remains significant deliver risk in respect of run rate balance at the year end.

4.5 The risk range on the income and expenditure forecast is £(9.0m) to £(5.2)m.

5. Recommendation

5.1 It is recommended that the committee notes the content of the report.

1. Executive Dashboard

Surplus / (deficit) £m Net Current assets / (liabilities) (£m) - (1.0) 0.0 (2.0) (3.0) (5.0) (4.0) (10.0) (5.0) (6.0) (15.0) (7.0) (20.0) (8.0) (9.0) (25.0) (10.0) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual Plan Cumulative Plan Cumulative Actual / Forecast 13 Week Cash Forecast(£m) Cumulative capital expenditure (£m) 20.0 7.0 6.0 15.0 5.0

10.0 4.0

5.0 3.0 2.0 0.0 1.0 13-Oct 20-Oct 27-Oct

05-Jan 0.0 03-Nov 10-Nov 17-Nov 24-Nov 01-Dec 08-Dec 15-Dec 22-Dec 29-Dec Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual spend Annual Budget Cash forecast Forecast month end cash balance (£m) In-month turnaround delivery(£m) 6.0 2.0 5.0 1.5 4.0 1.0 3.0 0.5 2.0

1.0 0.0

0.0 (0.5) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Forecast Actual Plan Actual

1 1. Executive Summary

1.1 Executive Summary Key Issue Executive Summary Year to Forecast Actions to be taken (where appropriate) date vs Outturn budget

EBITDA(1) In month EBITDA (£0.2m). Cumulative EBITDA of £0.1m. G R Trust in deficit cumulatively. £0.9m better than plan cumulatively. KPI will remain red rated whilst Trust Surplus/(Deficit) In month deficit of (£0.7m) and cumulative of (£5.4m). RRis in deficit. At the end of month 6 the Trust had £0.5m in cash which is £0.1m No cash support was required in Sept 2013. Further cash support of £2.5m Cash and Liquidity better than planned G R forecast for November 2013. Capital Expenditure £2m behind plan R G Programme expected to balance at year end Although savings are being delivered to plan as evidenced by the CIP Savings in year overall Trust financial performance being ahead of plan, overall A R Insufficient savings are being delivered recurrently. recurrent forecast savings are below plan. CIP Savings All savings achieved not yet validated as being recurrent Ensure all savings are delivered recurrently recurrent RR Monitor Financial FRR of 1 KPI will remain red rated whilst FRR = 1 Risk Rating RR

EBITDA and surplus/(deficit) Capital Expenditure G On or better than target G On or within 10% or £0.1m of plan whichever is higher A Between 0% and 5% below target A Outside green and red metrics R Greater than 5% below target R Greater than 25% below plan

CIP Savings Cash and Liquidity G On or better than target G Higher cash balance than plan or within 10% lower than plan A Between 0% and 10% below target A Cash balance lower than plan by 10% up to 20% R Greater than 10% below target R Cash balance lower than plan by greater than 20%

2 1.1 Executive Commentary M1 M2 M3 M4 M5 M6 YTD Actual £m £m £m £m £m £m £m Income 23.1 22.8 23 23.5 22.8 22.5 137.7 Pay ‐16.9 ‐16.7 ‐16.6 ‐16.6 ‐16.6 ‐16.6 ‐99.9 Non‐pay ‐7.4 ‐7.3 ‐7.1 ‐7.2 ‐7.6 ‐6.6 ‐43.2 Deficit ‐1.2 ‐1.2 ‐0.7 ‐0.3 ‐1.4 ‐0.7 ‐5.4 Budget ‐1.8 ‐1.4 ‐1.9 0 ‐0.4 ‐0.6 ‐6.3 Variance 0.6 0.2 1.2 ‐0.3 ‐0.9 ‐0.1 0.9 Income and Expenditure • This month shows a deficit of £0.7m (£0.1m adverse variance from plan) and is primarily driven by a marked reduction in non-pay. • Income is £0.1m below budget this month. Detailed commentary is provided in section 2.2 • Pay costs are static this month and continue to show good cost control within the divisions. However, an under-delivery of CIP schemes produces an overspend of £0.4m on pay (2.5%). Some of this has produced an over-delivery in income. • It has been noted at previous F&I committee that whilst the deficit for the first 3 months was much better than expected, this needs to be set against a rapidly accelerating CIP/efficiency programme for the last 9 months of the year where there was a known delivery gap of £3.2m (due to early start of corporate restructures but late start of clinical restructures). • The monthly trend figures suggest that the divisions are strongly focussed on achieving the year end position and savings are being made over and above those identified by the turnaround programme. At present the three clinical divisions show a net adverse variance of £0.5m on a budget of £109.0m. The divisions have plans to bring most of the adverse variance back in line. • Work is being undertaken to understand the reasons for these additional savings and the split due to timing, non-recurrent or recurrent savings (some is known to be related to vacancies being held by clinical divisions prior to department restructures in the income and cost improvements programme in order to assist with redeployment). • The year end outturn position remains forecast to be £7.8m deficit as last month. The organisation is taking action to achieve run rate balance, this includes: bringing forward CIPs, funding discussions with CCGs and maintaining underspends in divisions (further details see 8.1). • All divisional gaps within budgets have been removed and all CIP targets have been allocated to specialities.

3 Cash and Capital

• Cash has been managed effectively with a £0.1m cash outflow and a £0.5m cash balance at the end of the month.

• PDC funding is currently forecast with a £2.5m requirement in November and another £1.0m in December well within the profile agreed with Department of Health.

• The year end position assumes support of £17.25m from DoH. The assumptions behind this assume delivery of £7.8m deficit.

• The Trust cash position at the end of September is £0.1m better than plan. However the Trust hasn’t drawdown £8.4m of PDC as planned. The main reason for this is commissioners haven’t yet deducted penalties from their cash payments.

• The capital budget for the year is £5.9m profiled equally by month. To date this is underspent by £2.0m. Historically capital expenditure accelerates through the year.

4 2.1 Income & Expenditure

2.1.1 I&E In-Month Year To Date Annual Prior Income and Expenditure M6 Budge t Budge t Actual V ar . Year Budget Actual Var. £m £m £m £m £m £m £m £m Patient income 245.6 20.5 20.6 0.1 123.9 123.7 123.9 0.3 Other Income 27.8 2.2 1.9 (0.3) 13.2 13.2 13.8 0.5 Total Income 273.5 22.7 22.5 (0.1) 137.1 136.9 137.7 0.8 Pay (194.6) (16.2) (16.6) (0.4) (103.4) (99.8) (99.9) (0.1) Non-Pay (75.7) (6.2) (5.7) 0.5 (37.9) (37.9) (37.6) 0.3 Total Expenses (270.4) (22.4) (22.3) 0.1 (141.2) (137.7) (137.5) 0.2 EBITDA 3.1 0.3 0.2 (0.1) (4.1) (0.8) 0.1 1.0 Depreciation, interest & dividends (9.6) (0.8) (0.8) 0.0 (4.8) (4.8) (4.6) 0.2 Normalised Surplus/ (Deficit) (6.5) (0.5) (0.6) (0.0) (8.9) (5.6) (4.4) 1.2 Non-recurrent & exceptional (1.3) (0.1) (0.2) (0.1) - (0.7) (1.0) (0.3) Deficit (7.8) (0.6) (0.7) (0.1) (8.9) (6.3) (5.4) 0.9

2.1.1 Summary I&E

• This month the trust shows a deficit of £0.1m worse than budget . YTD the Trust has a deficit of £5.4m, £0.9m better than plan and has a budgeted and forecast deficit for the whole year of £7.8m.

• Income shows an adverse variance of £0.1m in month but is favourable £0.8m YTD. £0.3m of the variance relates to over-performance on pass-through drugs.

• The adverse variance on pay in month is driven by non delivery of pay CIPs

• Although there is a £0.3m underspend on non-pay YTD, there is an overspend of £0.3m on pass-through drugs in this category. This demonstrates a good underlying control on non-pay expenditure.

5 2.1 Income & Expenditure

2.1.2 YTD deficit bridge (£m) -

(1.0)

(2.0) (5.4) (3.0) (6.3) (0.3) (4.0) 0.3 0.2 (5.0) 0.5 0.3 (0.1) (6.0)

(7.0) Budget deficit YTD Patient Income Other Income Pay Non-Pay Depreciation, interest Non-recurrent and Actual deficit YTD & dividends Exceptional

2.1.3 Surplus / (deficit) £m - (1.0) (2.0) (3.0) (4.0) (5.0) (6.0) (7.0) (8.0) Cumulative Plan Cumulative Actual / Forecast (9.0) April May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

6 2.2 Income

2.2.1 Income Summary 2.2.1 Income summary Month 6 Year to date Plan Actual Var Plan Actual Var • Gross PbR income is (£0.4m) below plan in £'000 £'000 £'000 £'000 £'000 £'000 Gross PbR income (2.2.4) 13,481 13,095 (385) 80,901 79,949 (952) M06. Year to date gross PbR income is Income reductions (2.2.6) (309) (264) 45 (1,854) (2,105) (252) (£1.0m) below plan. Other patient income (2.2.7) 7,325 7,700 375 44,626 46,105 1,479 Ledger timing differences(1) - 104 104 - - - • M06 PbR income is below plan in all areas Total patient income 20,497 20,636 139 123,673 123,948 276 other than Outpatients which is only Other income (2.2.8) 2,172 1,893 (279) 13,222 13,751 529 marginally above plan. Total income 22,669 22,529 (140) 136,895 137,699 805 (1) reflects impact of coding of prior month activity and in respect of the plan represents agreed contract variation • Year to date income reductions are £(0.3)m higher than expected mainly due to the 2.2.2 Monthly Income Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 YTD estimate for the potential impact of being £'000 £'000 £'000 £'000 £'000 £'000 £'000 above the C-Diff trajectory. Gross PbR income 13,746 13,513 12,816 13,976 12,802 13,095 79,949 Income reductions (605) (343) 29 (627) (295) (264) (2,105) • There was minimal favourable adjustment for Other patient income 7,636 7,546 7,682 7,600 7,940 7,700 46,105 the NEL threshold in month as the actual Ledger timing differences (1) (171) (342) 46 504 (141) 104 (0) value for relevant NEL admissions was very Total patient income 20,607 20,374 20,572 21,454 20,306 20,636 123,948 close to the 2008-09 baseline Other Income 2,503 2,411 2,427 2,070 2,446 1,893 13,751 Total income 23,109 22,786 23,000 23,523 22,753 22,529 137,699 2.2.3 YTD Income variance (£m) 140.0 139.0 +0.5 138.0 +1.5 137.0 (0.1) (0.1) (0.6) 136.0 (0.3) 135.0 134.0 136.9 137.7 133.0 132.0 131.0 130.0 Budget Income YTD PbR - Volume PbR - Price Reductions - Contract Reductions - Other Other patient income Other income Actual Income YTD

7 2.2 Income

2.2.4 Gross PbR Income Month 6 Year To Date Activity Income Activity Income Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var Plan Actual Var Var # # # % £'000 £'000 £'000 % # # # % £'000 £'000 £'000 % A&E 9,469 8,977 (492) (5.2%) 963 922 (41) (4.2%) 57,479 57,269 (210) (0.4%) 5,844 5,885 41 0.7% Day Cases 2,079 2,306 227 10.9% 1,624 1,515 (109) (6.7%) 12,620 13,087 467 3.7% 8,927 8,922 (4) (0.0%) Elective IP 533 504 (29) (5.5%) 1,281 1,228 (53) (4.2%) 3,238 3,166 (72) (2.2%) 7,776 7,813 38 0.5% Non-Elective IP 3,043 3,136 93 3.1% 4,969 4,883 (85) (1.7%) 18,470 18,638 168 0.9% 30,160 29,767 (393) (1.3%) Delivery Episodes 521 521 0 0.1% 927 903 (24) (2.6%) 3,160 2,962 (198) (6.3%) 5,626 5,157 (469) (8.3%) Outpatients 22,580 22,308 (272) (1.2%) 2,466 2,481 15 0.6% 137,064 135,676 (1,388) (1.0%) 14,971 15,117 147 1.0% Ante/Postnatal Pathw ays 978 945 (33) (3.4%) 904 835 (69) (7.7%) 5,939 5,783 (156) (2.6%) 5,488 5,350 (138) (2.5%) Excess Bed Days 1,462 1,440 (22) (1.5%) 347 329 (19) (5.4%) 8,874 8,312 (562) (6.3%) 2,109 1,936 (173) (8.2%) Gross PbR Income 40,665 40,137 (528) (1.3%) 13,481 13,095 (385) (2.9%) 246,845 244,893 (1,952) (0.8%) 80,901 79,949 (952) (1.2%) Income Reductions (2.2.6) (309) (264) 45 (14.7%) (1,854) (2,105) (252) 13.6% Other patient income (2.2.7) 7,325 7,700 375 5.1% 44,626 46,105 1,479 3.3% Ledger timing differences - 104 104 n/a ---n/a Total income from activities 20,497 20,636 139 0.7% 123,673 123,948 276 0.2% Memo: Divisional PbR Income Acute Adult 19,174 18,948 (226) (1.2%) 5,092 5,143 52 1.0% 116,391 116,543 152 0.1% 30,907 31,657 750 2.4% Elective 16,645 16,253 (392) (2.4%) 5,078 4,859 (219) (4.3%) 101,039 99,990 (1,049) (1.0%) 30,824 30,446 (378) (1.2%) Family 4,846 4,677 (169) (3.5%) 3,093 2,966 (127) (4.1%) 29,415 27,974 (1,441) (4.9%) 18,777 17,658 (1,119) (6.0%) Gross PbR 40,665 39,878 (787) (1.9%) 13,263 12,969 (294) (2.2%) 246,845 244,507 (2,338) (0.9%) 80,508 79,761 (747) (0.9%) 2.2.4 Gross PbR Income

• Gross PbR income is £(0.4)m (2.9%) below plan in M06. This is driven by a volume variance & price variance of £(0.2)m each

• Total income from activities (after penalties etc.) is £0.1m , 0.7% above plan in M06 and £0.3m, 0.2% above plan year to date.

• Elective Care & Family Care divisions were below plan for both gross PbR income and activity in M06.

• To date Adult Acute division is ahead of plan for both income & activity for gross PbR income. Elective Care is now slightly below circa 1%) the YTD gross PbR income & activity plan due to the underperformance in M05 & M06.

• Family Care Division is below plan by £(1.1)m of which Delivery episodes and Ante / Postnatal pathways registrations & other Obstetric / Midwifery activity account for £(1.0)m, Paediatrics/Neonatology are £(0.4)m below plan offset by Gynae being over plan by £0.3m.

8 2.3 Pay

2.3.1 Pay - Actual vs Budget 2.3.1 Pay spend

Annual In-Month Prior Year To Date • The classification as “other pay budgets” arises Budge t Budget Actual Var. Year Budget ActualVar. because although the division and speciality has £m £m £m £m £m £m £m £m agreed the savings these are only allocated at Senior Managers (5.0) (0.4) (0.4) 0.0 (3.0) (2.5) (2.1) 0.4 Medical and Dental (47.3) (4.0) (3.9) 0.1 (22.9) (24.1) (23.3) 0.8 specialty level not subjective code level. Nursing, Midw ifery And Health Visiting (75.3) (6.3) (6.0) 0.3 (37.3) (37.9) (36.5) 1.3 Scientific, Therapeutic and Technical (23.4) (1.9) (1.8) 0.1 (12.2) (11.7) (11.1) 0.6 • The ‘other pay budget’ contains the divisional Professional and Technical (5.1) (0.4) (0.4) 0.0 (2.6) (2.6) (2.3) 0.3 and CIP gap where costs have not yet been Administrative and Clerical (23.2) (1.9) (1.8) 0.1 (11.9) (11.7) (11.1) 0.7 allocated to individuals budget lines. Healthcare Assistants and Other Supp o (20.6) (1.7) (1.5) 0.2 (9.7) (10.2) (9.2) 1.0 Other Pay Budgets 8.0 0.8 0.0 (0.8) (0.0) 2.3 (0.1)• (2.3) Although the pay budget is now overspent by Agency Staff (2.6) (0.3) (0.7) (0.4) (3.7) (1.4) (4.1) (2.8)£0.1m YTD an additional £0.8m of income has Pay (194.6) (16.2) (16.6) (0.4) (103.4) (99.8) (99.9) (0.1)been generated. Bank (included in above) (3.0) (0.3) (0.5) (0.2) (2.9) (1.7) (2.9) (1.2) Agency Split Nursing (0.2) (0.0) (0.2) (0.1) (0.1) (1.0) (0.9) A&C (0.7) (0.1) (0.2) (0.1) (0.3) (0.8) (0.5) Locum Doctors (1.7) (0.2) (0.3) (0.1) (0.9) (2.0) (1.1) Other (0.0) (0.0) (0.0) (0.0) (0.0) (0.3) (0.3)

2.3.2 Pay variance to budget (£'000) 1,000 765

500 8 45 - (15) (48) (55) (102) (500) (447) (410) (765) (1,000) Acute Elective Family Corporate Trust YTD In month 9 5. Cashflow

5.1 13 Week Cash forecast (£m) 5. Cashflow summary 20.0 • The 13 week cash forecast includes PDC funding of 16.0 £2.5m in November and £1.0m in December.

12.0 • The DH has approved £11.7m of funding to the end of 8.0 quarter 2. Current forecast indicate that the Trust will only

4.0 need to request £6.75m to the end of December.

0.0 13-Oct 20-Oct 27-Oct 05-Jan 03-Nov 10-Nov 17-Nov 24-Nov 01-Dec 08-Dec 15-Dec 22-Dec 29-Dec

Cash forecast

5.2 Actual month end cash balance (£m) Key assumptions 6.0

5.0 The cashflow forecast is underpinned by the following assumptions: 4.0 • PDC funding of £17.25m included in the forecast; 3.0 • Level of overdue debt to remain at current levels; 2.0 • Forecast is based on a outturn of a £7.8m I&E deficit 1.0 before exceptional items. 0.0

Forecast Actual

10 6. Capital expenditure

6.1 Capital expenditure YTD Year to date Annual Budget Actual Var Budget Fcast Var £000 £000 £000 £000 £000 £000 6.1 Capital expenditure Re place m e nts Sigmoid Flexiscope 56.5 0.0 56.5 113.0 113.0 0.0 Blood Gas Analyser 26.5 0.0 26.5 53.0 53.0 0.0 • The Trust capital plan as submitted to Monitor at the Laporoscopic Stacking System 29.5 0.0 29.5 59.0 59.0 0.0 end of May is £5.9m Upgrade of Haemoglobin Testing Systems 171.0 0.0 171.0 342.0 342.0 0.0 Tissue Processor 20.0 0.0 20.0 40.0 40.0 0.0 Replacement of Franking Machine 8.5 16.2 (7.7) 17.0 17.0 0.0 • At the end of September capital expenditure was Replacements Subtotal 312.0 16.2 295.8 624.0 624.0 0.0 £2.0m underspent Maintenance Urology Fire Precautions and Structural Floor 71.0 0.0 71.0 0.0 0.0 0.0 Urology Scheme Design and Consultancy Fees 0.0 0.0 0.0 40.0 40.0 0.0 • The Trust has spent 37% of the capital plan, this is Repairs to Highw ays Churchill Drive 0.0 0.0 0.0 50.0 50.0 0.0 below the 85% Monitor threshold C Difficile - Purchase of 4 HPV fogging units 43.5 125.8 (82.3) 300.0 300.0 0.0 Upgrade of Ward A4 401.0 392.5 8.5 802.0 802.0 0.0 Churchill Service Duct Fire Precautions 648.5 0.0 648.5 1,297.0 1,297.0 0.0 Ugrade of Parental Accomodation for MIB 5.0 6.1 (1.1) 10.0 10.0 0.0 Maintenance Subtotal 1,169.0 524.4 644.6 2,499.0 2,499.0 0.0 Enhancements Endoscopy 425.0 357.5 67.5 850.0 850.0 0.0 PACS 150.0 93.7 56.3 300.0 300.0 0.0 CT Enabling Works 25.0 1.0 24.0 50.0 50.0 0.0 Information Technology 403.5 0.0 403.5 807.0 807.0 0.0 Enhancements Subtotal 1,003.5 452.2 551.3 2,007.0 2,007.0 0.0 Othe r Capitalised Salary Costs 65.0 65.0 0.0 130.0 130.0Cumulative 0.0 capital expenditure (£m) Fees Maternity Unit 16.7 1.5 15.2 40.0 40.07.0 0.0 Other Subtotal 81.7 66.5 15.2 170.0 170.0 0.0 6.0 2012/13 Slippage Endoscopy - phase 1 365.0 0.0 365.0 365.0 365.05.0 0.0 Other 235.0 111.2 123.8 235.0 235.04.0 0.0 2012/13 Slippage Subtotal 600.0 111.2 488.8 600.0 600.0 0.0 3.0 GROSS CAPITAL EXPENDITURE 3,166.2 1,170.4 1,995.8 5,900.0 5,900.0 0.0 2.0

1.0

0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Actual spend Annual Budget

11 10. Financial risks & opportunities

10.1 Financial risks and opportunities Mitigated Re s idual Ris k Plan Ris k @ M th6 Ris k £m £m £m Planned deficit (7.8) - (7.8) Bolton CCG income (including QIPP) - no dow nside risk because of the patch financial management framew ork. --- Other income - Results for first six months show significant mitigation to this risk. (1.4) 0.7 (0.7) Turnaround cost reduction - gap in identified savings mitigated by delivery of budget balance at divisional level. (5.9) 3.0 (2.9) Maintain non recurrent savings risk 50% (2.7) 1.3 (1.4) Cost pressure management - the operation of the Divisional Financial Management Framew ork and the results at month six give comfort that this risk has reduced. (2.0) 1.0 (1.0) Dow nside risk scenario (19.8) 6.0 (13.8)

10.1 Financial risks and opportunities

• The risk on the income and cost improvements has been mitigated by use of the risk reserve and non recurrent savings

12 11.1 Appendix: Activity trends

A&E activity O/P activity (including procedures)

11,000 27,000

10,500 25,000 10,000 23,000 9,500

9,000 21,000

8,500 19,000 8,000 17,000 7,500

7,000 15,000 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

13/14 Actual 13/14 Plan 12/13 Actual 13/14 Actual 13/14 Plan 12/13 Actual

Non elective activity (spells only) inc births Elective / day case activity (spells only)

4,000 3,000 3,900 2,750 3,800 3,700 2,500 3,600

3,500 2,250 3,400 3,300 2,000 3,200 3,100 1,750 3,000 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-131,500 Mar-13 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

13/14 Actual 13/14 Plan 12/13 Actual 13/14 Actual 13/14 Plan 12/13 Actual

13 2013/14 I&E Forecast as at 30th September Context • Based on bottom up forecasts signed off by Divisions • Divisional forecasts have improve since Q2 • Adjusted for forecasting risk

Forecast • £7.8m is deliverable – by non recurrent means • Recurrent position major concern

Actions • The Trust is taking measures to ensure run rate balance by the end of 2013/14 • The Trust is bringing forward delivery of the pay element of the corporate directorates 2014/15 cost improvement plan into quarter 4 of 2013/14 BFT ‐ 2013/14 I&E Forecast Summary

Revised Control Forecast Variance Total Plan £m £m £m PbR income 161.4 159.8 ‐1.6 Other income 90.5 91.8 1.3 Income reductions ‐3.8 ‐4.0 ‐0.2 Divisional Income 26.2 27.3 1.1 Total income 274.4 275.0 0.6

Pay ‐196.2 ‐198.1 ‐1.9 Non‐Pay ‐72.9 ‐75.0 ‐2.1 Capital items, interest & dividends ‐9.6 ‐9.3 0.3 Non recurrent items ‐1.3 ‐1.4 ‐0.1 Risk Reserve ‐2.2 1.0 3.2 Total Expenditure ‐282.1 ‐282.8 ‐0.6

Surplus/(deficit) ‐7.8 ‐7.8 0.0 BFT ‐ 2013/14 I&E Forecast Divisional Variance

Q2 Q3 £m £m

Adult ‐1.5 ‐0.9 Elective ‐1.5 0.0 Family Care ‐1.0 ‐0.3 Estates 0.0 0.4 Community Funding 0.0 1.2 Activity undertrade 0.0 ‐1.5 Corporate 0.3 1.0 Financial Charges 0.5 0.3 Risk Reserve 2.2 2.2 Balance Sheet 1.0 1.0

Sub Total 0.0 3.4

Forecast ‐ optimism bias 0.0 ‐2.8 Winter 0.0 ‐0.6

Total 0.0 0.0

Committee Chair Report

Name of Committee: Quality Assurance Committee Date of Meeting: 9th October 2013 Report to: Board of Directors Chair: Gina Ashworth

Key Issues Discussed Chairman’s report the Committee noted the items devolved from the Board for further consideration: Audit of compliance with the falls strategy Audit of readmissions Integrated performance – the Committee received a presentation outlining the background to the development of the new integrated performance report scheduled for presentation to the Board in October. The new report has been designed to provide an Executive summary to the full board with the option to drill down into ward level detail for areas of interest or concern. The Quality Committee will focus routinely on the Quality metrics in this report. The Committee also received the NHS North Quality dashboard and agreed that this should be received quarterly by the Committee. Division Reports – The Family Division attended to present their Q1 Quality report. Committee members discussed the metrics and assurance included in the report and asked for further assurance to be provided with regard to learning from incidents and data protection issues. From November all three divisions will share their reports at the same meeting at the end of the reporting quarter. This will provide timelier reporting and allow divisions to share learning. SUIs – The Committee received an update on implementation of SUI action plans. CQC report – The Trust is now fully compliant with all standards C Difficile action plan – The QA committee continue to receive monthly updates on the implementation of the CDT action plan. Keogh Review and Berwick report – The Committee received presentations on the implications of these national reports

For Escalation to the Board Committee members agreed that their concerns with regard to the closure of incidents on Safeguard should be escalated to the Board Apologies received from See minutes

Date of next meeting – 6th November 2013

Agenda Item No : 23

Meeting Board of Directors

Date 31st October 2013

Title Charitable Funds

Executive Summary

• Why is this paper going to the Board • To summarise the main points • To accept the Minutes of the Charitable Funds Committee Meeting and key issues that the Board held on 28/08/2013. should focus on including risk, • To approve the amended Charitable Funds –Terms of Reference. compliance priorities, cost and penalty implications, KPI’s, Trends and Projections, conclusions and proposals

Next steps/future actions

Clearly identify what will follow a Board decision i.e. future KPI’s, assurance Discuss Receive requirements Approve 9 Note

Assurance to be provided by:

This Report Covers (please tick relevant boxes)

Strategy Financial Implications

Performance Legal Implications 9

Quality Regulatory 9

Workforce Stakeholder implications

NHS constitution rights and pledges Equality Impact Assessed

For Information Confidential

Alison Tilley Mr E Adia Prepared by Presented by Finance Manager Non-Executive Director

MINUTES OF THE CHARITABLE FUND MEETING held on Wednesday 28th August 2013 in the Estates Conference Room, Royal Bolton Hospital

PRESENT Abbreviation for Minutes Mr A Duckworth Non-Executive Director (Chair) AD Mr S Worthington Director of Finance SW Ms Sheila Roberts Interim Divisional Director of SR Families Ms Pauline Lee Public Elected Governor PL Ms Janet Roberts Staff Elected Governor JR Dr G Halstead Consultant – Medicine & GH Emergency Care Mrs A Tilley Deputy Finance Manager AT

1. Apologies

Apologies were received from E Adia, Gina Ashworth and J Ramsden.

No conflict of interests were disclosed.

2. Minutes of Previous Meeting

The minutes of the meetings held on 12th March 2013 were accepted as a true record.

3. Matters Arising

Ethiopia Fund – AT met with Mr Hobbiss and a visit is to be arranged to Gondar.

4. Terms of Reference

The updated Terms of Reference (ToR) were discussed, AD asked how the ToR compared to other standard ToR’s and SW stated that they were comparable. AT went through the points that had changed. SR asked why the Estates department weren’t represented, SW suggested that Estates would be represented at future meetings if required.

SW asked if the Audit Committee had reviewed the ToR and AT confirmed that they hadn’t and that the ToR are sent to the Board of Directors for approval.

CFC/1301- AT to send the Terms of Reference to the Board of Directors for Approval.

5. Investments

The Committee has approximately £1.3m to Invest, SW stated that for the short term leave the money in the bank.

The Committee discussed the possibility of depositing the monies in a bank account with a better rate of interest and a guarantee.AD asked if the Committee had ever looked into pooling the money with another Trust’s Charitable Fund, AT informed the committee that this had never been done, she was then asked to investigate this.PL asked if we could put the monies into a Bond.

AD suggested that the committee review the Investments every 12 months.

It was decided that there will be a further update at the next meeting to consider Investment options that are available.

CFC/1302 – AT to investigate putting the monies into a Bond. CFC/1303 – AT to investigate pooling the funds with another NHS Charity. CFC/1304 – AT to update the committee on Investments available at the next meeting.

6. Fund Balances

The Fund balances were discussed, AT stated that the divisions were being asked to spend their ‘Old Funds’ by the end of this financial year. Monies are not transferrable from one fund to another.

The committee discussed fundraising, SW asked that the divisions discuss fundraising at their divisional board meetings and put forward their fundraising ideas. SW asked that the divisional fundraising ideas are discussed at the next Committee meeting that is due to be held in November.

This led to the Committee discussing fundraising and AD suggested that the Committee focus on one large item.

Divisions are to be asked to submit their views by the end of October to AT.

CFC/1305 – AT to ask the divisions for fundraising suggestions. CFC/1306 – AT to inform the committee of the divisions suggestions at the next meeting.

7. Annual Report

AT explained how the Annual Report was produced and answered questions raised. It was confirmed that the Auditors were happy with the content and the report was accepted by the committee and the statements be signed off by the Chairman and SW.

8. Funding Requests

There were no funding requests for discussion.

PL asked how the departments ask for funding. AT explained the process.

9. Any Other Business

AT produced a copy of a letter regarding an estate that includes a property that is currently on the market for £69,950 – an offer has been made for £61,500. AT stated that the property was in need of repair. The Committee recommended to accept the offer.

CFC/1307 – AT to confirm acceptance of the offer to the Solicitor.

10. Date and time of next meeting

Wednesday 27th November 2013 at 8.15am in the Estates Conference Room- This is to be confirmed due to the new membership.

BOLTON NHS FOUNDATION TRUST TERMS OF REFERENCE

Charitable Funds Committee

1. Constitution

The Trust Board has resolved to establish a committee of the Board to be known as the Charitable Funds Committee (CFC). The board has delegated the responsibility for the overall management of the Charity to the CFC. The Committee has the responsibility to:

i. Accept, control, apply and administer all Charitable Funds in accordance with the NHS Charities Act 1977, the National Health Service and Community Care Act 1990.

ii. Ensure that ‘best practice’ is followed in the conduct of all its affairs fulfilling all of its legal responsibilities.

iii. Ensure that the Trust’s management and reporting arrangements are followed, and that Charitable funds procedure notes are produced and followed.

iv. Provide support, guidance and encouragement for all its income raising activities and monitor the receipt of all income.

v. Ensure that the investment policy is followed and that funds are invested to provide a balanced return from income and capital growth with a low level of risk.

vi. Monitor the activity, performance, and risks of the Charity and keep the Trust Board fully informed.

vii. Oversee and monitor the functions performed by the Director of Finance as defined in Section 16 of the Trust’s Standing Financial Instructions.

2. Membership of the Committee

2.i Membership of the Committee shall comprise of:

3 Non-Executive Directors Director of Finance Divisional –Nursing Representative Divisional –H.O.D. Divisional –D.D.O. or General Manager

Charitable Funds Committee

Finance Manager (Charitable Funds) Two Public Elected Governors A Staff Elected Governor

2. ii The Chair of the committee shall be one of the Non-Executive Directors.

3. Quorum

A quorum shall require the attendance of four or more of the Committee members, which must include at least one Non-Executive Director, the Director of Finance or Finance Manager and two other Committee members.

4. Attendance at Meetings

The Committee may request the attendance of relevant senior staff of the Trust as and when required.

5. Frequency of Meetings

Meetings shall take place at least twice a year.

6. Support and Advice to the Committee

The Committee shall receive reports, advice, support and information at each meeting and on an ad-hoc basis upon request from:-

The Director of Finance The Trust’s Investment Advisers The Trust’s Legal Advisers The Trust’s Auditors The Trust’s VAT Advisors

7. Charitable Funds Objectives, Structure & Policy

Bolton NHS Charitable Fund was created using the model declaration of trust and there are a number of ‘special purpose trusts’ which are registered under the ‘Umbrella’ of the Bolton NHS Charitable Fund. The Charitable Funds registration number is 1050488. The Trust is responsible for holding it’s Charitable Funds upon trust, and the object’s of the charity are to apply income and at their discretion so far as permissible the capital, for any charitable purpose or purposes relating to the National Health Service. The Trust has powers to accept gifts, bequests or donations only for the purposes relating to health services including, patients, staff welfare and amenities and research. All such gifts,

Charitable Funds Committee

bequests or donations should be accepted in the name of ‘Bolton NHS Charitable Fund’, and should be administered in accordance with Trust policies and the donor’s wishes.

All correspondence and communications in connection with legacies are conducted through the Director of Finance in accordance with the Standing Financial Instructions; ‘The Director of Finance is kept informed of all enquiries regarding legacies and a legacy register is maintained by the Finance Department. After the death of a testator, all correspondence concerning a legacy is dealt with on behalf of the Trust by the Director of Finance who alone is empowered to give an executor a good discharge.

Each fund has a designated signatory and the Charity has a Scheme of Delegation which is:-

Up to £1,000.00 Designated Fund Holder £1,000.00 to £5,000.00 Divisional Director of Operations £5,000.00 to £10,000.00 Deputy Director of Finance Over £10,000.00 Director of Finance

The policy of the charity is to ensure that all fund holders spend donations as they are received and not to build up fund balances unless funds are being accumulated for a specific purpose, e.g. the purchase of more expensive piece of equipment. A review is undertaken of fund balances on a regular basis and a report is made to the CFC detailing the expenditure plans of funds with balances in excess of £5,000.

8. Investments

The charity’s investment policy is based upon the powers within the trust deed, this forms the basis of the formal investment agreement with our investment managers. The CFC must comply with the Trustee Investment Act 1961, The Charities Act 1993 and the terms of the funds governing documents. The Investment Managers are required to provide;

A balanced return from income and capital growth, with a low level of risk.

The Investment Managers may only purchase investments for the portfolio which it has reasonable grounds for believing it to be suitable for the Trust.

Ethical considerations should be made when making Investments.

To provide regular updates and visit the Trust when required.

Charitable Funds Committee

An update on Investments is made to the CFC at every meeting, members of the committee may be contacted of any material changes or an emergency meeting called if found necessary.

Other funds are held in a bank account that is separate to the Trust’s NHS funds.

9. Application of Funds

9.i. The Committee will ensure and keep under review a scheme of reserved powers and delegation of powers to commit funds.

9.ii. Monitor expenditure/the application of funds:-

The Charitable Funds Accountant will commit all Charitable Fund expenditure, and ensure that it is in line with the objectives of the Charity/and the wishes of the donor. Fund holders will be issued with a list of fund balances on a monthly basis, and statements will be available upon request, with full explanations given as and when required. The Charitable Funds Accountant will produce ad hoc reports for fund holders as requested.

9.iii. Monitor fund balances to ensure that there are plans to spend large fund balances:-

The Charitable Funds Accountant will investigate fund balances over £5,000 to ensure that funds are being accumulated for the purchase of a larger piece of equipment.

A report of fund balances will be made to the CFC on a regular basis.

10. Delegated Powers and Duties of the Director of Finance

The Director of Finance or Deputy has the prime responsibility for the Trust’s Charitable Funds as defined in Section 16 of the Trust’s Standing Financial Instructions (See Appendix A). The specific powers, duties and responsibilities delegated to the Director of Finance are outlined below:

10. i. Administration of all existing Charitable Funds.

10. ii. Review the number of funds in existence and were appropriate either rationalise or increase the number of funds and provide governing documents were appropriate.

Charitable Funds Committee

10. iii. Provide guidelines in respect of income from donations, legacies and bequests, fundraising, investment and trading income.

10. iv. Responsible for the management of investment of Charitable funds.

10. v. Ensure appropriate banking services are made for charitable funds.

10. vi. Ensure that regular reports are made available to the CFC and Trust Board.

10. vii. Preparation of the charities Annual Accounts and Annual Report for submission to the Charities Commission.

Accepted by CFC 28/08/2013 Accepted by Board of Directors xx/xx/2013

Charitable Funds Committee

Appendix A.

Bolton NHS Foundation Trust –Standing Financial Instructions

Paragraph 16 – CHARITABLE FUNDS (FUNDS HELD ON TRUST)

16.1 Corporate Trustee

(1) The Trust Board is the corporate trustee of the Charitable Fund(s).

(2) The discharge of the Trust’s corporate trustee responsibilities are distinct from its responsibilities for exchequer funds and may not necessarily be discharged in the same manner, but there must still be adherence to the overriding general principles of financial regularity, prudence and propriety.

The Board may delegate such trustee functions as it determines to the Charitable Funds Committee subject to written terms of reference approved by the Board. The Board must receive and adopt the annual accounts of the Charitable Fund(s).

16.2 Accountability to Charity Commission

The trustee responsibilities must be discharged separately and full recognition given to the Trust’s accountability to the Charity Commission for charitable funds held on trust.

16.3 Applicability of Standing Financial Instructions to funds held on trust

(1) In so far as it is possible to do so, these Standing Financial Instructions will apply to the management of funds held on trust. (See overlap with SFI 7.12).

(2) The over-riding principle is that the integrity of each Trust must be maintained and statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.