BIRMINGHAM & SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD OF DIRECTORS
To be held on Wednesday 31st May 2017 Plymouth room, Uffculme Centre, Moseley
BOARD AGENDA
8.30 – 9.30 Remuneration Committee (Private)
9.30 – 10.00 Feedback from the Trust Board Story : Invitations to meet (Sue Davis and Ali Simpson)
10.00 – 12.30 Public Board (including a 15 minute break)
Lunch 12.30 – 1.00
1.00 – 2.00 – Test Bed Demonstration – Helen Cross (CSU), Rosemary Adebola, Sam Munbodh and Shaun Griffiths and Shamas Rahim and Safia Khan
2.00 – 3.00 – Care Planning – Sel Vincent
3.00 – 3.30 – Digital Innovations – Carl Beet
3-30 – 4.30 – Operational Update – John Short
Item Purpose Lead Enc 1. Questions from Governors and members of the - - - public 2. Apologies - - - 3. Declaration of Interests (as required) Information Chair No 4. Chair’s Report Information Chair No
5. Chief Executive’s Report Information CEO No
6. Quality and Performance 6.1 Director of Nursing Report Assurance S Hartley Yes 6.2 Medical Directors report Assurance H Grant Yes
6.3 Chief Operating Officer Operational Assurance B Hayes Yes Escalation Report
6.4 People Report Assurance B Hayes Yes
6.5 Director of Finance Report Assurance D Tomlinson Yes
BREAK 15 MINUTES 7. Strategy 7.1 STP Memorandum of Understanding Assurance CEO Yes 8. Policy 8.1 None Item Purpose Lead Enc 9. Governance 9.1 Board Assurance Framework Information, D Lawrenson Yes assurance and approval 9.2 Information Governance annual report Information D Tomlinson Yes and assurance 9.3 Annual self cert declaration Information, D Lawrenson Yes assurance and approval 9.4 Dear John Annual report Information D Tomlinson Yes and assurance 9.5 Quarterly Guardian Report Information Sajid Muzaffar Yes and assurance 9.6 Stakeholder insight next steps Information D Tomlinson Yes and assurance 9.7 Declarations of Interest Information, D Lawrenson Yes assurance and approval 10. Board Committee Chair Reports 10.1 Integrated Quality Committee report Assurance J Warmington Yes
10.2 Finance Performance and Productivity Assurance B Henley Yes Committee report
10.3 Audit Committee report Assurance G Hunjan Yes
10.4 Remuneration Committee (verbal) Assurance S Davis No 11. Minutes of the last Board – April 2016 Approval Chair Yes
12. Actions from the last Board Information Chair Yes
13. Matters Arising (not on the Agenda) - - -
14. Board forward planner Information Chair Yes
15. Any Other Business
Date, Time and Venue of the Next Trust Board Meeting Wednesday 28th June 2017, Uffculme Centre 09.30 - 12.45 In accordance with Section 1 (2) Public Bodies (Admissions to Meetings) Act 1960, the Board is invited to approve the following resolution: “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 Item Purpose Lead Enc transacted, publicity on which would be prejudicial to the public interest”.
Private Session
16. Estates Strategy Information, D Tomlinson Yes assurance and approval
Item 6.1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017 DIRECTOR OF NURSING REPORT Strategic or Regulatory Requirement to which the paper reports – • We will put service users first and provide the right care, closer to home, whenever it’s needed • We will listen to and work alongside service users, carers, staff and stakeholder; • We will champion mental health wellbeing and support people in their recovery. ACTION: The Board is requested to discuss, note and receive the report which is received for assurance
Executive Summary • Flu planning has commenced for the year in order that we are adequately prepared for the Autumn/Winter of 2017/18. • As we are now nearing the opening of Rookery Gardens we are completing all environmental and ligature risk assessments ensuring that these meet ‘gold standards’. • There were 11 formal complaints received during April 2017 compared to 20 in April 2016. Closed complaints included the need for us to ensure that patients have information relating to medications so that they can activate choice and also the need to avoid advising patients of appointments by letter when the appointment is less than a week away. Delays in the postal system often mean that individuals do not receive the letter in time for the appointment and a telephone call would be a good alternative communication mechanism. • Of the 11 complaints received in April, one has been responded to so far within the month. 9 complaints were responded to overall in April achieving 100% compliance with contractual targets. The average length of a complaint from registration to closure in April 2017 was 29.3 days. • There were 14 Serious Incidents reported in April 2017. All 14 incidents are in the course of being investigated. Two related to failures to return from leave for secure care patients. There were six cases of suspected suicide within the community. • There were a total of 89 deaths reported in April 2017. 13 will receive a full RCA review, 11 were downgraded as they were not receiving mental health services other than RAID involvement and 65 will receive a management report (natural causes). All deaths meeting the criteria for SI will also be subject to a mortality case note review, reporting the level of preventability. Those 65 dying of natural causes will also be triaged for mortality case review (those with SMI (severe mental illness) diagnosis). • With regard to our quality goals, we have seen a continual reduction in the number of physical assaults on staff since November 2016. We can also see that restraint (and in particular the use of prone restraint) has considerably reduced during April 2017. The full report is appended at Appendix 3.
BOARD DIRECTOR SPONSOR Sue Hartley, Executive Director of Nursing
REFERENCE: Appendix 1, Complaints Report; Appendix 2: Serious Incident Report (Private and Confidential) - exempt under S40 (2) of the Freedom of Information Act - Personal Information – In Reading Room
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Appendix 3: Quality goals, - In the Reading Room Appendix 4 – Patient Experience & Recovery Report – In the Reading Room Appendix 5 – HPFT Carer Pathway, referred to within appendix 4. – In the Reading Room
Appendix 1 - Customer Relations including Complaints and PALS Strategic or Regulatory Requirement to which the paper reports - Continuously improving quality by putting service users at the heart of everything the Trust does to deliver excellence ACTION: The Board is asked to note the contents of the report. Executive Summary
• Complaint and PALS data for month 1, April 2017: 11 formal complaints registered so far during 2017/18 compared with 20 registered in the same period for the previous year. • 63 PALS resolutions were reported during 2017/18 so far against 97 for the same period for the previous year. • 204 general PALS contacts during month one. • 11 complaints received and registered within April 2017, this is in comparison to 20 received and registered for April 2016. • Main themes from complaints raised during April 2017 include: failing to provide adequate care, attitude of staff, clinical treatment, communication with patient, mental health act and staffing levels. All complaints are shared with the service Associate Director of Operations and Clinical Director for wider circulation to the services and, at the same time, an independent investigating officer is sought to investigate.
Customer Relations report: month 1 Customer Relations contacts April 2017 The table below provides a position statement for April 2017 and comparable data from 2016/17.
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The Trust registered a total of 11 formal complaints during months 1 of 2017/18 compared with 20 registered in the same period for the previous year. The PALS team have assisted in 63 resolutions and case work so far during 2017/18, in comparison with 97 for the same period last year, and supported 204 general PALS calls so far this year, in comparison with 293 for the same period the previous year.
Who has raised issues of concern with the Trust
Who made contact?
Apr-17 Source Type Complaints Pals Resolutions
Anon (Includes General PALS Calls) 0 204
Advocate 0 2
CCG 0 4
Father 1 0
M.P. 0 1
Member Of Staff 0 3
Mother 2 1
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Other 0 1
Other Professional 0 1
Partner 1 7
Patient 6 32
Relative 1 11
Grand Total 11 267
Complaint Response Time Compliance Of the 11 complaints received in April, one has been responded to so far within the month. 9 complaints were responded to overall in April achieving 100% compliance with contractual targets. The average length of a complaint from registration to closure in April 2017 was 29.3 days.
Below the chart shows the average length of a complaint in each service area, from registration to closure during the month of April 17. Where there is 0.0 these service lines have not received any complaints.
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Customer Relations contacts by Service Line month 1
Complaint KO41 Categories and Sub-Categories for month 1
KO41a Categories Total
Clinical Treatment 2
Inappropriate Treatment 1
Delay Or Failure To Follow Up 1
Communications 1
Communication With Patient 1
Commissioning 1
Services - Not Commissioned 1
Patient Care 3
Failure To Provide Adequate Care (Inc. overall level of care provided) 2
Inadequate Support Provided 1
Staff Numbers 1
Staffing Levels 1
Trust Admin/Policies/Procedures Including Patient Record 1 Management
Mental Health Act 1
Values and Behaviours 2
Attitude of Nursing Staff/Midwives 2
Grand Total 11
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Detained patients: Three complaints came from detained patients during April 2017. One case relates to leave when placed on different ward. The second case concerns a restraint issue. The final case relates to a section and being transported to a secure unit.
Individuals who have raised more than one complaint or issue received during March 2017: There was one complainant who has registered a complaint during April who has previously raised a complaint with the Trust.
Returned complaints: 1 complainant has returned during March dissatisfied with their complaint response. Further communication and support is being offered to this service user by both the Customer Relations and their clinical team.
Parliamentary and Health Service Ombudsman (PHSO) referrals:
There are five complaints open to the PHSO at the point of writing this report. Of these five complaints, 2 are under investigation, 1 being a new case during April 2017. Cases 1 and 3 have outcomes of “partially upheld” where the Trust is updating the progress of the outstanding action to the PHSO. Case 2 has received an outcome of “upheld”. The Trust has appealed this outcome and we are awaiting further details at this time.
Case 1 - The PHSO have partially upheld a complaint made by the family of a young person who died under our care in 2008. The PHSO had previously investigated this complaint and not upheld it, but further information was provided to the Ombudsman, and the case was reopened with an outcome of partially upheld. We are reporting the outcome of the remaining action following recommendations made by the PHSO.
Case 2 - relates to the wife of a service user who feels the medication her husband was prescribed was dangerous and his withdrawal has left the patient with additional health issues. The PHSO have upheld the following aspects:
• The prescribing of lorazepam to the service user for two and a half years that was not in line with clinical guidance or established good practice and is a service failing. • The service users detoxification was not conducted in line with national clinical guidance which amounts to a service failing. We have appealed the outcome and are awaiting further details from the PHSO at present.
Case 3 - relates to the parents of a service user who took his own life following discharge from acute services. We are reporting the outcome of the remaining action following recommendations made by the PHSO.
Case 4 - relates to a former service user who is complaining about his care and treatment, medication prescribed over a period of time and a breach in confidentiality. This case is under investigation at the time of writing this report.
Case 5 – relates to the family of a deceased service user, who are raising questions in relation to the service users care whilst under Trust services.
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Actions and Learning Lessons
Actions resulting from upheld/partially upheld complaints from April 2017 are documented in the updated appendix 1 with themes being identified in a simple way to focus learning.
Complaint Outcomes to Date
Complaints Received and Responded to Total
April 2017
Not Upheld 3
Partially Upheld 4
Upheld 2
Complaint Withdrawn 0
Grand Total 9
Outcomes from complaints closed within April 2017 indicate the following lessons and reminders of practice:
Trust wide lessons/ Innovations to service: • No appointments should be made at short notice without prior discussion with service user. In addition, also agreed that where someone is not able to make an appointment, whether due to short notice or any other reason, the team should very carefully consider using the term "disengaging from services" as this has a negative connation and is not always the case. Investigator has also asked for team, along with administration staff, to consider how records can indicate preference and unavailability when arranging appointments. The experience of this complaint will be utilised as part of the improvement processes to ensure that letters are addressed correctly and signed. • Investigation into whether an electronic diary of all prescriptions can be set-up on this system to give the medical secretaries an advanced warning of due dates for medication to be issued. If and when this is possible, prescriptions due can be printed off and signed and then monitored for collection. If there are any outstanding prescriptions, this can be flagged with team members to follow-up.
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Reminders of practice:
• RIO must be kept up to date with all relevant and current information. • Ensure all services are practicing to good standards regarding medication and choice ensuring that all service users are offered routinely the patient information leaflets on medications produced by the Trust.
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Case Directorate Details Of Complaint Aspects upheld Actions identified
6028 Community - Failure To Provide Adequate Aspect upheld: Action identified: South, West & Care Solihull - Inappropriate appointment times and letters received Agreement that no appointments should be made at Yewcroft Unhappy with standards of late in the date of appointment upheld, attitude of short notice without prior discussion. In addition, also Resource Centre practice and treatment received. clinician and permission to approach school partially agreed that where someone is not able to make an - Yewcroft CMHT Concerns regarding lack of upheld. appointment, whether due to short notice or any other respect, care, compassion & reason, the team should very carefully consider using dignity. Given appointments they the term "disengaging from services" as this has a were unable to make, despite negative connation and is not always the case.
explaining situation. Alleges lack Investigator has also asked for team, along with of professionalism from member administration staff, to consider how records can of staff. Request referral indicate preference and unavailability when arranging however received appointment appointments. letter on same day of appointment which caused them inconvenience & caused
distress. Further appointment offered again letter arrived on Some changes to the assessment have been agreed the same day, requested and staff will consider their approach when another appointment however communicating with patients. service questioned the reason for non-attendance. States letter and assessment received was Appointment with clinician, approach to school and inadequate and inaccurate. inaccurate assessment made. Plans to discharge were not discussed beforehand.
Outcome: Upheld
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Case Directorate Details Of Complaint Aspects upheld Actions identified
6078 Community - Communication With Patient Aspect upheld: Action identified: South, West & Solihull - Solar - Patient opened post which had The referral letter should have been sent to the family A member of staff has received the appropriate Solihull CAMHS been addressed to him however and a copy to the referrer. management supervision and staff members reminded this should have been of procedures. addressed to his parents. Incorrect spelling of service;
Clarity required re Engage The experience of this complaint will be utilised as part Service; Lack of consistency Letter suggested to contact the 'Cyst' service, of the improvement processes in Solar to ensure that from service. typographical error should have been SISS service. letters are addressed correctly and signed.
Outcome: Upheld The experience of this complaint will be utilised as part of the improvement processes in Solar to ensure that Letter sent out with sons name highlighted in window letters are addressed correctly and signed of envelope.
6087 Dementia & Communication With Aspect upheld: Action identified: Frailty Services Relatives/Carers - Juniper centre - Unable to speak with member of staff directly as This learning point will be highlighted with the member Rosemary ward Clinical team failed to listen to unavailable at the time regarding allegation regarding of staff concerned. the family at recent meeting as theft & safeguarding referral, although team believe patient's husband could not they were acting in the best interest of the patient. attend. A letter written by Discussion between member of staff and their PA husband was also dismissed. regarding establishing availability and signposting Serious concerns regarding risks Confusion which resulted in member of staff not families appropriately. posed by patient to herself and returning phone calls. others being ignored in decision to discharge patient home.
Outcome: Partially Upheld
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Case Directorate Details Of Complaint Aspects upheld Actions identified
6097 Community - Failure To Provide Adequate Aspect upheld: Action identified: North & East, Care Recovery - Vital information missing from patients notes. Team Manager to remind all staff to ensure that RIO is Reservoir Court - Patient had not been receiving kept up to date with all relevant and current
North HuB medication for Alzheimer's for 10 information. months. Complainant believes
this has severely impacted on mother's well-being and he and This is one of the standard questions made by the his sister have witnessed assessing practitioner when they have patients in noticeable deterioration in her Why wasn't the issue of out of date prescription clinic. condition and appearance in last picked up in appointments. 6/7 months. Concerns raised that this hadn't been picked up by the team. Lack of The service is committed to changing practice so that
communication from team. medications can be clearly monitored. Doctor not aware that prescription was out of date for
collection. Outcome: Partially Upheld Investigation into whether an electronic diary of all
prescriptions can be set-up on this system to give the Why was the order for medication cancelled? medical secretaries an advanced warning of due dates for medication to be issued. If and when this is possible, prescriptions due can be printed off and signed and then monitored for collection. If there are any outstanding prescriptions, this can be flagged with team members to follow-up.
6111 Community - Attitude Of Medical Staff Aspect upheld: Action identified: North & East, Recovery - Concerns raised regarding Regarding medication information, felt concerns Ensure all services are practicing to good standards Small Heath comments made by Doctor in regarding side effects not dealt with sensitively. regarding medication and choice and that service Health Centre - relation to patients citizenship. users are offered routinely the patient information
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Case Directorate Details Of Complaint Aspects upheld Actions identified
Small Heath Unhappy with the attitude and leaflets on medications produced by the Trust. (O’Donnell) behaviour of doctor; comments CMHT made in relation to their weight gain and refusal to assist with a Dr concerned advised to take complaint to next 360 form that CAB advised they degree appraisal and RMS to discuss as a reflective need to complete. Patient states practice exercise and learning. doctor has left them feeling vulnerable and requests to see Acknowledging patient felt downgraded by way another doctor. questioned by Dr and felt eligibility to be in the UK questioned, although not intention questioning part of assessment.
Outcome: Partially Upheld
6158 Community - Failure To Provide Adequate Aspect upheld: Action identified: North & East, Care Recovery - Care plan under care support should have been Issue highlighted with Clinical Director, and Clinical Northcroft - Despite a support plan having completed with service user, recorded and a copy Director to raise with Consultant and other medics for Erdington And been formulated for a specific sent, which did not happen. ensuring patients on care support plan are regularly Kingstanding medication to be prescribed updated, discussed with and shared, with the patient.
CMHT during crisis, this did not happen on contact with the team when in
crisis. Queries why duty & the Team overseeing care to meet with patient to update Consultant did not follow the Medication not written up as part of crisis plan. personal care and crisis plan. For this to be reviewed crisis plan & what the point is if it at regular intervals to ensure plan remains appropriate is not followed. Wishes for this to needs. not to happen again and why this broke-down.
Outcome: Partially Upheld
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Item 6.2
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
MEDICAL DIRECTOR’S REPORT
Strategic or Regulatory Requirement to which the paper reports
• Mental Health Legislation - Police & Crime Act
ACTION: Trust Board is requested to note and receive this report for assurance.
ISSUES • Pharmacy – performance, medicines code, waste medicines & EPMA; • Positive & Proactive Care – increased membership and attendance at R&I Committee; • Medical job planning – policy under review; • Medical appraisals – draft policy and annual organisational audit by NHS England; • Psychology – Prevent, job planning, workforce and personality disorder; • Integrated clinical risk group – clinical risk strategy, clinical risk tool, clinical risk training, suicide prevention & positive and proactive care; • Medical Workforce – recruitment & clinical excellence awards; • Mortality – masterclass, data collection & business case; • Mental health legislation – focussed visit by CQC on 4th May.
BOARD DIRECTOR: Dr Hilary Grant, Executive Medical Director
References: • Appendix 1 - BSMHFT preparedness report referencing the Police & Crime Act – see section 9 of the attached report – Confidential reading room
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1. Pharmacy
Performance of pharmacy services has continued to improve throughout 2017. Overall dispensing activity remains stable. However, the number of missed runs and other problems have continued to decrease. This has been brought about by a number of factors including:
• A number of staff returning from maternity leave and long term sick leave • Improvements in internal pharmacy processes • Improved liaison with community teams on ordering of medicines from Pharmacy and reducing waste medicines • Embedding of the EPMA system within inpatient wards and pharmacy
The new pharmacy refrigerators are now purchased and in place within Central and Summerhill Pharmacies. The former refrigerator has been decommissioned and removed, with some refurbishment of Central Pharmacy to improve the working environment. This work is also now complete. Discussions are ongoing with Estates and Facilities as well as with ICT to install remote temperature monitoring for the new refrigerators. It is intended to extend this to all wards and teams so that significant improvements in environment monitoring across the trust can be achieved.
The Trust Medicines Code has recently been revised and updated. This includes strengthened procedures on temperature monitoring with a trust wide form.
Information on waste medicines has been circulated for the first quarter of 2017. This shows that wards and teams are wasting approximately £130k of medicines per annum. Trust operational managers have been asked to support the improvement of this over the next few months. The service improvement work is almost complete for CMHTs and AOTs. Work continues with Home Treatment teams. Pharmacy staff are working with individual wards to reduce waste in these areas.
Pharmacy are also supporting the EPMA roll out to community teams which commenced at the beginning of May 2017. It is expected to be completed by end of September 2017.
The commissioning of the Robotik compliance aid filling machine in Summerhill Pharmacy is expected to be completed during May 2017. The machine will begin to be used during June 2017 formally and be in full use by end of July 2017. This will enable a faster turnaround of compliance aids by Summerhill Pharmacy and enable Pharmacy staff to provide greater support on medicines management issues to wards and teams than at present.
2. Positive & Proactive Care
Membership of the Positive and Proactive Care Expert Panel (PPCEP) has now risen to 9 clinicians. The Chair of the Panel has met with the Medical Director to discuss the operational practicalities of running the group in terms of consistent and proportional representation. The chair and co-chair are scheduled to attend the Perfect Governance meeting in May. Panel members have conducted visits at the Trust PICUs (psychiatric intensive care inpatient units) to explore the service users’ lived experience of seclusion as part of a wider Trust-wide seclusion audit, overseen by PPCEP Chair. A programme of familiarisation visits are also being developed to include panel members attending stakeholder forums such as NAC (Nursing
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Advisory Committee), MAC (Medical Advisory Committee) etc. See Me representatives are currently engaging with service users to gain their perspective of restrictive practices within the organisation. This data is informing the PPCEP restrictive practice work streams.
A project evaluation proposal is being prepared for the R&I Committee with the aims of establishing the benchmarking progress/effectiveness of the PPC agenda within the organisation in Year 1 of the Five Year Strategy and to identify service gaps for prospective quality improvement. The Trust three year Quality Strategy is now embedded in the panel’s TOR (terms of reference), as is the QA (quality account) goals for 2017/2018 outrun.
Safewards continues to be rolled out within the organisation and 18 month embedding process begins in May 2017. In conjunction with ward managers, the AVERTS team have developed an evaluation model that has been developed in conjunction with ward managers. This will be an ongoing evaluation process over the next 18 months.
3. Medical Job Planning
The restructuring of Clinical Director portfolios is now complete and clinical leads are currently being appointed to within portfolios where appropriate. Unfortunately the anticipated date for the re-build of the system of 31st March 2017 was not met and so a decision has been made to commence the rebuild without this key information and as an interim measure input Clinical Director details as an alternative. In the meantime, doctors that commence employment within the Trust are being requested to complete an interim job plan using the current system until revised templates can be issued alongside all other eligible doctors.
The Job Planning policy is also currently under review. The policy review group met on 25th April 2017 and good progress made. The Deloitte internal audit has been completed and a management response returned to the auditors. Timeframes for actions are currently in the process of being worked through and will be shared in due course.
4. Medical Appraisals
A new medical appraisal and revalidation policy was implemented on 1st May 2017. The Trust retains 40 medical appraisers to conduct Trust appraisals, the number of which is sufficient and meets the NHSE Framework of Quality Assurance for Responsible Officers and Revalidation – Core Standards.
The team are currently compiling information for the NHS England Annual Organisation Audit (AOA).The AOA is designed to assist the NHS England regional team to assure the appropriate higher level Responsible Officer that BSMHFT as a designated body has a robust consistent approach to revalidation in place, through assessment of our organisational system and processes in place for undertaking medical revalidation.
The AOA has a dual purpose to provide the required assurance to higher level responsible officer whilst being of maximum help to the Trust responsible officer in fulfilling their obligations.
The aim of the annual organisational audit exercise is to: • Gain an understanding of the progress that the organisation has made during 2016/17. • Provide a tool that helps the responsible officer assure themselves and their
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• Boards/management bodies that the systems underpinning the recommendations they make to the General Medical Council (GMC) on doctors’ fitness to practise, the arrangements for medical appraisal and responding to concerns are in place. • Provide a mechanism for assuring NHS England and the GMC that systems for evaluating doctors’ fitness to practice are in place, functioning, effective and consistent.
5. Psychology
Prevent
• 2 new Prevent co-ordinators now in post • Trust Prevent policy re-drafted and initiating consultation, hoping for ratification in July • Meetings commenced with clinical teams and professional forums • Liaison with other partners and agencies to ensure broad review of Prevent and how it is delivered • Update next month to Trust IQC
Psychology job planning
• All psychologists have agreed job plans but currently utilising different systems and approaches. • Reviewing 3 systems for job planning with aim of agreeing and implementing a standardised approach • Have explored option of psychologists using e-job planning tool for medics, however have been informed this will not be possible as it is a bespoke system. We are not aware of any other systems that can support this work electronically, but are in the process of exploring this, and the option of a locally generated system.
Workforce planning
• Considerable work has been completed in the past year relating to demand and capacity, workforce modelling, skill-mix analysis in relation to care packages, job planning and structures. This now to be consolidated into a formal workforce plan with input from Mark Ratley, Head of HR • Training for non-psychology clinical staff in low intensity clinical interventions is being offered across the Trust with challenge now to enable staff to attend and feel supported in developing and utilising these new skills
Personality Disorder
• Strategy and model of care to be consulted via professional forums during June • Following coproduction of training packages and resources now ready to pilot both in selected community and in-patient teams. • Solihull enhanced service is currently recruiting to new posts and evaluation of outcomes has commenced • PD data set now established to enable review of progress against programme objectives • Discussions with Birmingham based commissioners and partners (e.g. FTB – Forward Thinking Birmingham) regarding necessary developments to improve services and clinical pathways across Birmingham
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6. Integrated Clinical Risk Group
Clinical Risk Strategy - Work has begun looking at the interdependencies between current policies such as the CPA (Care Programme Approach) policy and the new clinical risk strategy (in development). In order to mitigate the risk of conflicting advice to staff the amendments to existing policies will be made first where these are required. Clinical Risk Tool - A second draft of a new risk tool has been prepared for group members and will be discussed in the May meeting, expecting to be consulting this on widely during June. An implementation plan will be required. Clinical Risk training - Much of the work developing the tool is also useful to inform the training review and this will report once the tool and strategy are finalised. We expect to develop a range of training resources including face to face training, e- learning and web best practice resources. Training will be also developed for non- registered staff in risk identification and assessment. Suicide Prevention -The proportion of staff who have completed training at level 1 was 75% at the end of March and rising. With regard to the audit of the last three years of suicides, this will be presented to June IQC. Level 2 training is in the process of being delivered to 8 teams throughout 2017/18. The thematic review of suicides is nearing completion and will be reported through professional forums and ICRG (Integrated Clinical Risk Group) and CGC (Clinical Governance Committee).
7. Medical Workforce
Recruitment and Agency Overview
The Deputy Medical Director is working closely with Clinical Directors to recruit and/or replace locums with substantial appointments, while maintaining safe staffing levels, to manage clinical demand in line with the current recruitment plan for medical posts. The recruitment plan is reviewed periodically at the weekly Staffing and Agency Performance meetings. Over 60% of agency shifts worked in April were due to vacancies, with the remaining shifts worked due to clinical demand and to cover absences on account of maternity or sickness.
We are currently working with the Royal College of Psychiatrists to look at the possibility of developing Clinical Fellowship roles in order to attract overseas candidates into hard to recruit posts (SAS (speciality & associate specialist) doctors and CT (core training) posts). Separately, we are exploring the use of Physician Associate Roles in order to complement the existing medical workforce and reduce reliance on agency.
As per previous update the Trust currently pays a standard pay rate of £27 per hour for all doctors undertaking out of hours internal locum work for the Trust. This rate of pay applies to all doctors irrespective of pay grade. Junior doctors currently working under the new 2016 contract are contractually obligated to undertake NHS locum work at the rates set out within the new contract (which in some cases could be lesser than the rate paid by the Trust for locum work). This has made it challenging to fill gaps with internal locums which has resulted in over-reliance on the same doctors to cover shifts repeatedly or agency doctors. The Deputy Medical Director with input from HR is currently undertaking a review on internal locum pay rates to look at options for varying existing pay rates in order to fill short term gaps on rotas internally without relying on agency. There is also a review group set up led by the Deputy Medical Director to review existing rotas with a view to streamline and reduce the number of rotas to enable effective deployment of doctors based on service need and reduce reliance on agency. A further update will be provided in June.
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Clinical Excellence Award Scheme
The Trust launched the 2016 Clinical Excellence Award Round (2016) on 2 May 2017. The application process will conclude on Tuesday 30 May 2017 (midnight) with the Employer Based Awards Committee scheduled to take place on Thursday 13 July 2017.
8. Mortality
• Over the last month there has been progress made in organising a further Mortality Masterclass for senior medics of all our Merit partners; this will take place on 3rd October at the MAC in Edgbaston; • Data collection and monitoring is ongoing with regard to mortality reporting on RiO; • Draft business case for additional resources to implement the mortality review; process is being developed and coordinated by Dr Maganty via the Mortality Surveillance Group.
9. Mental health legislation
On 4th May 2017, there was a CQC focused visit to the Trust on detentions, detention process and reduction in detentions under the Mental Health Act 1983. This has specific significance in light of the Prime Minister’s commitment to reduce detentions under the Mental Health Act. We are 1 of 12 trusts which the CQC are visiting to address the question of why detentions have been increasing year on year. They were clear that whilst the Trust would be named as one of those visited, individual issues/practices would not be identifiable. The inspectors spent the day consulting with Trust leads, commissioners, Birmingham City Council (BCC) leads, responsible clinicians and AMHPs (approved mental health professionals – social workers). An expert by experience also visited the wards to speak to patients and staff. Their feedback was not available at the briefing session.
We will receive formal feedback report within a few weeks and the official national report should be ready for September.
In relation to the Police & Crime Act, appendix 1 is BSMHFT preparedness report.
10. Conclusion
The Board is requested to note and receive this report for assurance
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Item 6.3 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD/ COMMITTEE TO BE HELD ON WEDNESDAY 31 MAY 2017
OPERATIONAL ESCALATION REPORT
Strategic or Regulatory Requirement to which the paper reports: • We will listen to and work alongside service users, carers, staff and stakeholders. ACTION • To provide the Trust Board with an update on a number of service area issues. • The Board is asked to note the issues regarding HMP Birmingham and the proposal for Simulation Modelling to commission future beds.
ISSUES
1.0 Acute & Urgent Care Services 1.1 RAIDPlus RAIDPlus Test Bed has now reached the implementation stage with Crisis Prevention Workers now working on the identified target patient cohort in order to reduce crisis across the Birmingham Community Trust, Police, Ambulance Service and in BSMHFT.
1.2 Resource Management Acute inpatient areas have been working hard to reduce agency nursing staff, and this month has seen a marked reduction in agency spend (average weekly spend on nursing agency in April was 17k and in May this is down to 6k). In addition, the service areas have increased their monitoring and introduced additional controls to manage their overall spend rate. Acute services have recently appointed 2 new Matrons (Hayley Carolan at Oleaster and Dan Lewis at Mary Seacole House) and 2 new Ward Managers (Levi Rowe, Saffron and Matt Williams, Mary Seacole Ward 2).
1.3 Capacity & Flow Acuity levels remain high across acute wards, particularly at Eden PICU. Patients who have Delayed Transfer of Care are currently at 11 (5.9%) in Adult service which is down from 12 last month. Demand for beds continues to be high and currently have 4 patients in out of area placements (1 in NHS and 3 in Private). However due to daily reviews by Clinical Directors and Associate Directors, waiting lists have been reduced to a safe, manageable level. Clinical utilisation project has now commenced.
The service area has developed a proposal in response to the Mental Health Strategies Systems Simulation Modelling, in terms of increasing bed capacity within BSMHFT. The proposal has identified 27 beds that could be commissioned for patients aged 18 years. The proposals will be detailed in next month’s FPP Estates Strategy.
2.0 Integrated Community Care and Recovery 2.1 Addictions services Solihull Integrated Addictions Service (SIAS): The service awaits formal confirmation back from the CQC on the registration of Clarity House following a formal visit on 4th May. The changes to service provision following consultation are now being implemented with all in the service providing input to both drug and alcohol misuse service users.
Recovery Near You (RNY): Two stakeholder days have been undertaken in Wolverhampton requesting input from the wider community for the upcoming tender. Staff attending from RNY gave feedback on the current service position. Commissioners have been undertaken a number of visits to RNY services in readiness for the upcoming tender, again positive feedback was given in regard to
Page 1 of 3 staff supporting these visits. The partnership board for the service met to finalise the financial outturn position of the service overall, which was slightly underspent in 2016/17.
Tenders: Unfortunately the trust were unsuccessful in the bid to manage substance misuse services in Coventry; the winning bid was from Change, Grow, Live (CGL). The Trust has been successful in getting through to the second stage of the bid for the management of Sandwell Substance Misuse services and is currently writing a bid for submission on 2nd June 2017.
Homeless primary care service: The team are currently working closely with commissioners and Cape Hill GP practice to provide regular GP sessions. As it stands the current service is only able to offer twice weekly GP sessions and prescribing is provided on the other days via nurse lead clinics. Close working and risk assessments are in place during this transitional phase with the team.
2.2 Solihull Children’s and Young Persons Service - Solar The Eating Disorder Service (TEDS) has now gone live with the children’s and young persons’ eating disorder access and waiting time standards. The team exceeded the expected threshold of 73% and are on a trajectory to achieve 76% this quarter.
2.3 Rehabilitation Rookery Gardens is nearing its completion ahead of schedule and will be in a position to commence the admission of service users from the 12th June following the refurbishment of the Ardenleigh Houses.
3.0 Specialties 3.1 Neuropsychiatry There is ongoing work within Neuropsychiatry to address waiting times and capacity within the service. Neuropsychiatry have been advised of actions required for referral and caseload management. Team members will also complete one-to-one discussions with managers to support the development of team work within the service. Facilitated sessions will be put in place to support this process.
3.2 Perinatal Care All posts have been recruited to for the perinatal project based at Birmingham Women’s Hospital (BWH). All staff should be in post by early June.
3.3 Older People A paper regarding acuity on older adult wards was presented to the May CQRG. The paper was received well and provided a broad overview of the challenges facing older adult services. It was agreed that commissioners would support a joint review of older adult service provision to look at immediate and long term issues regarding the development and sustainability of older adult services.
3.4 Birmingham Healthy Minds Birmingham Healthy Minds (BHM) are below trajectory for numbers entering treatment in month one. This is primarily due to recruitment difficulties as there is a national shortage of Psychological Wellbeing Practitioners (PWP’s). A review of workforce requirements has taken place to look at a more varied skill mix within the team. Forecasts show we will be able to recover this position in year.
4.0 Secure Care and Offender Health 4.1 CAMHS Proposals: Larimar staff have now been informed that there will be a change of use of the ward during the next 3- 4 months, subject to confirmation from Clinical Commissioning Groups (CCG’s). Staff have been assured that there are roles in the new service or existing services for them and that a detailed project timeline will be developed over the next month.
4.2 Prison: National Offender Management Service (NOMS) have now shared the draft report on the formal inquiry into the concerted disturbance at HMP Birmingham in December 2016. A response is
Page 2 of 3 required by the 26th May; this is being prepared and will be shared under separate cover.
A meeting is scheduled with the Director of Prison Services, Richard Stedman, on the 1st June with commissioners to review progress against the previous concerns raised regarding safety of staff and improving access to healthcare.
Two wings that were closed following the disturbance (L & M) are now open again; the remaining two (N & P) are scheduled to re-open from the 24th May. A new regime has been introduced which restricts association time for prisoners out of cells other than when attending work or education. This has resulted in an upturn of incidents on the wings which is being closely monitored in conjunction with G4S.
We have also received a request from commissioners to consider a further 1 year extension to the current contract for healthcare provision which would extend the existing contract to November 2019.
4.3 Staffing Changes Matt Thomas was appointed as Clinical Nurse Manager at Reaside Clinic on 17th May and will take up his position immediately. Jan Morris has been appointed CNM and will be leading the Reach Out Operational Community Team.
BOARD DIRECTOR: Brendan Hayes, Chief Operating Officer / Deputy CEO
Page 3 of 3
Item 6.4
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
PEOPLE REPORT
Strategic or Regulatory Requirement to which the paper reports • We will attract, develop and support an exceptional and valued workforce.
ACTION:
To inform Trust Board of key HR issues and performance against commitments for activity in the month of May 2017
ISSUES
The attached report asks the Board to note the following updates: 1. Staff Opinion Survey 2. Agency Reduction 3. Employee relations casework (Suspension and Employee Casework) 4. April 2017 Recruitment Equality Analysis
BOARD DIRECTOR: Brendan Hayes, Chief Operating Officer / Deputy CEO
References: Reading room: Appendix 1 - Staff Suspensions (personal information exempt under FOI S40 (2) in the Reading Room Appendix 2 - Employee Relations Casework (personal information exempt under FOI S40 (2) in the Reading Room Appendix 3 - Recruitment Equality Analysis in the Reading Room Appendix 4 – MARs Scheme (the appendices are commercial in confidence under FOI S43 (2))
Page 1 of 8
1. Staff Opinion Survey – Update on High Impact Change Number 2
The Board of Directors agreed at the March Meeting that the Trust would agree three High Impact changes in response to the Staff Opinion Survey Results. The Trust Board were briefed in April of the first High Impact Change – Health and Wellbeing, and an Annual Plan was introduced and agreed. The second of these “High Impact Changes” is to address Bullying and Harassment. This links very clearly with Key Area 6 of the People Strategy regarding Valued and Included colleagues.
As part of the commitment to tackling bullying and harassment the trust have committed actively promote a working environment that supports the rights of each individual to be treated with dignity and respect.
The Bullying and Harassment policy has been re-written, in a full consultation exercise with internal stakeholders including the Trusts Trade Unions. The reworked Policy is entitled Dignity at work”. The theory is not everyone will be bullied or harassed, but everyone will be treated with Dignity whilst they are at work. The policy will be issued on Connect for full consultation from 1 June.
The key principles are:
• encourage staff to raise concerns as openly as possible; • encourage staff to hold themselves and each other to account by challenging unacceptable behaviours; • deal with concerns identified as quickly as possible; • address matters highlighted as locally as possible; • continually improve as a result of lessons learned through our experiences; • collaborate with our staff and partners to maximise the opportunity to develop positive working environments to enable all staff to thrive and develop
In order to achieve the required change in culture, please do not believe the HR Team are not simply writing a new Policy. The team are also working on associated guidance and training which the Operational HR Team and Trade unions can influence.
The Trust will also need to:
• implement a robust communications plan to ensure all staff understand their responsibilities; • develop a new integrated Trust Code of Conduct for all staff which links to professional standards; • ensure that behavioural standards are enforced consistently through existing performance management and disciplinary processes. Review possibilities to align behavioural standards to appraisal/staff supervision or reward/career progression. • continue to obtain staff feedback about experiences through proactive inclusion focus groups and involvement in decision making to ensure the Trust tackle the real issues)
To supplement the focus on Bullying and Harassment, and Equality, Diversity and Inclusion update is provided at Section 7 of this report. There is a clear link between the Trusts approach to Bullying and Harassment and EDI. The Trust is responding to feedback received from the Staff Opinion Survey and the CQC inspection in the area of EDI. The Trust is working on implementing an annual plan to incorporate WRES, EDS2 and other Trust agreed actions. While this is being formulated, the Trust is continuing to deliver the EDI agenda, and the update at Section 7 provides an assurance update.
Page 2 of 8
Further updates will be provided in due course.
2. Agency Reduction update
This report details the April 2017 position of the Trusts use of Agency. Agency reduction continues to be a high priority for the Trust and the stability it provides to the services users within the Trusts care.
The NHSI target allocated to the Trust for Agency spend in 2017/18 is £8.105m.
The monthly spend in April 2017 is £467,751, which is £198k below the NHSI target. Comparison to similar months in previous years is strong. In April 2016 the Trust had an agency spend of £731k, and in April 2015, the Trust had an agency spend of £977k.
Overview position is attached at Appendix 1, and contains 2 tables, as follows:
• Table 1 shows the expenditure to date by month for 2017/18. • Table 2 is the comparison per month for 2014/15 – 2017/18.
The Staffing and Agency Performance Group continues to meet on a weekly basis, and considers a range of performance improvement measures, including Rostering, Resourcing, Workforce Planning and Medical Recruitment.
The Staffing and Agency Performance Group continue to strive to reduce Agency and have a targeted action plan aimed at addressing reduction further.
3 Employee Relations Casework
Please see Appendix 2 for a detailed breakdown of Staff Suspension cases.
There are 2 live suspension cases. Since the previous report to the Board, 2 suspensions cases have been concluded. The outcomes from these are no further action in relation to one case and a return to work with a commissioning manager decision on any further disciplinary process pending for the other.
Of the current 2 live suspension cases, the investigations for one of these has been concluded with a disciplinary hearing process pending and the other is awaiting confirmation from the police regarding outcome of a criminal process, prior to a commissioning manager review.
There are currently 4 lives cases which have been raised as whistleblowing concerns relating to the alleged conduct of Trust employees as follows:
a) concerns relates to the potential fraudulent behaviour of staff that are alleged to have a conflict of interest in regards to employment outside of the Trust, concerning which an internal investigation has been completed and is pending a commissioning manager review and decision. (Acute and Urgent Care)
b) a service review has been commissioned in relation to concerns regarding allegations of poor team functioning and inappropriate/unprofessional working relationships between colleagues in a position of Trust. The outcome of this process is a recommendation to the commissioning manager for further formal investigation under HR policies and procedures. (Primary Care and Dementia)
Page 3 of 8 c) allegations regarding inappropriate use of nurse prescribing privileges in external private practice. Disciplinary process placed on hold as a result of formal request by the Nursing and Midwifery Council (NMC). Currently pending NMC decision. (Integrated Care and Community Recovery)
d) a formal HR disciplinary investigation and clinical governance review was commissioned following allegations of poor managerial behaviours, a lapse in professional standards and clinical malpractice issues. Investigation report completed and due to be formally reviewed on 19th May 2017 by the management team with HR support to determine an appropriate way forward. (Secure Care and Offender Health)
3 Recruitment Analysis
The April 2017 recruitment analysis for applications and appointments by way of Gender, Disability, Criminal Conviction, Ethnicity and age is attached at Appendix 3.
4 MARS Update
The Executive Team agreed on 15 May 2017 to implement a Mutually Agreed Resignation (MAR) Scheme. The full detail of the ET report is enclosed at Appendix 4.
5 2016/17 Pay uplift
The 2016/17 1% pay uplift has been agreed and issued. Staff will receive payment in May, which will include back pay for April.
6 Organisational change
Following feedback at previous discussion in Trust Board Strategy Days, Trust Board and Trust Board Sub Committees, the Workforce Sub Committee has reviewed the ongoing Organisational Change cases with a view to allocating resources in an appropriate manner. Feedback is that, in a large number of organisational change cases which take longer than the Trust would wish to resolve. These cases are monitored through weekly Management meetings and assurance process through the Workforce Sub Committee.
Short term action has been taken, and the number of organisational change cases in the Trust has reduced from 33 in January to 20 at the time of production of this paper. The HR and managerial teams are concentrating their efforts on completing the outstanding organisational change programmes in a safe and transparent manner, and ensuring staff are supported through the change in a swift and pragmatic manner. The HR Team will continue to evaluate the effectiveness of this to inform the review of the Organisational change policy. .
7 Equality, Diversity and Inclusion (EDI)
This section of the report will provide an update of EDI activity within the Trust, and is for assurance purposes only.
7.1 NHS Employers – Diversity and Inclusion Partners Programme 2017/18
MERIT (to include Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, Coventry and Warwickshire Partnership NHS
Page 4 of 8 Trust and Dudley and Walsall Mental Health Partnership NHS Trust) has been chosen by NHS Employers to be one of the Diversity and Inclusion Partners for 2017/18.
As a partner, over the course of the year this will involve working with NHS Employers - as well as other national stakeholders such as NHS England, NHS Improvement and Health Education England – it will allow the trust to support systems to improve the robust measurement of diversity and equality across the health and social care system. This will include ensuring that we operate a systematic equality framework within our own organisation (e.g. the Equality Delivery System - EDS2 - or equivalent).
The programme will allow the Network to explore different experiences and share learning with the wider NHS and public sector. There is also an expectation that we will be actively involved in pioneering and championing many of the other measures and standards already in the system (such as the Workforce Race Equality Standard and the Accessible Information Standard) and help to implement successfully the forthcoming standards (such as the Workforce Disability Equality Standard). This will include presenting some of the work in the form of case studies or facilitating workshops or other learning forums at a national or regional level. In addition NHS Employers have organised 4 modules for the 2017/18 year. Each partner organisation is encouraged to identify two members from their organisation to attend.
7.2 Mental Health Awareness Week
Mental Health Awareness Week (MHAW) 2017 took place during the week beginning 8 May 2017. This annual event is co-ordinated by the Mental Health Foundation with the theme this year being “Surviving or Thriving”.
The focus of the week was to look at mental health from a new angle – rather than asking why so many people are living with mental health issues, the aim was to uncover why too few of us are thriving with good mental health. In recognition of MHAW the Trust promoted and delivered three Mental Health First Aid courses to staff.
7.3 Equality, Diversity and Human Rights Week
Equality, Diversity and Human Rights Week (EDHRW) took place between 15 - 19 May 2017.
Coordinated by NHS Employers it is a national platform for organisations to highlight their work to create a fairer, more inclusive NHS for patients and staff. The theme for this year was diverse, inclusive, together. A range of events open to staff, users and carers and the general public were organised-these included workshops on transgender awareness, forced marriage, female genital mutilation, and spirituality and hope. A marketplace featuring stalls representing different strands of equality was held in the main hall at Uffculme. The week also gave the Trust the opportunity to host a session with Stephen Frost, globally recognised diversity, inclusion and leadership expert. The event was well represented by trust board members and staff allowing an open and honest discussion around where we are as a Trust and what more needs to be done around inclusion. The Trust also took part in the Disability summit which was hosted by NHS employers in Leeds on 19 May 2017.
7.4 Staff Networks
Disability Staff Network
The network is pro-active and ensures staff with disabilities or impairments are represented equitably. The Finance Director is sponsor of the group. The network is about sharing best
Page 5 of 8 practice and the empowerment of staff members, supporting non-disabled staff and managers by raising awareness of issues relating to disability, ensuring that the trust benefits from disabled employees’ experience and changes policy and practice as a result. They act as a consultative group when looking to improve accessibility and as a resource for disabled staff to express their views and concerns.
The Trust recognises that equality and inclusion, although important, can be subsumed by a range of competing and urgent priorities and this is why we are reviewing the way we work and in particular how we drive our priorities across the Trust. BSMHFT actively encourages applicants who have lived mental health experiences to apply for positions within the Trust. The application of fair and transparent appointment and promotion opportunities will greatly enhance confidence of staff groups, in particular those who may have a disability.
The Dyslexia Workplace Group met throughout 2016 and continues to do so in 2017 to address and explore ways in which BSMHFT can better support staff with dyslexia. It aims to provide staff with information on where to go for support and what resources are available to them to use at work and aspires to become a staff network next year. Deborah Lawrenson, Head of Legal Services and Company Secretary is the group's Executive Sponsor.
Disability Confident Employer
The Disability Confident scheme aims to help you successfully employ and retain disabled people and those with health conditions. Being Disability Confident is a unique opportunity to overcome stigma and lead the way in the community.
The Trust has made a pledge to:
• Getting the right people for the business • Keeping and developing existing staff
The Trust attained Level 2, the Disability Confident Employer in February 2017 and is currently working on attaining level 3 (Disability Confident Leader).
BME Staff Network
Board members will be aware that it is widely accepted that BME staff in the NHS face greater barriers in attaining promotion, education and professional development. The network consists of staff from multi-disciplinary backgrounds across the trust and is an open and non-formal forum. The Chief Operating Officer and Deputy Chief Executive relaunched the BME network as the Executive Sponsor. The Trust is committed to tackling inequalities in the workplace wherever we find them. His message was as an executive team we know it’s important to realise the potential of all of our staff as their personal experiences can contribute to improving patient care.
LGBT+
BSMHFT hosted the LGBT+ network ‘Caring Minds Celebration of LGBT+ History Month’ on Valentine’s Day, 2017 for a celebration of all things LGBT+. The aim was to recognise the progress the Trust had made in workforce equality and improving the experience of LGBT+ service users, as well as reflecting on true life stories, promoting partnership working and embracing #EqualLove. The event was a great success with over 52 members attending.
Birmingham and Solihull Mental Health Foundation Trust moved up 162 places in one year to achieve a rank of 239 at the national Stonewall Workplace Equality Index 16/17. We still
Page 6 of 8 have a way to go to achieve a top 100 employer ranking, but the momentum is there and we are dedicated to making this trust a more inclusive workplace.
Stonewall held their Midlands Diversity Champions awards in March 2017. At the ceremony our Executive Director of Nursing, Sue Hartley, was named West Midlands Ally of the Year for her commitment to supporting and promoting diversity and inclusion in the Trust, particularly in relation to LGBT staff.
The Trust are due to make their Stonewall submission in September 2017 which will very much evidence the work that has been undertaken over the past 12 month with the aim to increase our index ranking.
8 Summary
This report is forwarded for assurance purposes and to provide the Board of Directors the opportunity to comment on People Management activity from April 2017.
Page 7 of 8 Appendix 1 – Agency position
Table 1 – Agency Spend 2017/18 (By Month)
April 2017 Agency Spend (£) 467,751 Target (£) 666,150 Net (£) 198,399
Table 2 - is the comparison per month for 2014/15 – 2017/18
Page 8 of 8
Item 6.5
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31st MAY 2017
DIRECTOR OF FINANCE REPORT STRATEGIC OR REGULATORY REQUIREMENT TO WHICH THE PAPER REPORTS: • Financial sustainability (underpinning strategic ambition) ACTION: The Committee is asked to note the contents of the report ISSUES Consolidated position for month 1 is a deficit of £290k, better than plan by £312k, consisting of: • Trust £290k deficit • SSL £110k deficit • Consolidation adjustment £110k surplus The key variances to year to date plan are summarised below: • Healthcare Income under recovered by £219k against plan, including expected underperformance on FCAMHS of £78k. The under recovery is partly offset by corresponding pay under spends • Other Income under recovered by £88k, offset by corresponding pay and non pay underspends • Pay under spent by £186k, including £119k through corporate vacancies and £49k due to over delivery of savings. Acute inpatient overspends are offset by vacancies in other directorates and pay underspends • Non Pay adverse variance of £94k, of which £231k is under delivery of savings. This is offset by £137k of underspend, £100k in Secure and Offender Health. • Unallocated budgets of £358k in month have not been spent, non recurrently supporting the in-year position
Savings of £8.2m have been achieved (54% of £15.1m savings requirement and 3.5% of turnover). Plans are in place for £12m of schemes. The Single Oversight Framework (SOF) scores 3, expected to improve to 2 for the full year. Consolidated capital expenditure at month 1 is £296k, £291k behind plan. A summary of key achievements, issues and developments in the Resources Directorate is provided at the end of this report, including: • Trust response to and handling of NHS cyberattack • Media activity and internal communications activity • Planning for Trust information strategy • REACHOUT activity data collection • Business development activity • Estates strategy
BOARD DIRECTOR SPONSOR: Dave Tomlinson, Executive Director of Finance References: Appendix 1: Finance Report Appendix 2: Private Finance paper available in Reading Room (the appendices are commercial in 1
confidence under FOI S43 (2))
Appendix 1 – Finance Report
Consolidated Income & Expenditure Statement
Plan Submitted Annual YTD YTD Actual Consolidated Summary monitor Budget Budget 2017/18 £000 £000 £000 £000
Income Healthcare Income 215,059 213,224 17,694 17,475 Other Income 14,081 18,751 1,564 1,477 STF Incentive Scheme - - - -
Total Income 229,140 231,976 19,258 18,951
Expenditure Pay (168,996) (169,610) (14,699) (14,512) Other Non Pay Expenditure (29,811) (25,398) (2,250) (2,334) Drugs (5,251) (5,493) (458) (437) Clinical Supplies (286) (214) (18) (51) PFI (8,447) (8,324) (694) (692) Indicative Forecast Risk - - - Unallocated Budget (4,295) (358) -
EBITDA £'000 16,349 18,642 783 925 EBITDA Margin % 7.1% 8.0% 4.1% 4.9%
Capital Financing Depreciation (6,267) (8,420) (702) (533) PDC Dividend (2,530) (2,650) (221) (211) Finance Lease (4,006) (4,006) (334) (335) Loan Interest Payable (1,592) (1,592) (133) (137) Loan Interest Receivable 70 50 4 1
Surplus / (Deficit) before impairment 2,024 2,024 (602) (290) Surplus / (Deficit) Margin % 0.9% 0.9% -3.1% -1.5%
2
Consolidated Financial Position
Healthcare Income has under recovered by £219k against plan at month 1. The under recovery is mainly due to: • expected underperformance on FCAMHS of £78k • unanticipated underperformance on: o Perinatal service £26k o Solihull NAIPS £48k o Birmingham Healthy Minds IAPT contract £66k, of which £50k is offset by pay underspends
Other Income is under recovered by £88k which is offset by corresponding underspends on expenditure. This is made up of: • £33k SIFT income shortfall • £30k in Offender Health offset by non-pay underspend • £37k in Perinatal service, offset by pay underspends • £12k over recovery in Solihull offsetting non-pay overspend.
Pay is under spent by £186k, Corporate services are £119k underspent, mainly in ICT, junior doctors (off set by other income shortfall above), estates and facilities all due to vacancies, which are being recruited to. £49k is over delivery of savings, operational directorates are £5k overspent. Of which Acute Inpatients are £240k overspent due to high acuity on the wards leading to increased temporary staffing spend, this is offset by vacancies in other operational areas, of which £90k are offset by income shortfall mentioned above.
Agency expenditure has continued to reduce since the second half of 2016/17, with an increased trend in bank expenditure as shown in the two graphs below. Current agency usage levels are the lowest for 2 years, and bank spend at the highest, due to the introduction of weekly pay for bank staff and there being two bank holidays in April 2017.
3
Non Pay has an adverse variance of £94k, of which £231k is under delivery of savings. This is offset by £137k of underspends, £104k is in estates and facilities budgets. £32k is in Offender Health against escorts and bed watches charge, the balance of £35k is spread over other operational areas which are offset by the income shortfall mentioned above.
Unallocated budgets of £4.3m, £358k in month, have not been spent, non recurrently supporting the position. These budgets contain funding for: • Healthcare income shortfall • Strategic investment • Research & Innovation • CQUIN • Non pay items to be devolved for month 2.
Capital financing is £170k underspent this is made up of consolidation adjustment of £110k, due to the different accounting methodologies in SSL and BSMHFT to give a consistent group approach.
Savings
Year to date recurrent savings of £8.2m have been achieved and removed from budgets, this is 54% of the £15.1m savings requirement and 3.5% of turnover. Two large schemes have been removed from the reported plans. These are: • Creation of a PICU on the Ardenleigh site. As previously reported NHSE have rescinded their intension to purchase the proposal for the Ardenleigh site. Further work is being carried out to replace some of this with the creation of additional Acute wards. • The main Acute and Urgent care scheme has been removed whilst a CQEIA is being carried out as it is not expected to be palatable. Progress is ahead at this stage confirmed with previous years. ICCR have achieved all their savings, other operational directorates still have £3.1m to achieve with the largest shortfall in SCOH of £1.8m. Corporate services have £0.8m still to achieve and Trustwide schemes still have £1.6m to achieve. Access to the £1.5m STF funding will be based on achieving the plan, which will operate on a cumulative basis so that if a provider misses the YTD control total in a quarter, but achieves the control total in a subsequent quarter it could receive the full amount of funding. The full £1.5m target is included in savings plans.
4
Other Resources Directorate issues/developments
ICT, Procurement, Contracts and PMO • Trust was not impacted by cyberattack because of effective arrangements already in place and the ICT team worked above and beyond to ensure we remain unaffected • No further stages are required to gain approval for Global Digital Exemplar, however a significant amount of work is required to establish baselines, project plans and associated documentation by end May • Significant improvements over last 6 months to procurement via quickest and safest method and ensuring we maximise value for money from existing frameworks • Looking to extend a contract review to ensure we have foresight of all contracts that are coming up for review over the next 18 months • The electronic document management records system specification is being prepared for tender and should go to framework in June
Communications & Marketing Recent media activity – April/May: Positive coverage • Announcement of BSMHFT as one of one of six Mental Health Digital Exemplars received a range of coverage • Publications: o Nursing Times - article on a research study into recruitment and retention of nurses in older people’s and mental health settings o BMJ - interview with Dr Amanda Gatherer about Trust approach to managing Prevent training and referrals; also mentioned the research led by Nicola Fowler in this area and an interview with Mark Rowley, national lead for counter terrorism policing o Independent Nurse - interview with Nicola Roberts, Acting Lead Nurse for Infection Prevention and Control about her involvement and the importance of the Infection Prevention Society • Made in Birmingham TV filmed a piece with our Memory Assessment Service to coincide with Dementia Awareness Week • An interview with Joanne Gill, Clinical Lead for Birmingham Healthy Minds was broadcast on 12 May student radio station, Scratch Radio
Negative coverage • HSJ ran a story about the Prevention of Future Deaths report issued by the Coroner following an inquest into the death of a service user who had been transferred to Forward Thinking Birmingham and had also been seen by RAID
Upcoming media activity • BBC 2 is due to broadcast the next series of ‘Ambulance’ shortly, which features the work of West Midlands Ambulance Service and includes our Street Triage Team • NHS England has requested to film our Mother and Baby Unit (due to take place in May)
Other activities • Stakeholder insight presentation to Board • Dragons’ Den II - launched on 5 April and closed for entries on 5 May. Eight teams to pitch their innovative ideas at two ‘Dens’ in June • Annual General Meeting and Annual Members’ Meeting – 11 July. The theme will be health and wellbeing and there will be a range of interactive stands and workshops • Quality and Excellence Awards - currently being planned, closing date for nominations 24 July, ceremony to take place in September. 5
• Listen Up conversations • Trust Talk • Walking out of Darkness • Annual report
Performance & Information • Mental Health Services Data Set (MHSDS) – final preparations for first submission of new version being undertaken • Physical health reporting – developing new reporting suite to monitor delivery of CQUIN commitments and to support clinicians with timely information • Completion of amended performance reporting for 2017-18 comprising revision of the Trust Performance Report and commissioner reporting • Service Profile Reports – intensive design and development work to design a template, which can now be used for an efficient roll out of monthly Service Profile Reports to all services over the next 6 months • Reach Out – established links with NHS England and partner organisations to review options for Reach Out activity data collection and start data quality work to establish the baseline caseload and activity position. • Trustwide information strategy – initial collaborative planning meetings held to establish scope and principles.
Information Governance • Supporting services in developing Information Sharing Protocols with other partners including MIND, Think Ahead work • Preparatory review work to develop the Trust’s work plan for the General Data Protection Regulation (GDPR) which will replace the Data Protection Act 1998 from May 2018
Estates & Facilities • Estates Strategy developed for consideration • Bank created for Domestics and Housekeepers positively addressing Agency Usage • Working with PFI providers to try and agree a number of variations and improvements • Fridge Alarms progressed at Pharmacy • Sugar Tax, CQUIN and new menus progressed. Removal of high sugar based confectionaries and drinks, alternatives provided • Transport services evaluation complete • Anti-barricade doorsets progressed at Reaside • Green Travel District/Sustainability work progressed in partnership with others • Development of internal training facility complete and officially opened • Survey undertaken of all Trust CCTV. New process agreed between IG, ICT and Estates overseen by LSMS
Planning and development • Currently actively pursuing five business development opportunities (2 at formal bid stage). Three opportunities are expected to commence procurement in next 2-3 months • Preparing official launch of Trust strategy to raise awareness, including: o Fully designed public facing document o Summary animation o Handy guide o Face to face engagement including roadshows and key meetings and events • All 2017/18 departmental business plans have been published on our business planning portal and services are being supported to further embed their monitoring arrangements
6
Item 7.1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 May 2017
Birmingham & Solihull Sustainability and Transformation Plan - MEMORANDUM OF UNDERSTANDING Strategic Ambition or Regulatory Requirement to which the paper reports: • We will work in partnership with others to achieve the best outcomes for local people. ACTION: The Board is asked to approve the Memorandum of Understanding for the Birmingham & Solihull Sustainability and Transformation Plan. Executive Summary
Background
As set out in the NHS Shared Planning Guidance for 2016/17 – 2020/2, the Parties to this MoU have agreed to collaborate in the development of a Sustainability and Transformation Plan (the STP) to transform the way that health and care is planned and delivered for the people living and working within the Birmingham and Solihull Footprint.
The attached Memorandum of Understanding (“MoU”) sets out the governance arrangements for the STP and the broad basis upon which the Parties will seek to collaborate.
It was received and agreed at the Birmingham & Solihull Sustainability and Transformation Plan (STP) Board meeting held on 8th May 2017 and is being presented for approval by the participating bodies.
Purpose and strategic objectives of the STP
With effect from the Commencement Date, the Parties have agreed to collaborate on the terms of this MoU for the purpose of working together to deliver better health and care for local people.
The strategic objectives of the STP and each STP Programme are set out in the October 2016 Submission. The Founding Parties have agreed and submitted the October 2016 Submission in the form as set out in Schedule 8 but agree that it is a living document that may be varied and updated from time to time.
The Parties will co-operate in good faith to achieve the STP Purpose and the STP Strategic Objectives.
The STP shall be established as a collaboration between the Parties, and it is not, at the date hereof, the intention of the Parties that it be incorporated as a separate legal entity.
Parties to the memorandum
The parties to the memorandum are:
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(1) Birmingham City Council
(2) Solihull Metropolitan Borough Council
(3) University Hospitals Birmingham NHS Foundation Trust
(4) Heart of England NHS Foundation Trust
(5) Birmingham Womens & Childrens NHS Foundation Trust
(6) Birmingham and Solihull Mental Health Foundation Trust
(7) The Royal Orthopaedic Hospital NHS Foundation Trust
(8) Birmingham Community Healthcare NHS Foundation Trust
(9) Birmingham Cross City Clinical Commissioning Group
(10) Birmingham South Central Clinical Commissioning Group
(11) Solihull Clinical Commissioning Group
(12) GP Consortium 1
(13) GP Consortium 2 and
(14) GP Consortium 3
Recommendation
The Board is asked to approve the attached Memorandum of Understanding
BOARD DIRECTOR SPONSOR: John Short, CEO REPORT AUTHOR: Deborah Lawrenson, Company Secretary References Appendix 1 – STP MOU – Reading Room – exempt under FOI - Information intended for future publication (S22)
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Item 9.1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD WEDNESDAY 31 MAY 2017
BOARD ASSURANCE FRAMEWORK Strategic or Regulatory Requirement to which the paper reports • NHSI/CQC risk assessment and compliance requirements, Well Led Framework
ACTION: The Board is asked to: • Note and receive the report including plans for refreshing the BAF in Q2 • Reflect on discussions on the Risk Register at Board Sub Committees to identify any further strategic risks that need to be considered for inclusion.
Executive Summary
The Internal Audit on the Risk Register and Board Assurance Framework for 2016/17 provided ‘Substantial Assurance’ and is reflected in the Head of Internal Audit Opinion received for the Annual Report.
At the request of the Audit Committee a seminar was held with the Board in April 2017, supported by Deloittes to reflect on strategic risks to delivering our new strategic objectives, with a view to developing a refreshed BAF at the start of Q2. A further seminar is planned for June to reflect on the output from the April session and to agree on risks to be included. The updated document is currently planned to be received by the Audit Committee and the Trust Board at their meetings in July.
The BAF presented this month is based around the new strategic ambitions with current risks matched against these. It should be noted however that the presentation of the BAF will be updated following the Board seminar and this version is an interim approach, designed to support committee members to begin to think about the BAF in the context of the 2017/18 strategic ambitions and risks to achieving these.
There are currently 13 red rated risks on the risk register within the categories of sustainability and quality/safety of care. When the committee last received the Risk Register and Board Assurance Framework in February 2017 there were 16 red risks. Since then 5 risks have been escalated to a red rating of 15 or above and therefore appear on the BAF. 8 have been de-escalated.
Colleagues will be familiar with the very recent cyberattack on NHS systems during May 2017. Whilst the Trust was not impacted upon as part of this attack, it has worked tirelessly to ensure that additional controls and safeguards are in place to minimise future risk based on national learning.
The Trust is a pilot member of care cert (cyber certification) and the committee should feel assured that there was a well-managed professional approach in place, with a dedicated team working across the weekend of the attack, to ensure all issues around systems, architecture, infrastructure
1 and communications with commissioners, other Trusts and NHS digital were in hand.
A verbal update on the latest position will be provided at the May Board by the Deputy Director of ICT in the Board seminar session.
Risks of 15 and above
Section 3 outlines risks of 15 and above including detail on new risks. Provided below is high level information about the newly escalated risks:
• Risk 422 (4 x 4 16) initial score 8 – There is a risk that the forensic service will fail to achieve financial savings in line with set financial balance targets. This will result in additional cost pressure to the Trust that will impact on the Trust’s overall savings target. • Risk 482 (4 x 4 16) initial score 12 – Larimar is commissioned on a cost by case basis, therefore if the unit is under-occupied there is a financial deficit. The service also has a contract which does not allow it to claim for specialing or for additional staff when service users are on additional observations. • Risk 684 (3 x 4) initial score 16 - Delayed transfers of care impact on capacity, preventing admissions to inpatient beds in a timely manner. • Risk 787 (4 x 4) initial score 9: The Northcroft and Solihull areas do not have a substantive Mental health Act Administrator with the post having been vacant for a number of months. Without a dedicated coordinator there are significant risks of sections lapsing, invalid/illegal detentions, errors in arranging tribunals and managers hearings etc. • Risk 233 (3 x5 15) initial score 9: No assurance as to appropriate access/waiting times for services and potential regulatory issues/risk of uncontrolled growth of waiting times due to not having a system in place to consistently monitor and report on all waiting times for access to services.
Further risks identified at Board Sub Committees
IQC asked that the following risks be investigated for inclusion in the risk register and BAF:
• Risk around incidents of self-harm – this is one of the highest categories of clinical instances but is scored relatively low currently on the risk register • Risk around information sharing between agencies • Risk associated with the PREVENT agenda
They asked that the risk 787 re MHA staffing issue currently scored as a 16 be potentially scored down at corporate risk level given mitigations in place.
FPP asked that the following risk be investigated for inclusion in the risk register and BAF:
• Risk around potential EPMA supplier change and adequacy of the system and processes in place to be ready for transition
BOARD DIRECTOR SPONSOR Deborah Lawrenson, Company Secretary REPORT AUTHOR: Deborah Lawrenson
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APPENDIX: Appendix 1: Board Assurance Framework Appendix 2: Risk matrix
PREVIOUSLY DISCUSSED: Local risks have been discussed through Local Clinical Governance Committees. The Trustwide register was discussed at the Clinical Governance Committee in May 2017 and at IQC and Audit Committee on 24 May 2017
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Appendix 1
Q1 BOARD ASSURANCE FRAMEWORK REPORT
1. Executive Summary
There are currently 13 red rated risks on the risk register within the categories of sustainability and quality/safety of care, which are escalated to the Board Assurance Framework (BAF).
When the Board last received the Risk Register and BAF in February 2017 there were 16 red risks. Since then 5 further risks have been escalated to the BAF and 8 have been de- escalated.
Whilst the current risks have been matched against the new strategic ambitions in this BAF report, further work is taking place on how the BAF will be presented going forward. This will include detail on further strategic risks identified by the Board.
Colleagues will be familiar with the very recent cyberattack on NHS systems during May 2017. Whilst the Trust was not impacted upon as part of this attack, it has worked tirelessly to ensure that additional controls and safeguards are in place to minimise future risk based on national learning. The likelihood score of 3 (possible) represents the possibility of risk occurrence. The risk was last reviewed by the Director of Resources on 20 March 2017 when it was noted that a range of additional actions for mitigation had been established including the plan for ICT Technical specialists to attend a certified information systems security professional course (CISSP).
At the time of writing we can confirm there have continued to be no issues and the Trust had already put a number of patches (anti-virus updates), through as part of continual updating. There are limited points of vulnerability and even if there had been a breach this would have been addressed quickly as we do not rely on third party hosts. There were no reported attacks on the service desk, AntiVirus console or evidenced in monitoring of the network. All guidelines and recommendations have been reviewed. Desktop and Server patching is ongoing and firewalls have been updated to SMB (service message block – looks for particular formats of messages and blocks them) on external connections.
The Trust has a standard approach to patches of review, test and roll-out, usually done within the month received. It should be noted this is done as quickly as possible given that a large number of patches are recalled or are shown to have adverse or unforeseen impact on other systems and therefore implementation can take time. Every time a patch is applied there is the potential for there to be an adverse impact on systems no longer talking to one another so there is a balance to be struck in terms of being risk averse to potential damage and risk tolerant in terms of not applying all patches that are received.
The Trust had 6 machines running with XP (which was the area viewed by NHS Digital as being highly vulnerable) which is now 4
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• 2 door controllers – Estates – we do not have standardisation on our systems, there would be costs attached to updating PC software and interfaces for car readers as well as cards • 2 document scanners – Finance – costs involved with moving to more modern scanners would be minimal and there is a plan to do so
There are 423 machines that are powered off and which have not yet been checked and patched, this is a level to be expected and relates to people being on leave or absent.
The Trust is a pilot member of care cert (cyber certification) and the Board should feel assured that there was a well-managed professional approach in place, with a dedicated team working across the weekend of the attack, to ensure all issues around systems, architecture, infrastructure and communications with commissioners, other Trusts and NHS digital were in hand.
A verbal update on the latest position will be provided at the May Board by the Deputy Director of ICT in the Board seminar session.
The Internal Audit on the Risk Register and Board Assurance Framework for 2016/17 provided ‘Substantial Assurance’ and this is reflected in the Head of Internal Audit Opinion.
2. Aligning our Red Risks to our Business Plan
As reported in the Risk Register, over the last six months we have seen a considerable shift in our high level risks whereby our risks now balance between two particular areas of focus for the Trust:-
• Sustainability • Quality and Safety
3. Mitigating Actions for our Red Risks
Sustainability
• Risk 479 - Significant financial risk due to under occupancy of beds, lack of appropriate referrals and contract capping by commissioners
This risk was first reported in November 2015 and has been on our high level risk register for 18 months. The current risk score is 20, suggesting that this is a risk that is occurring every day and one that is resulting in a major loss of budget with a value between £500K and £2M (source – risk management policy consequence matrix 2016). The risk was last reviewed by the team on 28 April 2017 following notification from NHSE that they will not be progressing with a contract variation for a CAMHS PICU. Alternative use options are now being explored.
• Risk 422 – There is a risk that the forensic service will fail to achieve financial savings in line with set financial balance targets. This will result in additional cost
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pressure to the Trust that will impact on the Trust’s overall savings target. Escalated risk NEW
This risk was reviewed on 28 April 2017 when the risk score increased from a moderate score to a 16. There are a range of controls in place to manage this risk however the high levels of acuity across the service area and ‘fixed’ and ‘semi-fixed’ costs inherent in the services do pose risk to the delivery of savings. The Associate Director for the area is now reviewing the scope of schemes that can be delivered based on opportunities posed via the Reach Out ACO.
• Risk 482 – Larimar is commissioned on a cost by case basis, therefore if the unit is under-occupied there is a financial deficit. The service also has a contract which does not allow it to claim for specialing or for additional staff when service users are on additional observations. Escalated risk NEW
The service is as a result significantly overspent. This risk was reviewed by on 15 March 2017 when the risk score was increased to 16 as a result of the NHSE decision relating to the CAMHS PICU proposal.
• Risk 724: There is a risk that due diligence will not be able to be completed appropriately for the Reach Out Partnership due to limited information being made available by NHSE and some data quality concerns.
Issues have been raised with NHSE both locally and nationally. This risk was last reviewed on 27 March 2017 when the score of 16 remained whilst access is given to the SMH database to allow reconciliation to take place between April and June 2017.
• Risk 747: BSMHFT will be the accountable lead provider for the West Midlands secure care budgets worth circa £105M which leads to financial risk of managing the budget
This risk was last reviewed on 27 March 2017 when the risk score of 16 remained. This risk remains on the register at this level whilst reconciliation of activity and financial information takes place during the period April to June 2017.
• Risk 748: Financial risk due to interdependency between parties resulting in potential loss of CQUIN payments if the STP does not deliver as a whole and risk to MH savings if other parties overspend
This risk was last reviewed on 27 April 2017. There are no mitigating actions documented on the register, however controls are noted to include the STP Steering Group with assurance to delivery being provided through Trust Board reports.
• Risk 774: Risk of cyberfraud enabling access to Trust systems affecting business continuity and potential loss of sensitive data to the Trust
This risk was added to the register following receipt and consideration of a report from the Local Counter Fraud Officer at the Audit Committee in November 2016. The risk score of 15 reflects the catastrophic impact that this risk could have on the Trust. Colleagues will be familiar with the very recent cyberattack on NHS systems during May 2017. Whilst the Trust was not impacted upon as part of this attack, it has worked
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tirelessly to ensure that additional controls and safeguards are in place to minimise future risk based on national learning. The likelihood score represents the possibility of risk occurrence. The risk was last reviewed on 20 March 2017 when it was noted that a range of additional actions for mitigation had been established including the plan for ICT Technical specialists to attend a certified information systems security professional course (CISSP) and will be updated following reflection on the recent national cyber fraud incident. A verbal update on the latest position will be given at the Board in May.
Quality
• Risk 320: There is a risk that the use of Novel Psychoactive Substances (legal highs) within HMP Birmingham may result in serious physical illness including seizures and cardiac problems and florid psychosis from a mental health perspective
Ultimately it could lead to death in custody. There is also an impact on prison officers and healthcare staff responding to these incidents which reduces the availability of staff to carry out other activities. Source: Incident Trends. This risk was entered by HMP Birmingham Healthcare and was first placed on the risk register in September 2015. The risk was downgraded at one stage, however a spate of incidents in the Autumn of 2016 has resulted in escalation of this risk score back up to 16 with incidents of this nature occurring on a weekly basis resulting in major injury leading to long-term incapacity / disability and/or mismanagement of patient care with long term effects. This risk was last reviewed on 9 May 2017.
There are a range of controls in place to try to manage this risk within the prison. Despite these NPS are still being received by prisoners. Following the appointment of a new Prison Director, netting has been placed not only around the perimeter of walls but also over courtyards in the new wings. This should help mitigate the likelihood of NPS being thrown over walls. Mesh is also being placed at the front of cell windows to prevent the delivery of NPS via drones. In addition, a business plan is being developed for approval by NHSE for an in-house paramedic service at HMP Birmingham which should assist with response times for medical emergencies. This has arisen from escalating NPS issues to NOMS and the Commissioners. NHSE are keen to see this business case.
• Risk 635: There is a risk that the level of violence, abuse and harassment towards healthcare staff in HMP Birmingham has increased and has now resulted in actual harm to members of staff as well as impacting upon their mental health wellbeing
This risk has been on the register since April 2016 at which point it was classified as a moderate risk with a score of 9. The risk score was reviewed following the riot disturbance at the prison in December 2016, resulting in an increased score of 16. This risk entry was last reviewed on 27 April 2017.
Whilst healthcare staff have a range of controls in place to try to manage this risk such controls are also dependant on the availability and responsiveness of G4S staff. Whilst there is a recruitment plan in place in the prison there continue to be some staffing issues within the prison which are leaving some areas of the prison feeling unsafe and
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the ability for security staff to be present at areas such as the medication hatch are being compromised. A new prison regime was put in place by the new Prison Director 2 weeks ago to gain more control and order in the Prison which includes the prison going ‘back to basics’ with a stronger structure around the release of prisoners from their cells. We have yet to see the effectiveness of these measures on incidents of violence and aggression however it is anticipated that the impact of this new regime will be more effective in the longer term.
• Risk 453: There is a risk that patients will not be able to be admitted to an acute inpatient bed within a timely manner, leading to a delay in start of treatment which could result in patients’ mental health being exacerbated
This risk was first entered on the register in March 2016 by Mary Elliffe and was last reviewed on 26 January 2017 by Samantha Munbodh. The risk score has remained at 16 through the last nine months suggesting that this risk is occurring on a weekly basis leading to mismanagement of patient care with long term effects and/or multiple complaints and/or non-compliance with national standards with significant risk to patients if not resolved. The last entry in terms of mitigating actions was made on 18 July 2016 when the following was added ‘review PDU usage and criteria with a view to using PDU as a fully functional assessment unit as an alternative to admission’. The register originally stated that this action would be complete by January 2017.
The latest review which took place on 26 January 2017 stated that this action was ‘ongoing’. We are however able to provide assurance to the Board that since our last report the Bed Management Policy for the Trust has been reviewed and ratified reflecting a range of additional controls that have been established to manage beds across our system following on from the PFD issued by the Coroner in the Autumn of 2016. Gaps in assurance relating to the mitigation of this risk relate predominantly to the challenges in assuring timely discharge of patients from wards due to challenges within the Local Authority. At the time of writing this report a further review of the risk remains outstanding and overdue.
• Risk 684: Delayed transfers of care impact on capacity, preventing admissions to inpatient beds in a timely manner. Escalated risk NEW
This risk was added to the system in July 2016 and last reviewed 15 May 2017 when the risk score increased to 15. The mitigating actions include the pilot of the ‘red to green’ initiative on Tazetta Ward and the potential roll out of this initiative to all acute inpatient services later in the Summer. Effectiveness of this initiative will also impact on risk 453 above.
• Risk 787: The Northcroft and Solihull areas do not have a substantive Mental health Act Administrator with the post having been vacant for a number of months. Without a dedicated coordinator there are significant risks of sections lapsing, invalid/illegal detentions, errors in arranging tribunals and managers hearings etc. Escalated risk NEW
This risk was added to the register in October 2016 by the Clinical Director for the service and was reviewed on 27 March 2017 when the risk core increased to 16. The
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mental health act service is currently out to consultation with the view of transferring all such posts under corporate services. Whilst the consultation reaches its conclusion, temporary arrangements have been made to provide cover to the service in an effort to eliminate risk.
• Risk 233: No assurance as to appropriate access/waiting times for services and potential regulatory issues/risk of uncontrolled growth of waiting times due to not having a system in place to consistently monitor and report on all waiting times for access to services. Escalated risk NEW
This risk has been on the risk register since August 2013 with a moderate risk score. It was reviewed on 24 April 2017 by the Information Services Team when the risk score was increased to a 15. In terms of mitigation, the team are now instigating a Trustwide internal waiting times reporting system and reporting data structures design work is underway. A target date for mitigation has been set of 30 September 2017.
4. High Level Risks removed from the Risk Register during the last quarter
• Risk 746: There is a risk that if there isn’t continued clinical and operational engagement and input from all core partner organisations, and internally within BSMHFT, there will be a significant impact on delivery of the Reach Out Programme.
• Risk 294: There is a risk that due to lack of bed availability service users will experience an undue wait for admission. This risk was entered by Imran Waheed on 1 February 2015. The risk score was originally a 12 (moderate risk) but was increased to 15 (high level risk) in July 2016 due to continued issues associated with an undue wait for access to beds. The risk was recently removed due to a duplicate risk entry (risk 453).
• Risk 641: Intermittent failure of software and hardware linked to the emergency alert pager system at Ardenleigh entered by Peter Wilson on 6 May 2016. This risk has been removed following technical resolution.
• Risk 642: The inconsistent anti barricade mechanisms across the site at Reaside Clinic could compromise patient safety. This risk has been removed following completion of all required Estates works resulting in a standardised system.
• Risk 699: There is a risk that the recent lack of runners at HMP Birmingham healthcare has resulted (at times) in only one runner being available on the healthcare wing with responsibility to both wards and the clinic area. This risk was reviewed by the Head of Prison Healthcare on 27 April 2017 when the risk score was reduced following new controls within the prison regime.
• Risk 750: There is a risk of not sharing appropriate information and of sharing information inappropriately because of a lack of an information sharing protocol and lack of regulated access to RIO by the specialist midwife and lack of access to Badgernet by the members of the perinatal team. This risk score has been reduced
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following positive developments in information sharing agreements enabling greater access arrangements.
• Risk 680:Failure to reduce mortality levels of service users. This risk was added to the risk register by the Medical Director in June 2016 following consideration of the Mazars Southern Healthcare Report and latest guidance relating to mortality amongst mental health service users. The risk score has been reduced following the implementation of the Mortality Surveillance framework and case note review system in the Trust in April 2017.
• Risk 502: Current electronic patient record does not have a dedicated safeguarding advice field. This means that there is inconsistency in the recording of safeguarding advice given to operational areas and that retrieval is difficult. This risk was added to the register on 6 April 2016 by the Head of Safeguarding and was last reviewed in May 2017 when the risk score was reduced due to new controls established within RIO. There remains an element of risk relating to records held on Illy and IAPTUS and this is under review.
5. Further Strengthening our Board Assurance Framework
The Risk Register paper outlines progress which has been made in 2016/17 in terms of capturing and updating risks and mapping these across to the Strategic aims. All risks with a score of 15 and above from significant change projects in the Trust are included on the corporate risk register and reported to the Committee and Trust Board via the Board Assurance Framework.
During the course of the year, and as appropriate, the Board has added strategic issues to the risk register which did not come up through the risk register process. However the Board agreed that further work was needed, by the Board, to ensure strategic risks, including those which are more longer term, are fully reflected. To support this, the Trust’s Internal Auditors Deloittes were asked to lead a Board seminar in April 2017 to enable further discussion on potential strategic risks to delivering our strategic objectives to take place. The output will be discussed at an additional seminar to be led by the Company Secretary in June with the aim of taking a refreshed BAF through the Audit Committee and Board in July 2017.
6. Recommendations
Deborah Lawrenson
Company Secretary
May 31 2017
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Appendix 1 BOARD ASSURANCE FRAMEWORK 2017/18
Work is underway by the Company Secretary, in support of the Board, to develop the new BAF for 2017/18 based around new strategic ambitions. This will reflect both the risks escalated through the Risk Register and risks identified by the Board as being of strategic importance. These risks identified through the recent Board seminar will be discussed in June and incorporated into the new BAF in July 2017.
Provided below for reference are the new strategic ambitions and beneath these the current BAF risks as escalated through the Risk Register.
Strategic Ambition 1 - We will put service users first and provide the right care, closer to home, whenever it’s needed
Why is this important We have a strong commitment to the quality of care. We earn the trust placed in us by insisting on quality and striving to get the basics of quality of care – safety, effectiveness and patient experience – right every time. Every day for every patient, quality should be underpinning every decision taken about care. The Five Year Forward View has a focus on early intervention, prevention and support for healthier lifestyles. We need to continue to develop integrated care and services which are delivered closer to people’s homes, reducing the need for people to travel or go to hospital unnecessarily. Service users should expect to receive flexible access and choice. Our service users should feel they are provided with the right response when in crisis with co-produced crisis plans, and their families and carers should feel supported and included in care planning. Patients should expect to receive NICE compliant, evidence based treatments and interventions that work well for mental health issues. Where are we now We have a clear, well recognised quality governance system from the frontline to Board, ranging from our service area Clinical Governance Groups up to our Trust wide Clinical Governance Committee and Integrated Quality Committee. Meetings include review of incidents, serious incidents, complaints, clinical audit outcomes, patient experience feedback and risk registers. There is a focus on lessons learnt and triangulation of issues arising from these meetings. Over the past two years we have been developing and implementing our New Dawn model of care for our adult mental health services, a service transformation based on needs and values, with recovery and service user experience at their heart. This commits to offer open access; choice of time and day of appointments, of practitioner and location; evidence based interventions, and hospital care as close to home as needed, when it is needed and only after all other options have been explored. We have many excellent clinicians with a wide range of skills and experiences in supporting service users and their families in community and hospital settings; however we would benefit from an assessment of where our specialist skills are and where we may have gaps. We have developed detailed care packages and outcome measures for the main mental health diagnoses to ensure consistency and transparency of expectations for a service user’s journey and we now need to embed these in clinical decision making and treatment. We have some excellent hospital buildings and a sophisticated range of services to support those in crisis. We have a long history of enabling people who are in contact with the criminal justice
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system, with mental illness or substance misuse. Our Reach Out partnership and new clinical model will ensure people are treated close to home in the least restrictive setting. Where do we want to be How will we get there We aspire for excellence in quality. A three year programme of work has been designed to ensure staff have the capability The feedback from our service users will say and technology to deliver high quality care we put them first. Care plans and crisis plans packages across community and inpatient will be truly co-produced by service users services. and with the involvement of families and carers (with service user agreement) Our Quality Strategy has been refreshed alongside the development of our Trust We will have introduced a systematic and strategy and will describe what we want to efficient approach to packages of care based achieve to improve safety, effectiveness and on NICE guidance, supported by helpful experience of our services. electronic tools. This will also enable service users and carers to understand what they Embedding of our Positive and Proactive can expect and make some meaningful Care strategy and safe wards programmes. choices about their treatment. Our Estates Strategy describes how we will Care will be delivered as close to home as improve the condition of the buildings we possible in the least restrictive setting, with deliver our services in, with a focus on out of area placements greatly reduced. compliance against statutory standards and enhancing therapeutic environments. We will have a clear understanding of the demand and capacity in our acute and crisis Our MERIT and Reach Out partnerships will services in order to better use resources and reduce out of area placements, reduce offer immediate and urgent support as close length of stay and ensure care is provided to home as possible, ensuring inpatient care close to home in the least restrictive setting. is only used when really needed and delayed STP demand capacity modelling will see transfers of care are minimised. where investment on mental health services We will continue to focus on important safety needs to be concentrated and where concerns, improving our approach to falls additional investment is needed. prevention, use of restraint and reducing We will implement our business plan for the suicides and acts of violence. reduction of delayed transfers of care. We will have a more robust approach to Our ICT strategy will continue its focus on clinical risk management and crisis planning introducing innovative ideas for mobile reducing in a year on year reduction of working solutions and digital applications for suicide rates. our staff to work in flexible locations to suit We will have safer and more suitable service users needs. environments for our service users and staff Our professional groups – medical, nursing, where improvements are needed. psychology and allied health professionals – We will be better at evidencing and reporting are all developing their own strategies to our outcomes, facilitated by an integrated respond to the strategic ambitions and the information reporting system. priorities for their professions. We will develop an Information Strategy; a key aim will be the implementation of a single integrated reporting system bringing together workforce, performance, quality and financial information for service intelligence. Indicative measures of success CQC rating and feedback Integrated quality, outcome, finance, workforce and performance dashboard measures Improved feedback from our service users
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Reduction in out of area placements and delayed transfers of care Reduction in incidents of physical assault on staff and service users Reduction in the numbers of suicides
Current Risks to Strategic Ambition 1
We will put service users first and provide the right care, closer to home, whenever achievement of it’s needed
Risk 774 - Risk of cyberfraud enabling access to Trust systems affecting business continuity and potential loss of sensitive data to the Trust. Updated February March 2017 Moderation 2017 Risk level 15 15 None This risk was added to the register following receipt and consideration of a report from the Local Counter Fraud Officer at the Audit Committee in November 2016. The risk score of 15 reflects the catastrophic impact that this risk could have on the Trust. Colleagues will be familiar with the very recent cyberattack on NHS systems during May 2017. Whilst the Trust was not impacted upon as part of this attack, it has worked tirelessly to ensure that additional controls and safeguards are in place to minimise future risk based on national learning. The likelihood score represents the possibility of risk occurrence. The risk was last reviewed on 20 March 2017 when it was noted that a range of additional actions for mitigation had been established including the plan for ICT Technical specialists to attend a certified information systems security professional course (CISSP) and will be updated following reflection on the recent national cyber fraud incident. A verbal update on the latest position will be given at the Board in May.
Controls (gaps) Assurances (gaps) Actions/progress
• Trust induction (gaps • Audit (gaps penetration • ICT technical specialists staff knowledge) possible) attending certified • BSMHFT have a number • Will be reviewed following information systems of measures that look at CareCert audit security professional ICT security see risk course CISSP – complete register for list • ICT carrying out security • The Trust has signed up review of ICT solutions, to UK Health cyber anti-virus, encryption, security alerts and is an data loss prevention early adopter of the NHS • Replacement of internet CareCert programme. filter solution for the This will give independent opennet and BSMHFT assurance about our domains security and highly the • BSMHFT has joined the areas where we could early adopter CareCert improve (Feb 2017) programme by NHS (gaps gap in control will Digital to access and be reviewed following the improve system level security – action plan
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CareCert audit) created and action completion underway. Audit completed.
Risk 635 - There is a risk that the level of violence, abuse and harassment towards healthcare staff in HMP Birmingham has increased and has now resulted in actual harm to members of staff as well as impacting upon their mental health wellbeing.
Updated December February April 2017 Moderation 2016 2017 Risk level 16 16 16 None This risk has been on the register since April 2016 at which point it was classified as a moderate risk with a score of 9. The risk score was reviewed following the riot disturbance at the prison in December 2016, resulting in an increased score of 16. This risk entry was last reviewed on 27 April 2017.
Whilst healthcare staff have a range of controls in place to try to manage this risk such controls are also dependant on the availability and responsiveness of G4S staff. Whilst there is a recruitment plan in place in the prison there continue to be some staffing issues within the prison which are leaving some areas of the prison feeling unsafe and the ability for security staff to be present at areas such as the medication hatch are being compromised. A new prison regime was put in place by the new Prison Director 2 weeks ago to gain more control and order in the Prison which includes the prison going ‘back to basics’ with a stronger structure around the release of prisoners from their cells. We have yet to see the effectiveness of these measures on incidents of violence and aggression however it is anticipated that the impact of this new regime will be more effective in the longer term.
Controls (gaps) Assurances (gaps) Actions/progress
None listed None listed • Staff continue to be encouraged to report incidents of this nature and not become immune to the threats • Changes to prison regime by G4S are expected to reduce the opportunities for violence and aggression. Action to review changes once they are embedded. • A new prison regime was put in place to gain more control and order in the prison (July 2016). The short term impact resulted in more disturbance but the
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impact should be effective in the long term • Ongoing shortages of G4S staff mean this is an on-going problem (Oct 16 and Jan 2017)
Risk 453 - Demand outweighing capacity for inpatient beds across the AWA and MHSOP sites. There is a risk that patients will not be able to be admitted to an acute inpatient bed within a timely manner, leading to a delay in start of treatment which could result in patients’ mental health being exacerbated. Updated Original Nov March May Oct Jan Moderation risk 2015 ‘16 2016 2016 2017 score Risk 16 16 16 16 16 16 None level Last updated on 26 January 2017
This risk was first entered on the register in March 2016 by Mary Elliffe and was last reviewed on 26 January 2017 by Samantha Munbodh. The risk score has remained at 16 through the last nine months suggesting that this risk is occurring on a weekly basis leading to mismanagement of patient care with long term effects and/or multiple complaints and/or non- compliance with national standards with significant risk to patients if not resolved. The last entry in terms of mitigating actions was made on 18 July 2016 when the following was added ‘review PDU usage and criteria with a view to using PDU as a fully functional assessment unit as an alternative to admission’. The register originally stated that this action would be complete by January 2017.
The latest review which took place on 26 January 2017 stated that this action was ‘ongoing’. We are however able to provide assurance to the Board that since our last report the Bed Management Policy for the Trust has been reviewed and ratified reflecting a range of additional controls that have been established to manage beds across our system following on from the PFD issued by the Coroner in the Autumn of 2016. Gaps in assurance relating to the mitigation of this risk relate predominantly to the challenges in assuring timely discharge of patients from wards due to challenges within the Local Authority. At the time of writing this report a further review of the risk remains outstanding and overdue.
Controls (gaps) Assurances (gaps) Actions/progress
• Commissioner • Risk register will continue • All AD's & CD's investment in a new to be monitored closely. requested to pro- female ward opened on • Bed management issues actively manage the 8/9/15 discussed daily with the beds within their area executive director of (Gaps: Demand for male operations and weekly at • Cover arrangements beds continues to be high. OMT performance for Doctors when on Commissioners and local management, Urgent leave being authority discussing delays in Care Forum and Acute introduced to ensure
15 weekly panel, the issue Care Forum. patient reviews take requires daily management). place. (Gaps: CQC IMR for February 2016 shows the • Electronic system of Trust carrying a risk relating bed management to to bed occupancy levels) be introduced to ensure; • Effective calculation of risk • Effective assessment of need for bed • Estimate length of stay
• Introduction of enhanced delayed discharge co- ordinators • Introduction of inter- agency bed management meetings, looking at delays and planning ahead • Review of PDU usage and criteria with a view to using PDU as a fully functional assessment unit as alternative to admission. Target date extended to January 2017
At the September Audit Committee it was reported that the bed management policy for the Trust was currently under review and was expected to be ratified in October. This is now in place.
Risk 320 - Risk of use of Novel Psychoactive substances (legal highs) within HMP Birmingham may result in serious physical illness and florid psychosis from a MH perspective which ultimately could lead to death in custody. Impact on prison officers and healthcare staff responding to these incidents
Updated September October February May 2017 Moderation 2016 2016 2017
Risk level 12 16 16 16 None
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Last updated 9 May 2017
Ultimately it could lead to death in custody. There is also an impact on prison officers and healthcare staff responding to these incidents which reduces the availability of staff to carry out other activities. Source: Incident Trends. This risk was entered by HMP Birmingham Healthcare and was first placed on the risk register in September 2015. The risk was downgraded at one stage, however a spate of incidents in the Autumn of 2016 has resulted in escalation of this risk score back up to 16 with incidents of this nature occurring on a weekly basis resulting in major injury leading to long-term incapacity / disability and/or mismanagement of patient care with long term effects. This risk was last reviewed on 9 May 2017.
There are a range of controls in place to try to manage this risk within the prison. Despite these NPS are still being received by prisoners. Following the appointment of a new Prison Director, netting has been placed not only around the perimeter of walls but also over courtyards in the new wings. This should help mitigate the likelihood of NPS being thrown over walls. Mesh is also being placed at the front of cell windows to prevent the delivery of NPS via drones. In addition, a business plan is being developed for approval by NHSE for an in-house paramedic service at HMP Birmingham which should assist with response times for medical emergencies. This has arisen from escalating NPS issues to NOMS and the Commissioners. NHSE are keen to see this business case.
Controls (gaps) Assurances (gaps) Actions/progress
• Education of healthcare • Reduction in incidents • Prison Drug Strategy is staff involving NPS completed • Notice to prisoners to • All incidents involving the • The number of incidents raise awareness of use of NPS are reported is increasing and was dangers of NPS use on eclipse discussed at a recent • Signage providing • External visits/coroners regional G4S conference awareness of risks recommendations require but locally the actions • Discussions at prisoner G4S to maintain a vigilant taken by the prison have forums approach to NPS not been sufficient to • Psycho-education via • (Gaps - Not all prisoners resolve it. DART team will read or take notice of • To develop a business • Information to all the risk information case for an in house prisoners at point of provided. It is not within paramedic service – this reception our remit to effect the has arisen from • The risks are monitored change required by the escalating NPS issues to at HMP CGC and at the coroner on G4S) NOMS and the partnership board Commissioners. NHSE • G4S have introduced are keen to see this netting at points around business case. the perimeter wall which • Amended wording to catches drugs being incorporate risk 321 thrown over the wall • (Gaps - NPS continues to be available in the prison despite searches and information risks. The netting is not around
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all of the wall)
Risk 422 - There is a risk that the forensic service will fail to achieve financial savings in line with set financial balance targets. This will result in additional cost pressure to the Trust that will impact on the Trust’s overall savings target. Escalated risk NEW
Updated April 2016 January 2017 April 2017 Moderation
Risk level 8 8 16 None
This risk was reviewed on 28 April 2017 when the risk score increased from a moderate score (8) to a 16. There are a range of controls in place to manage this risk however the high levels of acuity across the service area and ‘fixed’ and ‘semi-fixed’ costs inherent in the services do pose risk to the delivery of savings. The Associate Director for the area is now reviewing the scope of schemes that can be delivered based on opportunities posed via the Reach Out ACO.
Controls (gaps) Assurances (gaps) Actions • SFIs • Monthly reports • To review scope of • monitored and non- Active budgetary control schemes based on recurrent savings within all departments opportunities via Reach • maximised where Vacancy review Out • Strategic plans in place possible (gaps – limited involvement development scope for additional of forensic pathway savings due to high levels • PMO initiative in SITU of acuity across the (Gaps – implications of service area and overall Trust CRES proportion of ‘fixed’ and programme not being ‘semi-fixed’ costs inherent delivered and additional in the services) targets being imposed late in financial year with little scope to deliver in year)
Risk 787 - The Northcroft and Solihull areas do not have a substantive Mental health Act Administrator with the post having been vacant for a number of months. Without a dedicated coordinator there are significant risks of sections lapsing, invalid/illegal detentions, errors in arranging tribunals and managers hearings etc. Escalated risk NEW
Updated October 2016 March 2017 Moderation
Risk level 9 16 Potential mitigation to corporate score taking place
This risk was added to the register in October 2016 by the Clinical Director for the service and was reviewed on 27 March 2017 when the risk core increased to 16. The mental health
18 act service is currently out to consultation with the view of transferring all such posts under corporate services. Whilst the consultation reaches its conclusion, temporary arrangements have been made to provide cover to the service in an effort to eliminate risk.
Controls (gaps) Assurances (gaps) Actions/progress
• MHA administrative • The team of MHA • The MHA service is assistant acting up from administrators have been currently out for April 2017 for the MHA informed of cover consultation with the view administrator who arrangements (gaps if of these posts coming covered Northcroft and one or more MHA under corporate Solihull. An admin administrators falls • The VR form for the member of staff has been ill/takes annual leave) vacancy pertaining to employed via the bank to North was submitted in assist the acting up March. The VR form for administrator (gap the the vacancy within member of staff on the Solihull was submitted in bank may not be fully August 2016 but was conversant with the MHA placed on hold due to and will require training. senior operational The acting up managers decision. administrator may fall ill • In March the Clinical and or take annual leave. Governance Committee Another MHA agreed the original score administrator will be was incorrect and it was required to cover in those amended to 4 x 4 circumstances
Risk 233 - No assurance as to appropriate access/waiting times for services and potential regulatory issues/risk of uncontrolled growth of waiting times due to not having a system in place to consistently monitor and report on all waiting times for access to services. Escalated risk NEW
Updated August 2013 April 2017
Risk level 9 15
This risk has been on the risk register since August 2013 with a moderate risk score. It was reviewed on 24 April 2017 by the Information Services Team when the risk score was increased to a 15. In terms of mitigation, the team are now instigating a Trustwide internal waiting times reporting system and reporting data structures design work is underway. A target date for mitigation has been set of 30 September 2017.
Controls (gaps) Assurances (gaps) Actions/progress
Trust processes established • Trust process and • Instigate trust wide for IAPT and FEB national routine tracking of internal waiting times standards and teams have patients accessing reporting – reporting
19 individual access to RIO IAPT and FEP in data structures design waiting time information for place. Manal monthly work underway new referrals and people checking of young • Review details they explicitly assign to a RIO people’s eating populated by the waiting list. But RIO module disorder waits in Governance has errors and is therefore place. For overall Intelligence team – not reliable ( no routine waiting times, reviewed. Action plan corporate level reporting of currently no routine already in place and waiting times as a whole and systematic processes progress will start to no availability of information in place (gaps no be made from May on total waiting times where routine overall 2017 people have been passed processes exist that between teams. Need to can be assured) finish establishing more robust reporting for young people’s waits for eating disorder services in response to new national standard
Risk 684 - Delayed transfers of care impact on capacity, preventing admissions to inpatient beds in a timely manner. Re- Escalated risk NEW
Updated July 2016 January 2017 May 2017 Moderation
Risk level 16 16 15 None
This risk was added to the system in July 2016 and last reviewed 15 May 2017 when the risk score was reviewed in terms of both likelihood and impact resulting in a score of 15. The mitigating actions include the pilot of the ‘red to green’ initiative on Tazetta Ward and the potential roll out of this initiative to all acute inpatient services later in the Summer. Effectiveness of this initiative will also impact on risk 453.
Controls (gaps) Assurances (gaps) Actions/progress
• Bed management • Meetings in place and • Pilot of red to green meeting identifies situation monitored initiative on Tazetta people who are going regularly ward – July 2016 – to have barriers to • Escalation to reported to be discharge at an early commissioners via completed in May stage, which prevents the weekly bed 2017 DTOC management meeting • To evaluate the pilot • All ward managers and the daily with a view to rolling it are proactively escalation call out across all acute challenge to ensure regarding older adults services plans are followed and weekly through commissioner/director • These are followed up level conversation
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at the following • Reported to Trust weekly meeting to Board, A & E Boards ensure movement and contract review • Discharge liaison meetings (gaps no nurse dedicated to clear recruitment and acute services (gaps retention plan – risk is the currently in place for responsibility of wider medical cover – organisation, however operating on high our team are levels of locums at expected to escalate present, which in turn issues and have has an impact on processes in place for financial balance) monitoring and managing for all, which is not feasible • There is currently no robust process in place to monitor ward rounds and or medical cover • There is no DTOC policy in place for the Trust to follow • No dedicated social worker as part of MDT • Lack of funding to support refugees and asylum seekers
Risk 482 - Larimar is commissioned on a cost by case basis, therefore if the unit is under-occupied there is a financial deficit. The service also has a contract which does not allow it to claim for specialing or for additional staff when service users are on additional observations. Escalated risk NEW
Updated November 2011 May 2017 Moderation
Risk level 12 16 None
If we are under occupied there is a financial deficit. The service also has a contract which does not allow it to claim for specialing or if multiple patients are on observations. The service is as a result significantly overspent and under review. This risk was reviewed by on 15 March 2017 when the risk score was increased to 16 as a result of the NHSE decision relating to the CAMHS PICU proposal.
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Controls (gaps) Assurances (gaps) Actions/progress to date
• Referral system in • Referral meeting (Gaps • NHSE have confirmed place to ensure we unable to control the that they will not proceed complete gateways number of referrals) with a contract variation. • Promotion of the • Agreement in October PICU will have to go service e.g setting up 2015 to spot purchase up through formal website, letters to to 10 beds (Gaps – procurement. Trust Board community predicting demand for are due to make a consultants additional beds) decision on future of • Effective discharge Larimar. planning and spot purchase will allow an increase of beds to 10 which will help manage periods of under occupancy (gaps – number of referrals is governed by clinical need and commissioners)
Risk 479 - Significant financial risk due to under occupancy of beds, lack of appropriate referrals and contract capping by commissioners. We have a gap between health care income and expenditure Updated Original November September October April Moderation score 2015 2016 2017 2016 Risk 16 16 20 20 20 None level
This risk was first reported in November 2015 and has been on our high level risk register for 18 months. It was last updated on 28 April 2017. The current risk score is 20, suggesting that this is a risk that is occurring every day and one that is resulting in a major loss of budget with a value between £500K and £2M (source – risk management policy consequence matrix 2016). The risk was last reviewed by the team on 28 April 2017 following notification from NHSE that they will not be progressing with a contract variation for a CAMHS PICU. Alternative use options are now being explored.
Controls (gaps) Assurances (gaps) Actions/progress • Chair of national • Continue to explore • NHSE have referral meeting alternative avenues confirmed they will potentially increase not be progressing
access to appropriate with a contract
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referrals variation for a CAMHS PICU, • On medium and low alternative options will secure NHS Wales have to be sought Framework
• Planned links with Parkview Place of Safety • Exploring Republic of Ireland Youth Justice and Welfare System • Visit and market to Wetherby YOI • Pursue tender for Leicester secure college when available • Closure of one ward to manage staff resources • Liaison with FTB (Gaps- Reducing population within the custodial setting) • Awaiting 2016-17 contracts and procurement opportunities with NHSE later in year (*Gaps – This is not yet an assurity)
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Strategic Ambition 2 - We will listen to and work alongside service users, carers, staff and stakeholders
Why is this important A strong theme throughout Five Year Forward View is listening and learning, and this is fundamental to a strong governance framework to ensure safe, effective, responsive, caring and well led services. We need to understand what people’s experience of our services are to make sure that we are continually improving to meet their needs, that we are addressing poor experiences and that we are preventing avoidable harm. This involves listening to our service users, families, carers, staff and stakeholders and involving them in planning, developing, delivering and evaluating our services We don’t just need to listen, we also need to learn and act on our feedback. This includes looking at common themes across our incidents, concerns, complaints and outcome measures and ensuring we have mechanisms for sharing learning across the whole of our Trust. Our staff are our greatest asset and valuing them by listening resonates with our values. There is also strong evidence that an engaged workforce delivers better care and is more efficient. Our partnerships are very important to us and we need to understand what our partners think of us and how we can work better together. Where are we now We have a wide range of ways of regularly listening to our service users, carers and their families, although we believe this can still improve further, particularly in relation to carer involvement and engagement. We are proud of the mechanisms to routinely listen to service users, via the friends and family tests as well as focus groups and in-house forums and surveys. We have implemented new ways to share learning across our Trust, including “It takes three” videos, lesson learnt bulletins and lesson learnt lunches. We have an active group which drives forward new initiatives based on the findings from our staff survey and we have an improving relationship with our union representatives. Some of our service areas have active staff forums, although other areas need to learn from their effectiveness. Our bespoke “Proactive Partnership” staff-engagement initiative has seen a refresh of listen- up and team engagement approaches with good levels of participation by staff. We have recently commissioned an independent review of stakeholder views about our organisation and our Trust Board will be reviewing this feedback and creating a responsive action plan to improve stakeholders’ perceptions of us. Where do we want to be How will we get there We want people to say we are listening and Our Quality Strategy, developed alongside acting on what they tell us, evidenced by the this strategy, describes the actions we will staff and service user surveys. take to: We will have an embedded culture of co- • Continue to develop and implement design and co-production of service our mortality review process. pathways and programmes designed to • Further develop our lessons learnt improve the patient experience. framework. We will live by our values of honesty and • Develop and implement our openness, with a culture of transparency framework for co-production of service improvement initiatives.
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where staff, services users, carers and • Support teams to introduce new stakeholders feel safe to raise views and ideas and make changes as a result concerns. of feedback. We will learn lessons from those people and We will refresh our Carers Strategy, to organisations that do things well, as well as describe our approach to identifying, those who don’t. communicating and supporting carers. We will integrate learning from a range of Through our successful Proactive sources and ensure that lessons are offered Partnership we will continue our focus on in a range of ways to suit both the lesson staff engagement through regular ‘Listen Up’ and the audience. events with our executive directors, regular We will have an embedded mortality review recognition schemes and awards, increasing process and will engage with families and the visibility of senior leaders across the carers in the investigation of deaths of family Trust, and increasing the visibility of various members. routes to raise concerns including Dear John and the Freedom to Speak Up Guardian. We will have coherent and comprehensive approaches to actively involving carers, with We will develop new targeted channels and a clear understanding of our duty of care and methods to engage our stakeholders and sensitive approaches to confidentiality. have a greater focus on engaging and communicating with stakeholder groups. We receive positive feedback from our stakeholder groups about our reputation and how we engage and involve them. Indicative measures of success Quarterly pulse check of staff, service user, carers and stakeholder views. Improved scores on staff survey Improved scores on service user survey Numbers of people attending engagement events Systematic involvement of service users and carers in our incident and mortality investigations
Strategic Ambition 3 - We will champion mental health wellbeing and support people in their recovery
Why is this important Service users with mental health needs are people first. They come with lives and histories as well as aspirations and strengths. Evidence and service user stories have shown the importance of supporting people to live fulfilled lives even if they still have times when things are not so good. The recovery journey for someone with a mental health problem is about living hopefully and taking control over their problems and their life. Steps towards recovery will involve building a new sense of self, meaning and purpose and growing beyond what has happened, as well as pursuing dreams and ambitions. Independence can be eroded by long standing health issues and services need to be designed to support service users maintain and develop life skills, employment and housing. People who have mental health issues can be stigmatised. This is even worse for those who are poor or experience prejudice for other reasons such as their ethnicity, gender or sexual
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preference. The Five Year Forward View recognises that physical and mental health are closely linked and that over the next five years the NHS must drive towards an equal response to mental and physical health with the two being treated together, the ambition being to achieve genuine parity of esteem by 2020. Where are we now Through our recovery model we have developed peer support roles and a recovery college to widen opportunities for learning and support for staff, carers and service users. We recognise we need to want to further develop our recovery college to ensure it is embedded into our Solihull community. We have developed “Recovery for All” e-learning for our staff. Recovery is one of the clinical priorities of our MERIT partnership and we are exploring together how we can embed recovery as ‘ordinary business’. We have a strong community engagement focus, with varied examples of working with diverse groups and communities to reduce stigma including mental health first aid awareness training. We are piloting Individual Placement Support workers working alongside our multidisciplinary teams in forensic and community mental health services to support our service users in their efforts to achieve steady employment. The life expectancy of those with mental illness is lower than the national average. Higher levels of poverty, smoking and obesity contribute to this. We have physical health clinics and a range of approaches to tackle physical health needs. We have rolled out smoke free across all our sites and are working to support service users. As part of our New Dawn model we launched our new community hub at Northcroft in Erdington. Our community hubs have recovery at their heart and are a focal part of the community. As well as offering our community services and specialist interventions, they are a way for our staff to work with partners from a range of other local organisations. We have a range of rehabilitation services which, whilst delivering good care, are sometimes in unsuitable buildings, with limited opportunities to actively promote independence. Where do we want to be How will we get there We will embed a recovery culture through Our Recovery Strategy will be refreshed, to everything that we do. This will include consider how we can further embed recovery further expanding our Recovery College offer across our services, how we can work with to provide more sessions in more locations, our MERIT partners to learn and develop and obtaining accreditation. together, how we can measure outcomes related to recovery and how we work We will increase the number of trained and effectively with third sector partners in the employed peer support workers. recovery journey. We will be an advocate for mental health We will continue to increase our numbers of issues, both locally and nationally, to reduce peer support workers, and will develop a role stigma and increase opportunities for people for the carer peer support worker. with mental ill health. We will develop relationships with an We will focus on partnerships which improve accredited Individual Placement Scheme life-chances for people with mental illness, (IPS). We will evaluate the effectiveness of reducing stigma and health inequalities. the IPS worker pilots and roll this out across We will offer an exceptional range of support other services in the Trust. which intervenes directly with mental illness Our Community Engagement workplan will while helping people stay well and safe. We target communities at risk of greatest stigma, will support and signpost people to other hard to reach groups and those groups who choices. Wherever possible we will do this by are underrepresented in our services. working with the strengths and uniqueness of
26 individuals, friends and families and the We will refresh and implement our Physical wider community. Health Strategy, including routine reporting on physical health, making physical health a We will offer rehabilitation services in less factor in clinical decision making, developing restrictive environments. This will promote the skills and competencies of our workforce opportunities for supported and independent in the improvement of physical health living even for people who will always live interventions and provision of physical health with symptoms. opportunities and activities for patients. We will ensure that improving the physical We will work with our partners to develop health of our service users becomes “second approaches to integrated personal nature” and all clinicians are taking commissioning which will enable service responsibility for assessments and users to make clear choices about the interventions, even when people are in crisis. support and care they need and be able to Where possible we will treat physical health pay directly for it, even if the choices are not at the same time as mental health. In traditionally viewed as “healthcare”. partnership with primary care. We will further integrate our community services in community hubs. We will offer comprehensive assessments, leading to recovery goals; meaningful care plans including evidence based packages of care. We will redevelop the Ardenleigh houses into an adaptable safe and modern accommodation, offering some settings with high levels of support and some where people can live independently in flats, accessing help on their own terms if needed. Indicative measures of success • Increased numbers in employment, education or training • Increased number of recovery college sessions run and numbers of attendees • Increased numbers of peer support workers • Reductions in levels of smoking and obesity • High and improving scores on the Patient Reported Outcome Measures (ReQol) • % of people managing personal budgets • % of people currently in rehabilitation facilities living in either supported or completely independent settings. • % of people with protected characteristics accessing our services at the right time.
Strategic Ambition 4 - We will attract, develop and support an exceptional and valued workforce.
Why is this important Our staff are our greatest asset and our most visible and important ambassadors. We have a varied, dedicated, passionate and talented workforce of over 4,000 staff. Without our staff we could not deliver the diverse range of services we provide. There is compelling evidence that NHS organisations in which staff report that they are engaged and valued deliver better quality care. Highly engaged employees are healthier and happier, with lower sickness absence, lower staff turnover and a higher propensity to deliver high-quality care. Highly engaged employees are more likely to intervene to raise concerns about safety or address poor behaviours. They also make better use of resources and are more likely to think creatively and innovate. When staff do not feel well informed about what’s happening, it leads to lack of trust and reduced morale.
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We need to empower people across the organisation and at all levels to be able to communicate the values and ambitions of the Trust and celebrate our successes and achievements. Our workforce need to be equipped with the right skills, knowledge and experience to deliver high quality care and services. We need to have strategies in place to ensure we recruit the right staff, provide them with training and development opportunities and retain them. We need to have a flexible workforce that can adapt to new ways of working in the future. Where are we now We have many successes about our workforce, including increased use of apprenticeships and volunteers and the introduction of new roles such as peer mentors, nurse consultants and advanced nurse practitioners. We have invested in the time we spent training our staff and how we make this as efficient and effective for staff as possible. Over turnover and our spend on agency staff has reduced substantially. The results of the NHS national staff survey, which took place between September and December 2016, have shown that we have maintained the majority of our scores from the 2015 survey, with 28 of the 32 key findings showing no statistically significant change. In one way this is good, however standing still is not where we want to be. We know from feedback and engagement that the past year has been a challenging one for staff. There were the changes resulting from the transfer of nearly 5,000 patients to Forward Thinking Birmingham and the implementation of the New Dawn model, as well as the introduction of savings plans and new partnerships that involve working in a different way. In this context, the fact that we have maintained our scores during a period of such change is testament to the commitment of all our staff to working together to make changes for the better. The survey has shown us that we have considerable work to do in a number of key areas where we are still not performing as well as we would like, and we need to place particular focus and energy on really making a difference on some of the key themes raised in the survey. These include bullying and harassment, equal opportunities, team working and health and wellbeing. Where do we want to be How will we get there Quite simply, we want to be in the top Our People Strategy has been developed at quartile of trusts for the NHS staff survey by the same time as this Trust-wide strategy. 2020. This is underpinned by a detailed People Plan with actions and milestones to ensure We want to have a world class culture and to we achieve our key aims shown opposite. be the employer of choice for all staff who Key to this will be enabling a Leader Led wish to work within a mental health trust, and organisation and robust workforce planning aspire to be a ‘top 10 NHS trust’. supported by accurate, relevant and timely We will have sustained resourcing, with workforce information. improved workforce information, planning Our Organisational Development workplan and resourcing to understand the nature of will support the People Plan and will provide our workforce and support decision making targeted support to our major projects and as well as new roles and ways of working. developments, as well as supporting the We will have strong management practice so improvement areas highlighted in the staff all our managers are accountable and survey. effectively supported in the delivery of their A set of standards will be developed to role, managing performance and facilitating demonstrate excellent team working and teamwork. performance against our behavioural profile. We will have built a capable workforce where Every team will have a development plan all staff will have access to Learning and against these standards. Development opportunities to enable them in A new strategy for Communications and their roles and can develop their careers to Marketing has been developed alongside
28 their fullest potential, enhancing this strategy. This will ensure that staff will be compassionate leadership with staff feeling well-informed and engaged about listened to. developments inside and outside of the Trust and their achievements will be recognised We will support and promote the health of and celebrated. our staff. All staff have access to a range of information and services to enable them to ProActive Partnership approaches will be stay healthy. used to tackle Trust wide issues raised in the staff survey, for example bullying and We will be an inclusive, fair and harassment, equal opportunities and health representative employer, valuing all of our and wellbeing staff. Implementation of our dignity at work
approach, which is designed jointly with trade union colleagues, to reduce bullying and harassment in our organisation. Indicative measures of success Improvements in staff satisfaction measured through: • Quarterly pulse checks • National NHS staff survey Named as one of the top organisations to work in Meeting or exceeding targets set for a suite of workforce key performance indicators measuring turnover, training and promotion Every profession has a career plan Our workforce is representative of the communities we serve Numbers of apprenticeships, volunteers and experts by experience in paid roles
Strategic Ambition 5 - We will drive research, innovation and technology to enhance care.
Why is this important Research is essential to find out which treatments work better for patients. It plays an important role in discovering new treatments, and making sure that we use existing treatments in the best possible ways. It can find answers to things that are unknown, filling gaps in knowledge and changing the way that healthcare professionals work. Research and clinical trials are an everyday part of the NHS. People being cared for in the NHS benefit from past research, and continue to benefit from research that is currently being carried out. Ultimately, high-quality clinical research helps the NHS to improve patient outcomes for both now and in the future. We use the definition of Innovation as, “An idea, service or product new to the Trust or applied in a way that is new to the Trust, which significantly improves the quality of health and care wherever it is applied.” This is the definition as described in, Innovation, Health and Wealth (DH, 2011) which explained the importance of innovation to the future of the NHS in three key ways 1) it transforms patient outcomes, 2) improves quality and productivity and is good for economic growth. Using technology effectively is an enabler in many ways. It can ensure our clinical staff will have intuitive systems that provide information needed to make sound decisions and deliver excellent care and outcomes. It can offer opportunities for staff to see service users in a range of settings and for patient-held records. Our service users want to take ownership of their health and care information, updating directly into their care record and interacting with
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us. Where are we now We are currently leading the way in developing mental health research and innovation (R&I) across the West Midlands, securing on average £2 million a year in research and innovation grant income to deliver locally led projects. We recruit an average of 700 service users and/or carers into NIHR (National Institute for Health Research|) portfolio trials each year and produce an average of 90 publications in peer reviewed journals. BSMHFT publications are regularly cited in national guidelines (NICE). We have a long history of developing and delivering innovative services from functional community mental health teams such as Assertive Outreach to RAID liaison mental health services. We also continually strive to provide the latest technologies where possible to staff members to ensure their administration tasks can be delivered as efficiently as possible including electronic care records, mobile working, digital dictation, e-expenses. We are delivering RAIDPlus as part of the national Test Beds programme which aims to predict and prevent mental health crisis through a combination of predictive technology, online support tools and visual demand and capacity management systems, with the introduction of a mental health urgent care coordination centre and training unit. Where do we want to be How will we get there We want to be at the forefront of clinical We will deliver a cultural awareness plan research and innovation in Mental Health around R&I for our staff and service nationally competing with the large research users to ensure it is business as usual. active centres. By working closely with key stakeholders We want to develop local Principle we will develop joint posts to enhance Investigators to develop research that is our academic and/or commercial important to our local population (service standing and to contribute to improved users and carers) and generalizable for the health and wellbeing. wider NHS and to provide all staff with We will create opportunities to support opportunities to be involved in research. new innovators to develop ideas and We want to empower our staff to develop (where appropriate) source ideas in a structured way; to provide more funding/support. vehicles for staff members to tell us not only We will cultivate the next generation of their innovative ideas but also about researchers, supporting and incentivising to problems that innovations would help solve develop locally led research to improve to enable us to identify and test potential patient outcomes. innovative products and solutions to improve patient care and outcomes. Running an R&I Department that offers career progression from entry level We want to attract leaders in NHS research through to senior management positions and innovation and retain a highly trained in clinical and non-clinical positions will and motivated workforce that drive quality ensure longevity and retain an excellent based on the latest evidence ensuring we workforce. continually improve the outcomes of our service users. We willimplement our Paperless Strategy and develop a full Electronic Document We aim to be a digital trust - a paperless Management system. organisation by 2020. We want to have digital clinicians, working in digital hospitals, We will deliver an electronic care with digital patients, alongside digital pathways tool in the Trust Electronic communities. Patient Record system, RiO, enabling a consistent approach to care planning and reporting. Indicative measures of success
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By 2020 we will regularly be: • bringing in £4+ million a year in quality research and innovation grants • producing in excess of 100 publications in quality journals per year • recruiting an average of 1000+ service users and/or carers to NIHR portfolio trials to contribute to new knowledge and/or offer ‘better than standard’ treatment When asked, our staff and service users will know that we are a leader in Mental Health Research and Innovation and understand that R&I leads to improved outcomes for all service users Patients, carers and staff members will have access to the latest technologies and service provision which has been proven to support mental health recovery and improve service quality and outcomes for patients. Productivity within the organisation will be at optimum levels and income generation through innovative development and practice will further support delivery of excellent care.
Strategic Ambition 6 - We will work in partnership with others to achieve the best outcomes for local people.
Why is this important The Five Year Forward View emphasis that in order to create a better future for the NHS, we must make changes to how we live, how we access care, and how care is delivered. This means more preventative care, finding new ways to meet people’s needs, and identifying ways to do things more efficiently. We recognise it is difficult in isolation to make an impact at the scale needed to effect change and achieve productivity, cost savings and long term viability. We need to be working in collaboration to support people well. This brings clear quality benefits, by pooling expertise and best practice to improve outcomes and consistency of treatment across organisational and geographical boundaries to service the needs of our local population. Our patients journeys do not start or end with our services and effective partnership working is needed to make sure care is joined up to ensure quick access to our services when needed, that support is available on the pathway to discharge and that people can re-access our services if necessary. Some partners need our passion and expertise in mental health to better meet their own objectives too. Where are we now We have been at the forefront of the development of new care models. We were instrumental in the development of MERIT, the only mental health vanguard. Working with three of our local mental health trusts we are developing region wide approaches to shared bed management, information systems, workforce solutions and recovery models. Our Reach Out partnership was announced in 2016 as one of the first new care model sites to pilot the management of tertiary care budgets for adult secure care, with the intention of going live from 1 April 2017. Working with our core partners, South Staffordshire and Shropshire Healthcare NHSFT and St Andrews Healthcare, and a range of third and independent sector recovery partners we will move to a pathway focussed model of care with increased forensic outreach provision in the community to enable earlier discharge from inpatient services and care delivered closer to home in the least restrictive setting. Through implementation of our New Dawn model of care we have enhanced relationships with primary care, for example, providing Advanced Nurse Practitioners working out of GP practices. We also work closely with the health exchange around managing diabetes. In our community hubs we have evolving partnerships with third sector organisations, for example BITA Pathways to support our service users to gain employment and Citizens Advice Bureau
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delivering sessions around benefits and finances. As well as working with MERIT, we have a number of ongoing projects with other digital partners to enhance our use of technology and how this can deliver efficient patient care and improved outcomes. These include our electronic patient record supplier Serverlec, the patient-centric work with RAIDPlus, predictive analytics with Telefonica, developing portals with PKB and development of our electronic prescribing and medicines administration system with EMIS. We are developing partnerships to underpin our support for staff, including educational partnerships with Birmingham City University and work with dyslexia charities. Our Sustainability and Transformation Plan and the Mental Health Commission of the West Midlands Combined Authority facilitate collaboration across health and care systems to benefit people with mental health needs. Where do we want to be How will we get there We want to be the “partner of choice” for Implement the MERIT workplan for 2017/8 mental health services, to be seen as and develop the provider relationship and working equally well with third sector commitments further into 2018/9 and organisations, other health sectors and beyond. public services. Roll out of the new Reach Out clinical model We want our partnerships to be at all levels - over the next two years, and explore with local community groups, STP opportunities for managing the care budgets colleagues, and regional and national with regional and national NHS England. partners. Our Business Development Strategy will be We will focus on partnerships which improve refreshed to ensure it aligns with these life-chances for people with mental illness, strategic ambitions and we are clear where reducing stigma and health inequalities. we want to focus our efforts. This will include reviewing our strategic partnerships to make Through our new models of care we will sure they are built on strong and effective explore how the traditional commissioner- relationships, for example in the delivery of provider role can be improved, exploring addictions and offender health services. accountable care opportunities. We will continue to develop relationships We will proactively seek out opportunities to with Birmingham Women’s and Children’s develop new partnerships and be involved in NHS Foundation Trust and Forward Thinking new developments as they emerge to Birmingham, working together to develop our continually enhance our service provision, integrated offer for urgent and crisis care and staff support, care pathways, quality of care the CAMHS inpatient pathway. and clinical and financial sustainability. We will review our network of local partners
who work with our service users, families and carers in their journeys, to ensure care is joined up and seamless and all our staff are aware of who is available to help. We will continue to work with the Solihull Emergency and Urgent Care and Care Connected Now (formally Modality) vanguards. We will develop shared pathways of care with colleagues in primary care.
Indicative measures of success MERIT evaluation Reach Out evaluation
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Feedback from stakeholders Successes in retaining business and winning new opportunities
Current Risks to achievement of Strategic Ambition 6
We will work in partnership with others to achieve the best outcomes for local people
Risk 724 - There is a risk that due diligence will not be able to be completed appropriately for the Reach Out Partnership due to limited information being made available by NHSE and some data quality concerns.
Updated September February May 2017 Moderation 2016 2017 Risk level 16 16 16 None This risk was last reviewed on 10 May 2017 when the score of 16 remained whilst access is given to the SMH database to allow reconciliation to take place between April and June 2017. The risk remains as there are still significant issues with data quality meaning we have inaccurate data about our population and this is impacting on our ability to identify repatriations and establish accurate financial baseline. Issues have been raised with NHSE both locally and nationally.
Controls (gaps) Assurances (gaps) Actions/progress • Control added about • 80% of information • Flagged as national access to SMH received has been issue and a national database, validated group has met to discuss reconciliation period • Regular liaison with issues and actions that from April – June NHSE need to be put in place. 2017. Risk score • Internal data group in unchanged in March place; NHSE We are working with as inaccurate quarterly local and national NHS baseline could lead reconciliations and teams and our partners to major financial reconciliation of to validate and resolve. risk. baselines
Risk 747 - We will be the accountable lead provider for the West Midlands Secure Care budgets c £105 m from 1st April 2016, which leads to financial risk of managing the budget. Updated November March Moderation 2016 2017 Risk level 16 16 None This risk was last reviewed on 27 March 2017 when the risk score of 16 remained. This risk remains on the register at this level whilst reconciliation of activity and financial information takes place during the period April to June 2017
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Controls (gaps) Assurances (gaps) Actions/progress • REACH OUT Board • Monitoring reports to • None scrutiny REACH out Board • Collaboration and to Trust Board agreement in place • Agreement of risk includes risk share share with NHSE • Gaps – none • reflected in Contract Management
variation agreement in place
• Financial due diligence • Clinical delivery • Gaps – risk share agreement still to be reached
Risk 748 - Financial risk due to interdependency between parties resulting in potential loss of CQUIN payments if the STP does not deliver as a whole and risk to MH savings if other parties overspend - NEW Updated November April 2017 Moderation 2016 Risk level 16 16 None This risk was last reviewed on 27 April 2017. There are no mitigating actions documented on the register, however controls are noted to include the STP Steering Group with assurance to delivery being provided through Trust Board reports.
Controls (gaps) Assurances (gaps) Actions/progress • Steering group • Reports to Board • None identified governance (gaps none) structure, separate
workstream for MH chaired by BSMHFT CEO (gaps none)
Our financial strategy
We feel very strongly that financial sustainability should be built into everything that we do. The reason we exist is to provide excellent, compassionate, high quality mental health services that are innovative and involve service users, carers and staff. Financial sustainability is vital in order to do this.
Financial sustainability should not be a separate consideration in its own right but should be embedded in the culture of our organisation and in all of our thinking, conversations and areas of work. We need to ensure that our debate is about quality and financial sustainability and recognise how we can improve both at the same time. We have worked hard over the past three years to broaden people’s understanding of our financial position, and ensure that finance is seen as everyone’s business.
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We have a financial strategy which sets out the importance of financial sustainability to enable us to deliver quality services. This includes delivering a surplus each financial year to support investment in our services.
Our financial aims are to:
Develop financial sustainability in a way that fits with both our values and strategic ambitions
Increase the value of what we do where value is outcomes divided by cost
Develop a culture that supports financial sustainability by empowering staff across the Trust
Ensure that the view of sustainability is forward looking and longer term
Move to a position where every financial decision supports our corporate strategic ambitions
Making sure that our financial strategy is understood and implemented means that our Board members and managers can devote their time to quality and putting the patients at the heart of everything that we do and ensure that finance is a support, not a distraction from this task.
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Appendix 2 – Risk Matrix for reference
Risks are calculated using the 5x5 risk matrix scoring system as follows. The matrix considers the consequence/impact of the risk occurring and the likelihood of occurrence as detailed below.
Almost 5 10 15 20 25 L Certain Yellow Yellow Red Red Red I 4 8 12 16 20 K Likely E Yellow Amber Amber Red Red L 3 6 9 12 15 Possible I Green Yellow Amber Amber Red H 2 4 6 8 10 Unlikely O Green Yellow Yellow Amber Amber O 1 2 3 4 5 D Rare Green Green Green Yellow Yellow
Catastrophi Insignificant Minor Moderate Major c
CONSEQUENCE
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Item 9.2
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON 31 MAY 2017
INFORMATION GOVERNANCE ANNUAL REPORT Strategic or Regulatory Requirement to which the paper reports:
ACTION: The Board is asked to receive and note the Information Governance Annual Report for 2017/18.
EXECUTIVE SUMMARY
Information Governance (IG) provides a framework to ensure that all information held by the Trust (including clinical and corporate data and records) is handled in a legal, secure, efficient and effective manner, in order to meet organisational goals including the best possible care delivery. IG therefore covers all information systems and processes used to hold that information whether electronic or paper based
The Trust has a robust IG framework including professionally qualified staff and a committee structure for the development and management of policies, procedures, controls, and evidence based assurance to the Trust Board and Committees on all matters relating to IG.
The Trusts IG toolkit submission for 16/17 has recently been submitted and the Trust has submitted a ‘satisfactory’ rating with an overall score of 80%.
The IG toolkit submission provides assurance as to the IG management arrangements and practices within the Trust, but this does not negate from the importance of further and continued work.
As in other years a key area is maintaining IG training compliance of 95% which is a national requirement through the NHS Operating Framework 2010/2011 and monitored through the HSCIC IG Toolkit.
In 2016/17 the Trust reported 4 serious IG incidents to the Information Commissioners Office (ICO). No formal action was taken by the ICO, although the incidents will be flagged against the Trust and will be considered in future reporting.
IG is likely to stay at the forefront of NHS priorities due to the new legislation; the General Data Protection Regulation replacing the Data Protection Act in May 2018. Outcomes and actions as appropriate will need to be taken through the IG Steering Group to ensure Trust compliance for 2018.
BOARD DIRECTOR SPONSOR: Dave Tomlinson; Executive Director of Finance
PREVIOUSLY DISCUSSED: Not applicable.
Page 1 of 8
INFORMATION GOVERNACE (IG) ANNUAL REPORT
2016/17 Information Governance Toolkit Submission A “Satisfactory‟ rating with a score of 80% has been submitted to the Health and Social Care Information Centre (HSCIC) for 16/17. A level 2 is the minimum for passing a requirement and the Trust achieved a level 3 on 18 of the 45 requirements which is very positive as it identifies that there are a number of areas where the Trust is exceeding general standards.
A ‘satisfactory’ rating whilst providing assurance in relation to Trust IG practices is also significant in a growing tendering environment where IG Toolkit compliance is often a mandatory requirement for pre-qualification.
2016/17 Information Governance Incidents In 2016/17 the Trust met the criteria to report 4 IG incidents to the Information Commissioners Office (ICO). Of these, 2 related to lost or stolen paperwork, 1 inappropriate use of system access and 1 to information disclosed in error.
Following investigation the ICO determined to take no action against the Trust for any incident and for those relating to inappropriate use of access determined the Trust had taken appropriate action.
Overview of key areas of work undertaken within 16/17 The IG Framework includes a number of areas including, Corporate Records Management, Care Records Management, Data Protection and Confidentiality, Access to Information Legislation, and Information Asset Ownership.
The Framework provides support in a number of areas which are business as usual, including providing expert, and ‘hands on’ advice to the Trust, for areas such as tender support, new Information Sharing arrangements, organisational change such as new services/ office moves, new contracts, PMO framework, tailored training, incident management and investigation, as well as day to day customer and client services. The Trust is engaged with NHS England test beds and vanguards, which require heavy IG input and support.
This is in addition to the annual work plan that is required to support the IG Toolkit submission and general work plan for business improvement/planning. Some specific areas are outlined below.
IG Training
On 31st December 2016 the national IG training tool was decommissioned. New updated materials were being developed to align with changes in technology and the change in law to General Data Protection Regulations . The Trust transferred IG training to the corporate e-
Page 2 of 8 learning system so staff were not affected and could access internal training. The revised national training is due to be released in 2017/18 the Trust will need to review whether the national training tool is adopted or existing internal modules updated to reflect these changes.
The IG toolkit sets organisations a mandated target of 95% of staff to receive/undertake annual IG training. As at 31st March 2017 (submission date) the Trust was 91% for staff that had undertaken IG training.
In previous years this would have meant that the Trust would have failed to pass the IG toolkit to a satisfactory level, however due to the decommissioning of the IG training tool a short ‘grace period’ was given for Trusts. This will not be extended into 2017/18. Therefore as with previous years this can only be achieved with significant chasing, reminders and daily monitoring across the Trust.
Information Asset Ownership (IAO) In early 2016/17 significant work was undertaken in relation to the IAO framework to strengthen the evidence available to support the toolkit submission including the standardisation of several IAO documents, including Business Continuity Plans and the move to recording IAO risks on the corporate Eclipse system. Due to a period of change in IG management the IAO agenda was put on hold to ensure that other more time sensitive objectives could be met, such as the IG toolkit and Information Sharing protocols. 2017/18 will see a return to the work programme.
Care Records Management
A project was defined and undertaken to move to a new semi-permanent offsite storage provider, Iron Mountain, for physical care records (Supplementary Care Records) and corporate records. This change provides the Trust with a much higher level of assurance from the new provider who is cheaper and has better and higher quality facilities. This move was completed in December 2016 and all Care Records were indexed as part of the move, allowing the Trust to identify and retrieve records in a timely manner to clinical need and to comply our requirements under the Data Protection Act in relation to Subject Access Requests (SARs)
IG Site Visits/ Audits As is standard practice an annual audit programme was carried out in 16/17 which resulted in a number of Trust teams being visited by an IG professional. The audits were unannounced and focused on key areas of the IG framework. The results were largely positive, although there were areas of concern specifically in relation to staff awareness of the SIRO and Caldicott function and a lack of awareness of corporate records responsibilities. Audits were followed up with communications with managers as to recommendations for improvement and where required key areas of poor compliance were reported to Information Governance Steering Group
Whilst the audits are positive from an assurance perspective, a key benefit is that they continue to act as a knowledge sharing session and are an opportunity to have informal dialogue with staff. The knowledge sharing was positively reflected through the annual IG staff survey which identified an improvement in the awareness and understanding of staff in a number of areas.
Incident Reporting Themes: Emails In 2016/17 26% of all reported IG incidents related to the incorrect use of emails containing confidential information which were either; sent or received via a non-secure network or sent in error. The theme was raised at the Information Governance Assurance Group and part of the feedback received from the group was that a simple one page flow chart should be produced to aid staff in sending electronic communications to Service Users. The guidance was subsequently drafted and agreed by the group and is now available to all staff via the Information Governance page on Connect.
Page 3 of 8 The Trust wide migration to nhs.net, which has had significant IG input, may reduce the number of incidents relating to non-secure transfers of emails as staff will no longer be required to maintain two email addresses.
The use of emails is covered as part of induction and is a greater focus in the revised national training materials.
Freedom of Information (See Appendix 1 for statistics) The Freedom of Information (FOI) Act provides a right to request recorded information held by the Trust, the Trust is required to respond within a statutory timeframe of 20 working days and can only withhold information requested if an FOI exemption can be applied and justified.
The Trust received 429 requests in 2016/17, an increase of 39% from 2015/16. Request numbers have increased significantly during the period, and have almost doubled since 2013/14 when 216 requests were received in the year. The Trust dealt with six requests for internal reviews (‘appeals’) in 2016/17, in comparison to five appeals in 2015/16.
In 2016/17 91% of requests were responded to within 20 working days and 97% within 25 working days. There has been no formal complaint made to the ICO regarding the timeliness of FOI responses.
The categories of people making requests has remained fairly consistent with 2015/16 figures. The percentage of requests submitted by members of the public has increased by 5% making up 31% of all requesters. Requests from private businesses have dropped as a percentage of requests, although request numbers remain consistent with 2015/16.
The Trust’s Finance, Performance & Information (P&I), HR and ICT teams continue to deal with the majority of requests, reflecting the areas of most commonly requested information. Requests to Operations dropped slightly this year, which may be due to the P&I team fielding responses where the information is in a reportable format.
The use of exemptions has increased in comparison to previous years, with 114 responses citing exemptions, in comparison to 77 in 2015/16. This may be due to the increasing complexity of requests as the Section 12 cost limit remains the most used exemption, applied for 56 responses in 2016/17.
Data Protection/ Access to Health Records Requests- DPA/ A2HR (See Appendix 2 for statistics) Data Protection/ Access to Health Records Requests provide data subjects and/or their representatives with a right of access to all personal information the Trust holds about them within 40 calendar days. This right relates to all information systems in the Trust in manual or electronic form.
The number of requests the Trust received has increased for the 6th year with a total of 912 requests being received centrally (an increase of over 400 requests since the process was implemented in 2011/2012). The number of requests exceeding their 40 day statutory time frame was 7% of the total, this was due in the main to there being a delay in the records being reviewed, this is a small decrease on the previous year which was 8%. Whilst the number of breaches needs to be reduced this trend is positive, especially as the total number of requests continues to rise.
A piece of work remains on-going in relation to providing a simple method for extracting data from RiO via automated means. This is still a manual task which is resource intensive.
Key areas of work for 2017/18 An important piece of work continues to be for the Trust is to consider and define a strategic direction for records management including both care and corporate records. There are a
Page 4 of 8 number of national and government papers which detail where organisations are expected to aim for, such as The Power of Information1, which sets out a 10 year strategy, and this should be used to inform decisions.
The IG function works to an assurance plan which evolves according to the needs of the organisation or national requirements. A number of work streams for 2017/18, have been identified to date, a few of which are detailed below.
General Data Protection Regulations - GDPR New rules in relation to Data Protection were passed in 2016 and are due to come into force in May 2018. The aim of the European Data Protection Regulation is to harmonise and strengthen the current data protection laws in place across the EU member states. This impacts upon a number of key IG areas such as consent, the right to be forgotten and potential monetary fines.
A substantial piece of work will need to be undertaken to develop an action plan to ensure that the Trust is able to meet changes introduced from the new regulations. Existing policies, procedures and practices will need to be reviewed and aligned to the new legislation. IG training and guidance will also require updating.
Information Governance Awareness A regular and necessary piece of work is the need to have a current and on-going communications plan to maintain and develop awareness on an annual basis, particularly around key risk areas, such as safe-haven (post management) and legitimate access to systems. In order to maintain and increase the cultural improvements/ awareness in the Trust over the past few years, communications need to be regular and are vital to achieving this.
The IG professionals are looking to take a more modular approach to this during 17/18 focusing on General Data Protection Regulations, Care Records Management, Data Protection and Confidentiality, Freedom of Information and Corporate Records Management.
Care Records Management
An area of defined work is a project to procure an Electronic Document Records Management system for the Trust. This will allow all data, both Clinical and Corporate to be stored in a central repository and allow the Trust to move forward with its plan to become paperless.
Information Sharing Agreements There are a number of Trust projects on-going which require significant IG involvement and expertise to ensure the Trust has assurance and meets its IG responsibilities, e.g. MERIT, Test Beds, Reach Out, hybrid mail and nhs.net.
A critical area of this work will be the production and agreement of Information Sharing Agreements and Data Processing Agreements which safeguard all partners and ensure compliance with Data Protection and national standards.
Corporate Records in storage A project with Iron Mountain (IM) will be completed to index all corporate records that are with our off-site storage provider. This will result in a complete catalogue of all historic corporate records the Trust holds offsite, as 1,141 boxes of corporate records were identified during the transfer to IM in 2016/17 that have not been listed (64% of all corporate records in storage). Once this exercise is completed it is expected that a number of the corporate records will have reached their retention requirement and will be eligible for disposal.
1 http://www.england.nhs.uk/2012/05/21/the-power-of-information/
Page 5 of 8
Paperless programme To support the transition to paperless the corporate recordkeeping requirements of the Trust will be reviewed to support the implementation of a paperless system which will meet these requirements. This is expected to include the development of an updated records retention schedule for the Trust and proposed changes to the Trust File Plan.
CONCLUSION IG arrangements continue to work in a manner that supports the organisation and IG professionals understand the importance their roles play in achieving some important pieces of work in the Trust and associated benefits to the public. Work has continued to embed all elements of IG in the culture of the Trust and increase understanding and awareness, which in turn improves compliance with all areas of IG.
Compliance with information legislation is positive; breaches for DPA have reduced whilst request numbers continue to rise.
The progress made in regard to the Trusts IG management arrangement and practices need to continue and be built on, and further embedded in the Trust where necessary. IG will be staying at the forefront of national awareness due to the release of the General Data Protection Regulations and the Trust must be prepared to achieve the new standards.
Appendix 1 - FREEDOM OF INFORMATION
Compliance statistics
Total number of Responses Responses Responses over Year requests within 20 within 25 25 working days received working days working days 2016/17 429 91% 6% 3% 2015/16 308 90% 7% 3% 2014/15 259 98% 2% 0% 2013/14 216 98.60% 1% 0.40% 2012/13 165 90% 6% 4%
Requests closed by requester type (top 10)
2015/16 2016/17 Public 80 26% 136 31% Press 63 20% 88 20% Private 60 19% 63 15% business What do they 24 8% 43 10% know website NHS 21 7% 28 6% Academic 23 7% 20 5% Lobby 5 2% 13 3% Charity 9 3% 12 3% MPs 5 2% 10 2% Staff/Former 3 1% 9 2% Staff
Page 6 of 8
Requests closed by Trust department handling them (top 10)*
2015/16 2016/17 Finance (inc. 78 25% 128 29% Procurement) Performance 64 21% 93 21% and information HR 59 19% 86 20% ICT 39 13% 58 13% Operations 68 22% 55 13% Governance 31 10% 52 12% Estates & 20 6% 38 9% Facilities Legal / Exec 17 6% 20 5% Office Medical 7 2% 17 4% Nursing 7 2% 14 3% *Note one request might be handled by several departments.
Exemptions used
2015/16 2016/17 Section 12 - cost / time 29 9% 56 13%
Section 40 - personal 26 8% 33 8% information Section 21 - accessible by 12 4% 13 3% other means Section 43 - commercial 3 1% 12 3% interests
Section 22 - intended for 2 1% 3 1% future publication
S24 National Security 0 0% 1 <1% Section 31 - Law 2 1% 2 <1% Enforcement
Section 41 -Information 1 <1% 1 <1% provided in confidence
Page 7 of 8 Appendix 2 - DATA PROTECTION ACT/ ACCESS TO HEALTH RECORDS
Request received 2016/17
Q1 Q2 Q3 Q4 2016/17 TOTAL NO OF REQUESTS 298 228 194 191 911
SARs 149 184 130 114 577 Police 18 23 16 38 96 NHS 55 13 35 26 129 General 17 6 5 3 31 Access to Health Records 59 2 8 9 78 (deceased)
Percentage of requests which breached the statutory 40 day timeframe
Year Number of Increase Rate Breach Breach Rate Requests 2011/2012 549 ------114 21% 2012/2013 644 17% 96 15% 2013/2014 672 4% 93 14% 2014/2015 662 -2% 94 14% 2015/2016 884 33% 59 7% 2016/2017 911 2% 68 7%
Breaches: The statistics identify that whilst the total number of annual requests is increasing, the number breaching is slowly declining this is due to; • Increased use of escalation • Fewer requests being passed to the IG Team late in the 40 statutory timeframe. • Better relationship with West Midlands Police, following the revision of the Information Sharing Protocol, which formalised the process for requesting information.
Page 8 of 8
Item 9.3
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2016
SELF CERTIFICATION G6/COS7/FT4 (8) Strategic or Regulatory Requirement to which the paper reports: • Provider Licence – compliance NHSI requirement ACTION: The Board is asked to approve the attached self-certification declarations for signing by the Chair and Chief Executive. Executive Summary
The Board will recall that it has received annual self-certification declarations in May and June each year. There remains a requirement to undertake the self-assessments and updated templates have been provided by NHSI for doing so.
It is at the discretion of providers to determine their own process for receiving assurance conditions continue to be met.
The three self – certification declarations required by the Provider Licence are • Condition G6 (3) – providers must certify that their Board has taken all precautions necessary to comply with the licence, NHS Act and NHS Constitution – required to be considered by May 31 2017 – attached • Condition CoS7 (3) – providers providing commissioner requested services (CRS) have certified that they have a reasonable expectation that required resources will be available to deliver the designated service – required to be considered by May 31 2017 – attached • Condition FT4 (8) – providers must certify compliance with required governance standards and objectives – required to be considered by 30 June 2017 – attached
Providers are required to have effective systems and process in place to ensure compliance, that key risks to compliance are identified, and reasonable mitigating actions are taken to prevent those risks and failure to comply, from occurring.
We have a comprehensive risk management process in place and strong reporting via our sub committees and to Board.
Board members are asked to confirm if they believe there to be specific risks to compliance with the licence which should be identified.
1 & 2 General condition 6 – Systems for compliance with licence conditions (FTs and NHS Trusts) and F4 compliance with governance standards
Evidence of compliance: • Head of Internal Audit Opinion 2016/17 – substantial assurance • Board Assurance Framework – 2016/17 - substantial assurance - top risks discussed at
Page 1 of 3 least quarterly at Audit Committee and Board. Board requested a Deloitte facilitated seminar on identifying longer term strategic risks which took place in April 2017 and a refreshed BAF is under development. • Finance and use of resources – overall score 3 (scores are 1 – 4 with 1 being the strongest performance). We ended the financial year 2016/17 with a single oversight framework segment of 2 (this is the position as at 7 April 2017). NHS Improvement have not taken any enforcement action against the Trust and no actions are being taken or proposed by the Trust. • The Operating Plan is received and approved at Board • Finance reports received monthly at Board, detailed discussions also take place at FPP on finance, savings and capital plan • The Trust completes monthly submissions to NHSI which includes detail to confirm ongoing compliance and quarterly governance commentaries for the Single Oversight Assessment Framework requirements. • Availability of resources is picked up in the APR 2016/17 and APR 2017/18 final financial template which are required to be submitted as part of the final operating plan submissions • Strong business planning arrangements in place, with goals regularly monitored and progress tracked • Annual Report, Annual Governance Statement and Quality Account received at Audit Committee and shared with all Board members for comment. • A system of integrated reporting is being developed in 2016/17, milestones will be monitored in the quality reports received at the Clinical Governance Committee and Integrated Quality Committee and quarterly to Trust Board. • Current rating of ‘good’ with the CQC (we have not yet received the outcome of the recent CQC full inspection but no immediate serious concerns were raised) • Review of our governance arrangements undertaken in 2016/17 and progress reviewed in 2017/18 • Regular reviews against the ‘well led framework’ have taken place by the Board and are evidenced • Quality Surveillance and peer review process in place. Time to Shine mock CQC inspections have taken place. • Board visits programme in place, including out of hours
Foundation Trusts must have regard to the views of governors and the self-certification should be signed off by Boards. Our Governors have been consulted on development of the new overarching Strategy and on our Quality Accounts and goals; and have received financial reports at every Council of Governors meeting. They have also received presentations from the Chairs of our Board Sub Committees and participated in the appointment and review process for Non-Executive Directors. Governors have also participated in decision making around significant transactions ‘Reach Out’ accountable care partnership, and have participated in a range of strategic and operational discussions with our Board across the year. Areas of under representation in the membership have been identified and programmes of work put in place to address these.
The Board is asked to confirm that:
Following a review for the purpose of paragraph 2 (b) of licence condition G6, the Directors of the Licensee are satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirement imposed on it under NHS Acts and have had regard to the NHS Constitution
Page 2 of 3 Continuity of services condition 7 – Availability of resources (FTs designated CRS only).
The Board is asked to confirm that:
After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the required resources available to it after taking into account distributions which might reasonably be expected to be declared or paid for the period of 12 months referred to in this certificate
The development of the Accountable Care function/Reach Out will lead to the Trust taking on commissioning functions. It is not yet clear how this will be accounted for and therefore how it impacts on Use of Resources measures despite the Trust discussing the matter with NHS Improvement. However, at this stage there is nothing to suggest an adverse impact on our compliances with conditions.
The Board is asked to confirm that:
The Board is satisfied that during the financial year most recently ended the Licensee has provided the necessary training to its Governors, as required in x151 (5) of the Health and Social Care Act, to ensure they are equipped with the skills and knowledge needed to undertake their role
We have introduced annual skills audits to assess Governors knowledge, understanding and competence in a range of areas to inform our training and development plan. The key areas of focus are strategic planning, role of the governor, engaging with and representing their constituencies, holding the board to account, communications and marketing, finance in the NHS, the wider Health Economy and the Trust and its services. Training is provided to our Governors through a combination of dedicated in-house sessions (some with Trust Board), conferences and workshops such as those held by NHS Providers, or by the local health economy within the West Midlands.
Recommendation
That the Board confirms compliance as outlined for signature by the Chair and CEO
BOARD DIRECTOR SPONSOR: Deborah Lawrenson, Company Secretary REPORT AUTHOR: Deborah Lawrenson, Company Secretary
APPENDIX: • Self-certification forms G6 & CoS7, FT4 for approval
PREVIOUSLY DISCUSSED: None
Page 3 of 3 Worksheet "Training of governors"
Certification on training of governors (FTs only)
The Board are required to respond "Confirmed" or "Not confirmed" to the following statements. Explanatory information should be provided where required.
2 Training of Governors
1 The Board is satisfied that during the financial year most recently ended the Licensee has provided Confirmed the necessary training to its Governors, as required in s151(5) of the Health and Social Care Act, to OK ensure they are equipped with the skills and knowledge they need to undertake their role.
Signed on behalf of the Board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name John Short Name Sue Davis
Capacity Chief Executive Capacity Chair
Date 31 May 2017 Date 31 May 2017 Further explanatory information should be provided below where the Board has been unable to confirm declarations under s151(5) of the Health and Social Care Act
A Worksheet "G6 & CoS7"
Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.
1 & 2 General condition 6 - Systems for compliance with license conditions (FTs and NHS trusts)
1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are Confirmed satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS OK Acts and have had regard to the NHS Constitution.
3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only) EITHER: 3a After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have Confirmed the Required Resources available to it after taking account distributions which might reasonably be expected Please fill details in cell E22 to be declared or paid for the period of 12 months referred to in this certificate. OR 3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be declared or paid for Please Respond the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors (as described in the text box below) which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services. OR 3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to Please Respond it for the period of 12 months referred to in this certificate.
Statement of main factors taken into account in making the above declaration In making the above declaration, the main factors which have been taken into account by the Board of Directors are as follows: [e.g. key risks to delivery of CRS, assets or subcontractors required to deliver CRS, etc.]
Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name John Short Name Sue Davis
Capacity Chief Executive Capacity Company Secretary
Date Date
Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6.
A Worksheet "G6 & CoS7"
Declarations required by General condition 6 and Continuity of Service condition 7 of the NHS provider licence
The board are required to respond "Confirmed" or "Not confirmed" to the following statements (please select 'not confirmed' if confirming another option). Explanatory information should be provided where required.
1 & 2 General condition 6 - Systems for compliance with license conditions (FTs and NHS trusts)
1 Following a review for the purpose of paragraph 2(b) of licence condition G6, the Directors of the Licensee are Confirmed satisfied that, in the Financial Year most recently ended, the Licensee took all such precautions as were necessary in order to comply with the conditions of the licence, any requirements imposed on it under the NHS OK Acts and have had regard to the NHS Constitution.
3 Continuity of services condition 7 - Availability of Resources (FTs designated CRS only) EITHER: 3a After making enquiries the Directors of the Licensee have a reasonable expectation that the Licensee will have the Required Resources available to it after taking account distributions which might reasonably be expected Please Respond to be declared or paid for the period of 12 months referred to in this certificate. OR 3b After making enquiries the Directors of the Licensee have a reasonable expectation, subject to what is explained below, that the Licensee will have the Required Resources available to it after taking into account in particular (but without limitation) any distribution which might reasonably be expected to be declared or paid for Please Respond the period of 12 months referred to in this certificate. However, they would like to draw attention to the following factors (as described in the text box below) which may cast doubt on the ability of the Licensee to provide Commissioner Requested Services. OR 3c In the opinion of the Directors of the Licensee, the Licensee will not have the Required Resources available to Please Respond it for the period of 12 months referred to in this certificate. Statement of main factors taken into account in making the above declaration In making the above declaration, the main factors which have been taken into account by the Board of Directors are as follows: [e.g. key risks to delivery of CRS, assets or subcontractors required to deliver CRS, etc.]
Signed on behalf of the board of directors, and, in the case of Foundation Trusts, having regard to the views of the governors
Signature Signature
Name John Short Name Sue Davis
Capacity Chief Executive Capacity Chair
Date Date
Further explanatory information should be provided below where the Board has been unable to confirm declarations under G6.
A
Item 9.4
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD/ COMMITTEE TO BE HELD ON WEDNESDAY 31 MAY 2017
DEAR JOHN ANNUAL REPORT
Strategic ambition to which the paper reports – :
• We will listen to, and work alongside, service users, carers, staff and stakeholders
ACTION: The Board is asked to receive the report for information on the numbers, types and themes of Dear John submissions received by the Trust and for consideration of future actions.
ISSUES
The Dear John model, which allows staff to raise quality concerns, anonymously if they wish, has been in operation since the end of May 2013. Evaluation reports are produced annually with the last report to Board being in May 2016.
This brief report provides a summary evaluation of submissions between 1 May 2016 and 30 April 2017. In summary:
• There have been 120 submissions to Dear John between 1 May 2016 and 30 April 2017, compared to 111 in the same period last year. This suggests that it remains an important feedback tool in the Trust. • Analysis of sites/themes that submissions relate to shows that: o A wide range of issues have been raised, many specific to teams or individuals. o Where themes can be identified they are broadly similar to previous years, including staffing, HR issues, leadership and management behaviours. o A distinction this year is that 10% of submissions during the year have related to the introduction of the Trust’s Smoke Free policy. o There have been a relatively high number of Dear John submissions from staff in acute and urgent care, with a third of these raising concerns about Smoke Free. o The Barberry has also featured more regularly this year than in the previous year. • Staff continue to use Dear John to raise specific concerns relating to their role or site, and also to comment on Trust-wide issues. • Since the introduction of Dear John, there have been 487 submissions in total, 245 of them anonymous (50%). The percentage of anonymous submissions between May 2016 and April 2017 was 43%, which is a significant decrease on the previous year which saw 57% of submissions submitted anonymously. • The report suggests a number of next steps for the Dear John process.
Recommendation
• It is recommended that Dear John will continue to report annually to ensure the Trust Board is also able to benefit from the insight that Dear John gives to the organisation and suggest improvements to the process.
Page 1 of 5 BOARD DIRECTOR: Dave Tomlinson, Executive Director of Finance AUTHOR: Louise Butler, Head of Communications and Marketing
References: None
Dear John Analysis and Evaluation May 2017
Review of submissions 1 May 2016 to 30 April 2017 Number of submissions Since the last Board report in May 2016 there have been 120 submissions to Dear John, equivalent to approximately 2 per week, although with peaks and troughs during the year as shown on the chart below. This compares to 111 submissions in the previous year. The numbers have declined towards the end of the reporting period, however experience over the three years has shown that numbers are likely to fluctuate considerably from month to month and it is too soon to identify this as a trend. This decrease may in part be due to the other feedback mechanisms and opportunities that were available around the time of the Trust’s full CQC inspection at the end of March 2017. Charts for the previous two years are included for comparison. Number of Dear John submissions per month May 2016 to April 2017
20 18 16
14 12 10 8
6 4 2 0
Number of Dear John submissions per month May 2015 to April 2016
14 12 10 8 6 4 2 0
Page 2 of 5
Number of Dear John submissions per month May 2014 to April 2015
20
15
10
5
0
Themes • As in the previous two years, a wide variety of issues have been raised, some very specific to a site, service or personal situation, that cannot so easily be grouped or themed. • Where themes can be identified they are similar to those highlighted in previous reviews: staffing, including TSS; HR and recruitment issues; leadership and management (particularly of change) and bullying. • Unsurprisingly, some specific Trust wide issues and changes have continued to generate Dear Johns, notably this year concerns about the Trust’s Smoke Free policy which was mentioned in 10% of submissions over the year. • There have been a number of Dear John submissions about the way specific staff consultations and changes in teams have been managed and in some cases concerns have been raised through Dear John apparently before being discussed first with those managing the change, so it is seen as a direct route rather than an escalation. • Whilst Dear John was established for staff to raise quality concerns, very few of the concerns raised relate directly to specific incidents or examples of poor quality patient care. • While there is not one service area or site that could be said to dominate the submissions and not all submissions state a site or ward, of those where the location is identified acute and urgent care features regularly (18 submissions) as does the Barberry (13 submissions). A range of issues have been raised by staff in these services, with the Smoke Free policy accounting for a third of submissions from acute sites and around a quarter of submissions from the Barberry. • The trend from previous years for secure services to feature prominently compared to other service areas has not continued this year (8 out of 120 submissions came from secure care sites), suggesting an improvement in staff engagement and satisfaction in those sites.
Page 3 of 5 • Some staff continue to use Dear John to raise issues not directly relating to their role or quality of patient care, such as parking and facilities. • Alongside other feedback mechanisms, such as the ProActive Partnership ‘Listen Up’ sessions, this has enabled the Executive Team to understand how staff feel about events in the Trust in real time and sometimes to identify unintended or unpredicted consequences of decisions.
Type of submission 52 of the submissions in the review period were made anonymously (43%), which is down from the previous two years which had 57% and 56% respectively. This contradicts some anecdotal feedback that staff don’t trust the system and could suggest a number of things, including: • Staff trust that their details will be kept confidential. • Staff increasingly want to receive a direct response to their query, which is not possible if the submission is anonymous. • Staff believe in the Trust value of openness and honesty and feel comfortable putting their name to their concern. • Other mechanisms and activities, such as the Listen Up conversations led by executive directors, engagement in the Trust Strategy development and Freedom to Speak Up Guardian role, have had an impact on the confidence of staff to raise issues and give their views. • More in depth work would need to be done with staff to explore the above assumptions and verify which hold true. Overall, since the introduction of Dear John until the end of April 2017, 50% of submissions have been anonymous. In the past year, there has been no major distinction between the issues that people raise anonymously and those raised by named staff, with staff raising seemingly more minor issues such as estates issues anonymously and some named staff raising serious issues such as bullying. Although the analysis suggests that an increasing number of staff are prepared to give their contact details when raising concerns, it also shows that it is still important to provide an anonymous channel. The Dear John process and impact
Dear John can only truly deliver its intended purpose if action is taken, where appropriate, in response to the quality concerns raised. Although all concerns are followed up and addressed promptly, it continues to be difficult to pinpoint broader improvements in the Trust that have been made as a direct result of the Dear John process. This is partly due to the wide number and specific nature of many of the issues raised, although there is still scope to increase triangulation with other reports, such as the staff survey, quarterly Pulse Check and incident reporting. This would be particularly useful when Dear John is one of a number of mechanisms used to raise concerns on a particular theme, as is the case for example with Smoke Free.
Due to the above, it is difficult to evidence what changes have been made as a direct result of Dear John, other than responses to individual concerns. However, it is clear from the consistent level of submissions over the four year period since Dear John was launched, that in terms of staff engagement it remains an important tool for the Executive Team and for Trust staff.
Next steps and developments
Page 4 of 5 • Dear John will remain in its current format with continued internal communications to ensure that all staff are aware of its existence and purpose, for example as part of Trust induction, ProActive Partnership and wider communications around how to raise concerns.
• Dear John needs to be considered as just one channel for feeding back that is for raising concerns about quality and this should be promoted alongside other mechanisms such as Pulse Checks, Listen Up sessions, local staff engagement and the staff survey. Routes to raise more routine concerns about matters such as parking and facilities should be made more visible.
• More detailed analysis needs to be done to triangulate data from Dear John with other sources of information/feedback. With the development of the People Plan and Strategy for the Trust, there is an opportunity to incorporate themes arising from Dear John into the measurement of staff experience as part of a wider dashboard of indicators, which will enable better understanding of its impact alongside other initiatives and where improvements have been made as a result.
• The work under way to address the themes arising from the staff survey, particularly around team working and communication with managers, and the development of a new behaviours framework, should improve some of the issues around management of change, consultations, and leadership and management behaviour, or help staff to feel more confident in raising them locally before escalating to Dear John. If this work is successful then a decrease in Dear John submissions could be expected over the coming year or a change in the type of issue being raised.
• Finally, it is recommended that Dear John will continue to report annually to ensure the Trust Board is also able to benefit from the insight that Dear John gives to the organisation and suggest improvements to the process.
Page 5 of 5
Item 9.5
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
GUARDIAN OF SAFE WORKING HOURS QUARTERLY REPORT Strategic or Regulatory Requirement to which the paper reports:
We will attract, develop and support an exceptional and valued workforce.
ACTION: Trust Board are requested to consider the recommendation about the concerns about resources, both at number of junior doctor numbers and resources to facilitate timely resolution of exceptional reports. ISSUES 1) There are a significant number of rota gaps. This has been resolved in majority of cases by our doctors doing extra on-calls. This has a potential of taking the doctors above the safe work hours. At present we do not have a system of recording the aggregate number of hours of work for doctors working across rotas or across employers. 2) The guardian recommends that the Trust develops a clear strategy to manage the gaps in rotas. The regular gaps have potential risk implications. 3) There is a limited number of educational supervisors in the Trust. Junior doctors terms and conditions 2016, significantly increase the responsibilities of the educational supervisors. The data suggests that this is leading to exception reports being resolved significantly over the required time frames. This needs to be resolved and may involve review of the job description of existing educational supervisors or increasing the number of supervisors. BOARD DIRECTOR: Not applicable AUTHOR: Dr Sajid Muzaffar, Guardian of Safe Working Hours and Consultant Psychiatrist
References: None
Page 1 of 1
QUARTERLY REPORT ON SAFE WORKING HOURS: DOCTORS AND DENTISTS IN TRAINING
High level data
Number of doctors / dentists in training (total): 92 Number of doctors / dentists in training on 2016 CTs 21 GPVTS 19 total 39 TCS (total): Amount of time available in job plan for guardian 1 PAs per week to do the role: Admin support provided to the guardian (if any): Over the quarter in question admin support was provided by the medical secretary. An alternative arrangement is being agreed with the Medical Directorate. Amount of job-planned time for educational Information not available supervisors:
a) Exception reports on 7 April 2017
Exception reports by rota Specialty No. exceptions No. exceptions No. exceptions No. exceptions carried over from raised closed outstanding last report Solihull 0 8 6 2 East/Ardenleigh 0 4 0 3 North 0 7 7 0 HOB 0 4 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 0 22 17 5
Exception reports (response time) Addressed within 48 hours 1 Addressed within 7 days 9 Addressed in longer than 7 days 9 Still open 3 Total 22
Note: None of the exception report has raised concerns of immediate and substantive risk to safety of patients, or to safety of doctors.
Rota Monitoring for doctors on 2002 contract: There is a requirement to monitor the doctors on the 2002 contract twice a year. This will take place in April 2017.
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b) Work schedule reviews All the exception reports have been resolved by time off in Lieu or payment without a need for review of the work schedules. c) Locum cover (internal and agency)
Locum requirement for January 2017 – Core Trainees/Foundation Year Doctors and GP Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 9.5 529.5 331.75 161.5 94.25 Leave 10 236.75 128.25 108.5 (sickness, maternity, etc) Restrictions 3 78 58 20 (pregnancy, etc) Increased clinical demand TOTAL 22.5 844.25 518 290 94.25
Locum requirement for January 2017 – Specialty Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 17 922 546 376 Leave 1 40 24 16 (sickness, maternity, etc) Restrictions 2 80 48 32 (pregnancy, etc) Increased clinical demand TOTAL 20 1042 618 424
Locum requirement for February 2017 – Core Trainees/Foundation Year Doctors and GP Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency
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internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 11 786 431 184.25 170.75 Leave 6 228.25 97.25 126.5 4.5 (sickness, maternity, etc) Restrictions 5 417.25 211.75 157.75 47.75 (pregnancy, etc) Increased clinical demand TOTAL 22 1431.5 740 468.5 223
Locum requirement for February 2017 – Specialty Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 17 792 504 288 Leave 6 216 176 40 (sickness, maternity, etc) Restrictions (pregnancy, etc) Increased clinical demand TOTAL 23 1008 680 328
Locum requirement for March 2017 – Core Trainees/Foundation Year Doctors and GP Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 12 784.5 517.5 212.25 54.75 Leave 6.5 203.75 85.25 71.5 47 (sickness, maternity, etc) Restrictions 5 155.75 129.75 26 (pregnancy, etc)
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Increased clinical demand TOTAL 23.5 1144 732.5 309.75 101.75
Locum requirement for March 2017 – Specialty Trainees
Reason No. of hours No of hours No of hours No of hours requested worked by worked by worked by agency internal Trust trainees FY2 medics GPVTS CT1-3 ST4-6 Vacancy 20 816 464 352 Leave 3 104 40 64 (sickness, maternity, etc) Restrictions 2 136 120 16 (pregnancy, etc) Increased clinical demand TOTAL 25 1056 624 432 d) Locum work carried out by trainees At this stage the Trust is working with the Joint Local Negotiating Committee on agreeing a protocol to capture this information. e) Fines No fines have been imposed on the Trust in this quarter. f) Training issues There have been zero exception reports in relation to training issues in this quarter.
Trainees who work within the trust have a number of systems of educational supervision. Some Foundation year trainees have educational supervisors within the trust but the majority of FY educational supervisors are with host trust. GPVTS have education supervisors externally. For core trainees there are 5 college tutors who act as educational supervisors of 36 CTs. This additional role of reviewing exception reports is currently not reflected in college tutor job plan. This is a significant piece of work to be completed by tutors in very short time frames i.e. 7 working days which has resulted in delays.
The educational supervision of STs is allocated to clinical supervisors within and external to the trust.
Background In preparation for the implementation of Junior Doctors’ Terms and Conditions, 2016, the following has been put in place:
1) A guideline developed for exception reporting. The Guideline is available on Trust Intranet. 2) Engagement events with junior doctors were held.
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3) Terms of Reference for the Junior Doctors Forum have been agreed with the forum and via the Joint Local Negotiating committee. 4) The Junior Doctors Forum has been established with the first meeting held in January 2017. 5) An electronic system for exception reporting has been established via Allocate software. Junior doctors and supervisors have been provided access to this system. 6) Information about the exception reporting discussed with doctors on the 2016 contract as part of the induction into the Trust. 7) Procedures are in place for completion of Generic and Personalized work schedules according to the requirements of the contract.
Analysis of data 1) The majority of the rotas did not return any exception reports. This may indicate that there are specific issues in some of the rotas. However, not every doctor is on the new contract and doctors with access to the exception reporting system are not uniformly distributed across the rotas. More information is required before definite conclusions can be drawn. 2) Exception reports that have been submitted have mostly been about the average numbers of work hours on call being different from the actual hours. This may be a result of variability in workload across on-calls and the average may still be within the hours agreed in the work schedules. It is equally possible that the numbers of work hours on call were underestimated and this may require change in the on-call rotas and change in doctors work schedules. More information is required before a definitive opinion can be formed about this. 3) There are significant gaps in most of the rotas. The majority of the gaps are caused by vacancies. The gaps are particularly severe at senior trainee level. The rota gaps are being filled in majority of cases by internal locums by the trainees. This is a potential area of concern for safe working in future.
Issues that require resolution 1) Educational Supervisor Job plans have not been changed to reflect this additional duty. This needs to be reviewed by the Trust along with the Deanery. 2) In the majority of exception reports the investigation was not completed within the stipulated time frame. The major reason being that the number of educational supervisors in the Trust is limited. This is likely to become a greater problem as most doctors move to the Junior Doctors Terms and Conditions 2016. 3) There have been a large number of rota gaps across the Trust, nearly one third of the number of posts. The majority of rota gaps were created by vacant posts. The majority of gaps were filled by the existing trainees doing extra shifts. This is a potential risk in terms of safe working hours. The Trust does not have a current system for identifying the total hours an individual doctor works due to combination of locum and regular hours.
Actions taken to resolve issues 1) Ongoing discussions about the means of calculating average work hours during on call. Given the requirement for the systems to be electronic, it may involve some financial costs. This is an outstanding issue at present and will be discussed in the April Junior Doctors’ Forum. 2) Guardian safe working hours and the Director of Medical Education are working to review the time commitment required of educational supervisors to ensure timely investigation of exception reports. This will involve collection of information about the time spent on such activity. Possible solutions include appointing more doctors as educational supervisors to meet the extra workload. Alternatively the initial investigation can be delegated to another consultant in the service. These options will require to be discussed with the Junior Doctors in the Junior Doctors Forum and with the Trust Medical staffing committee before a solution is agreed. If the number of Educational supervisors increases, they will need to be appropriately remunerated. This will be a potential cost to implementation of the new contract.
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3) The Trust has been requested to develop a system for recording this information and the Guardian is informed that the Trust is working with the JLNC to agree on a mechanism for recording this.
Summary The guardian can assure the Board that there is no evidence to suggest significant breaches in the safe working of doctors on the Junior Doctors Terms and Conditions 2016. Systems have been put in place to ensure safe implementation of the Junior Doctors Terms and Conditions 2016. Five of the nine rotas did not return any exception reports. No exception report was raised on training issues. No immediate safety concerns have been identified through the exception reporting system. The majority of exceptions were about the difference between the average number work hours on-call indicated in the work schedules versus the actual work hours on call.
Implementation of the changes comes with additional workload on various relevant individuals. In particular, the workload on Educational Supervisors has increased significantly. This has resulted in delay in investigation of majority of submitted exception reports.
There is a high rate of rota gaps and this is a potential risk area for future.
Questions for consideration by the Board There is a high rate of vacancies and consequent rota gaps. At present, the Guardian has not found any evidence to suggest that these vacancies are compromising safety of doctors or the patients. However this is a potential area of concern. The majority of the vacancies were filled by the trainees doing locum shifts for additional payment. As majority of doctors move to the Junior Doctors’ Terms and Conditions of Service,2016, the willingness to do additional shifts is likely to reduce due to perceived unfavorable financial incentives under the new contract. To ensure safety of patients and doctors going forwards, the guardian would recommend that the Trust urgently develops a strategy to try and minimize vacancies in the rotas.
Dr Sajid Muzaffar MB BS, LL.M, MRCPsych Consultant Forensic Psychiatrist Reaside Clinic Birmingham Great Park Bristol Road South Birmingham B45 9BE Tel: 0121 301 3054 Fax: 0121 678 3014
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Appendix 1: Vacancies by rota:
JANUARY 2017
REASON EAST & GRADE No of No of hours No of Hours worked No of hours ARDENLEIGH SHO hours worked by by TRAINEES FY2s, worked by 1 in 10 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 0.5 16.5 5 0 11.5 Leave (Sickness, 2 44.5 5 39.5 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 61 10 39.5 11.5
REASON HOB 1 in 10 GRADE No of No of hours No of Hours worked No of hours ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 1.5 42 27 15 0 Leave (Sickness, Maternity etc). Restrictions 1 31 26 5 0 (Pregnancy etc) Increased clinical demand TOTAL 73 53 20 0
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 10 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 3 167 79 64 24 Leave (Sickness, 1 5 0 5 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand
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TOTAL 172 79 69 24
REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 SHO hours worked by by TRAINEES FY2s, worked by in 11 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 0.5 0 0 0 Leave (Sickness, 3 80 16 64 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 80 16 64 0
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 8 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 0 0 0 0 0 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 0 0 0 0
REASON SOUTH A 1 GRADE No of No of hours No of Hours worked No of hours in 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 0.5 16 16 0 Leave (Sickness, 1 69 69 0 Maternity etc). Restrictions 1 27 22 5 (Pregnancy etc) Increased clinical demand TOTAL 112 107 5 0
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REASON SOUTH B 1 in GRADE No of No of hours No of Hours worked No of hours 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 0.5 55 44 11 Leave (Sickness, 1 22 22 0 Maternity etc). Restrictions 1 20 10 10 (Pregnancy etc) Increased clinical demand TOTAL 97 76 21 0
REASON SOUTH GRADE No of No of hours No of Hours worked No of hours RESIDENT 1 SHO hours worked by by TRAINEES FY2s, worked by in 9 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 3 233 160.75 13.5 58.75 Leave (Sickness, 2 16.25 16.25 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 249.25 177 13.5 58.75
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 3 162 162 0 0 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 162 162 0 0
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REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 ST4- hours worked by by TRAINEES FY2s, worked by in 11 ROTA 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 6 336 336 0 Leave (Sickness, Maternity etc). Restrictions 1 32 32 0 (Pregnancy etc) Increased clinical demand TOTAL 368 0 368 0
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 5 312 288 24 Leave (Sickness, 1 40 24 16 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 352 312 40 0
REASON SOUTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA ST4- hours worked by by TRAINEES FY2's, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Medics Vacancy 3 112 96 16 0 Leave (Sickness, Maternity etc). Restrictions 1 48 48 0 0 (Pregnancy etc) Increased clinical demand TOTAL 160 144 16 0
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FEBRUARY 2017
REASON EAST & GRADE No of No of hours No of Hours worked No of hours ARDENLEIGH SHO hours worked by by TRAINEES FY2s, worked by 1 in 10 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1 123.75 52.25 25.25 46.25 Leave (Sickness, 0 Maternity etc). Restrictions 1 16.25 16.25 0 0 (Pregnancy etc) Increased clinical demand TOTAL 140 68.5 25.25 46.25
REASON HOB 1 in 10 GRADE No of No of hours No of Hours worked No of hours ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 4 259.5 164.75 41.5 53.25 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 259.5 164.75 41.5 53.25
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 10 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 2 184 83 65 36 Leave (Sickness, 1 4.5 0 0 4.5 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 188.5 83 65 40.5
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REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 SHO hours worked by by TRAINEES FY2s, worked by in 11 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1.5 88 40 48 0 Leave (Sickness, 2 40 40 0 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 128 80 48 0
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 8 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy Leave (Sickness, 2 144 40 104 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 144 40 104 0
REASON SOUTH A 1 GRADE No of No of hours No of Hours worked No of hours in 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 0.5 0 0 0 0 Leave (Sickness, Maternity etc). Restrictions 2 306.5 183.75 110.25 12.5 (Pregnancy etc) Increased clinical demand TOTAL 306.5 183.75 110.25 12.5
REASON SOUTH B 1 in GRADE No of No of hours No of Hours worked No of hours 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums
12
Vacancy 1 44 44 0 0 Leave (Sickness, 1 39.75 17.25 22.5 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 83.75 61.25 22.5 0
REASON SOUTH GRADE No of No of hours No of Hours worked No of hours RESIDENT 1 SHO hours worked by by TRAINEES FY2s, worked by in 9 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1 86.75 47 4.5 35.25 Leave (Sickness, Maternity etc). Restrictions 2 94.5 11.75 47.5 35.25 (Pregnancy etc) Increased clinical demand TOTAL 181.25 58.75 52 70.5
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 3.5 184 160 24 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 184 160 24 0
REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 ST4- hours worked by by TRAINEES FY2s, worked by in 11 ROTA 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 5.5 184 0 184 Leave (Sickness, 1 40 0 40 Maternity etc).
13
Restrictions (Pregnancy etc) Increased clinical demand TOTAL 224 0 224 0
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 6 296 232 64 Leave (Sickness, 3 96 96 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 392 328 64 0
REASON SOUTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA ST4- hours worked by by TRAINEES FY2's, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 2 128 112 16 Leave (Sickness, 2 80 80 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 208 192 16 0
MARCH 2017
REASON EAST & GRADE No of No of hours No of Hours worked No of hours ARDENLEIGH SHO hours worked by by TRAINEES FY2s, worked by 1 in 10 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1 63.25 51.5 11.75 0
14
Leave (Sickness, 1 11.75 0 11.75 0 Maternity etc). Restrictions 1 73 73 0 0 (Pregnancy etc) Increased clinical demand TOTAL 148 124.5 23.5 0
REASON HOB 1 in 10 GRADE No of No of hours No of Hours worked No of hours ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 4 259.5 237 18 4.5 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 259.5 237 18 4.5
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 10 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 2.5 204 77 101 26 Leave (Sickness, Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 204 77 101 26
REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 SHO hours worked by by TRAINEES FY2s, worked by in 11 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1.5 39 16 23 0 Leave (Sickness, 1.5 32 16 16 0 Maternity etc). Restrictions (Pregnancy etc)
15
Increased clinical demand TOTAL 71 32 39 0
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 8 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy Leave (Sickness, 1 48 16 32 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 48 16 32 0
REASON SOUTH A 1 GRADE No of No of hours No of Hours worked No of hours in 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 0.5 11.75 11.75 0 0 Leave (Sickness, Maternity etc). Restrictions 2 21.5 4.5 17 0 (Pregnancy etc) Increased clinical demand TOTAL 33.25 16.25 17 0
REASON SOUTH B 1 in GRADE No of No of hours No of Hours worked No of hours 7 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1 99.25 99.25 0 0 Leave (Sickness, 1 13.5 13.5 0 0 Maternity etc). Restrictions 1 56.75 47.75 9 0 (Pregnancy etc) Increased clinical demand TOTAL 169.5 160.5 9 0
16
REASON SOUTH GRADE No of No of hours No of Hours worked No of hours RESIDENT 1 SHO hours worked by by TRAINEES FY2s, worked by in 9 ROTA requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 1.5 107.75 25 58.5 24.25 Leave (Sickness, 2 98.5 39.75 11.75 47 Maternity etc). Restrictions 1 4.5 4.5 0 0 (Pregnancy etc) Increased clinical demand TOTAL 210.75 69.25 70.25 71.25
REASON NORTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 4.5 216 128 88 0 Leave (Sickness, 1 32 0 32 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 248 128 120 0
REASON REASIDE & GRADE No of No of hours No of Hours worked No of hours TAMARIND 1 ST4- hours worked by by TRAINEES FY2s, worked by in 11 ROTA 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 5.5 192 0 192 0 Leave (Sickness, 1 32 0 32 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 224 0 224 0
17
REASON SOLIHULL 1 GRADE No of No of hours No of Hours worked No of hours in 11 ROTA ST4- hours worked by by TRAINEES FY2s, worked by 6/MG requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 7 312 280 32 0 Leave (Sickness, 1 40 40 0 0 Maternity etc). Restrictions (Pregnancy etc) Increased clinical demand TOTAL 352 320 32 0
REASON SOUTH 1 in GRADE No of No of hours No of Hours worked No of hours 11 ROTA SHO hours worked by by TRAINEES FY2s, worked by requested internal Trust GPVTS.CT1-3 & ST4-6 AGENCY Locums Vacancy 3 96 56 40 0 Leave (Sickness, Maternity etc). Restrictions 2 136 120 16 0 (Pregnancy etc) Increased clinical demand TOTAL 232 176 56 0
18
Item 9.6
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD/ COMMITTEE TO BE HELD ON WEDNESDAY 31 MAY 2017
STAKEHOLDER INSIGHT AND ENGAGEMENT WORK – FEEDBACK AND NEXT STEPS
Strategic ambition to which the paper reports:
• We will listen to and work alongside service users, carers, staff and stakeholders.
ACTION: Board members are asked to note the feedback recorded from the April Board seminar and the proposed next steps for this work.
ISSUES
Following discussions by the Board during 2016, since January 2017 we have been undertaking work to understand stakeholder perceptions of the Trust and how they would like to engage with us in future. At the Board seminar in April, the findings from a series of focus groups with a range of key senior stakeholders were presented, along with recommendations arising from these.
The attached paper outlines those recommendations and the outputs from the Board seminar session, outlines immediate actions and proposed next steps for this work.
BOARD DIRECTOR: Dave Tomlinson, Executive Director of Finance AUTHOR: Louise Butler, Head of Communications and Marketing
References: None
Page 6 of 6 Introduction
Since January this year, we have been undertaking work to understand stakeholder perceptions of the Trust and how they would like to engage with us in future. At the Board seminar in April, the findings and recommendations from a series of independently facilitated focus groups with a range of key senior stakeholders were fed back and Board members considered what actions the Trust should take in response.
Recommendations
Based on the findings of the study into stakeholder perceptions, the following recommendations were presented:
• Recommendation 1: Consult stakeholders early and often - Stakeholders want to be engaged early on and to be able to influence the future direction of the Trust.
• Recommendation 2: Provide feedback on all engagement activities with stakeholders – Results and Actions - Stakeholders want to feel that their views are being taken into account.
• Recommendation 3: Ensure that the Trust’s vision is communicated to SHs and is communicated consistently by individuals working for the Trust - Stakeholders need a better awareness of the Trust and want clarity of the Trust’s vision.
• Recommendation 4: Provide clarity about the Trust (such as roles and responsibilities) and what the Trust does and does not do - Stakeholders need a better awareness of the Trust and want clarity of the Trust’s vision.
• Recommendation 5: Formalise partnerships with stakeholders - Cat. 2 stakeholders want more formalised contact with the Trust.
• Recommendation 6: Increase opportunities for open dialogue and discussion with stakeholders - Stakeholders want more transparency in partnerships with the Trust.
• Recommendation 7: Create a formal engagement strategy and repeat this insight in the future to measure change/improvement.
Feedback from Board
The BSMHFT Board took part in a DEMAND tool activity that aimed to pull out actions based on the findings and recommendations presented. The full responses collected during the Board session can be seen in Table 1. The actions and enablers (which often could be interpreted as actions) suggested by the Board can be grouped broadly into themes and these are outlined below, with the theme in bold text and bullet points below each showing suggestions made by Board members, the detail of which is in Table 1.
Page 6 of 6
Actions to improve understanding of BSMHFT - Better explanation of what we can and can’t do (Action) - Explain the Trust’s focus on severe mental illness (Action)
Actions relating to engagement and improving partnerships - Go back and tell them what we’ve done (‘you said’, ‘we listened’, ‘we did’) (Action) - Board meetings with partners (Enabler) - Early engagement (Enabler) - Update our various engagement strategies (including the Membership and Governor Involvement Strategy) (Action) - More formalised understanding in the Trust – the script – key messages and who to engage with (Enabler) - Doing what stakeholders said they wanted – Terms of Reference, face to face contact etc (Enabler) - Director of Strategic Partnerships to focus on these (Enabler) - Change of mindset (ours and theirs) (Enabler) - Investment in time and resources (Action)
Actions relating to communications - More good news stories (Action) - Media strategy and more media training (Action) - Targeted stakeholder communications (Enabler) - Put more resources into communications and marketing (Enabler)
Actions focusing on the community - Get alongside the community and others to argue for more resources (Action) - Focus on population issues (Action)
Actions we can take now
Some identified ‘quick wins’ and immediate actions are as follows:
• Ensure targeted and clear stakeholder communications about the new Trust strategy, vision and strategic ambitions. • Introduce a monthly targeted stakeholder e-bulletin to include successes and achievements, current developments, new partnerships etc. • Feed back to stakeholders on where we are with this work, how their input to date has already been taken on board (eg their feedback on our strategic ambitions) and how we will continue to engage with them. • Review other existing engagement strategies/plans in the Trust in light of the stakeholder feedback – eg membership and governor involvement, community engagement. • Discuss resource going forward for stakeholder engagement and insight.
Page 3 of 5
Next Steps
Some of the actions and enablers noted above are part of the Communications and Marketing Strategy that was approved by Board in March 2017:
• Strengthening media relations and PR including media training. • Reviewing and developing the Communications and Marketing skillset/resource and re-focusing resource from internal to external communications and marketing. • Communicating a clear and consistent vision for the Trust.
We will continue to develop the stakeholder strategy, with the recommended steps as follows:
• Further engagement with Board, along with Governors, at joint seminar - June 2017. • Engagement with and input from senior leaders (via senior leaders forum) - July 2017. • Engagement with and input from the new Director of Strategic Partnerships – August. • Outputs of the above to feed into a wider questionnaire to go to all Trust stakeholders, to ensure wide engagement and input into the strategy across a broad range of stakeholders – August/early September. • Cleanse and enhance wider database of Trust stakeholders (500+ individuals) – August 2017. • Finalise strategy – late September/early October.
Page 4 of 5 Table 1: DEMAND tool responses Driver Enabler Motive Action Network Demonstrate • Better services • Appoint new Director • BSMHFT will change • Better explanation of what • Good value for delivered. of strategic and be in a different we can and can’t do. money. partnership to focus form – to survive and • Minimise economic on these. succeed. and social cost through prevention and treatment.
• Help people • People think what • Explain focus on severe • Good news! understand what we • Board meetings with we do is wrong. mental illness. • Recovery! do. partners. • Get alongside comm + • Benefits to society! others to argue for more resources. • Focus on population issues. • Good news stories. • Better outcomes for • Change of mindset • Greater chance of • Director of Strategic • Better local MH • Leadership patients. (ours + theirs). success. Partnerships networks • Local engagement • What benefits? • Need to work in • Put more resources • Improved services • Go back and tell them • Clinical networks • Invite people to partnership for sake into comms + and health and what we’ve done (‘you (our clinicians) recognitions awards of SUs marketing wellbeing said’, ‘we listened’, ‘we • NEDs (already invite some • Better comms • Service users want did’). • Governors SHs) • Reputation will drive • Early engagement us to do it • Media strategy + more • Ambassadors • More showcase other • PR • Help us deliver our media training • Service user and events opportunities/growth • Doing what they said vision • Plan. carer network • Entering for more they wanted TORS, • Investment in time + • Comms networks awards F2F etc resources. • Volunteers • More formalised • Place more news stories. • Do more networking understanding in the • Update our various with universities we Trust – the script – engagement strategies don’t have key messages and (inc mem + gov one) [governors] from to who to engage with. collaborate. • Councillors • GP networks
Page 5 of 5
Item 9.7
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31st MAY 2017
DECLARATION OF INTERESTS Strategic or Regulatory Requirement to which the paper reports – • NHSI Well Led Framework • Constitution
ACTION: The Board is ask to note the contents of the updated Declarations of Interests for Board members and confirm any changes ISSUES
In accordance with the Trust’s Constitution a register of interests is maintained in respect of interests of Board and Governors. The updated register of interests for the Board of Directors is provided below. The Governors declarations of interest will next be updated in September 2017.
Board members have been providing updated declarations throughout the year (which includes compliance with the Fit and Proper Persons Test) and have completed the new forms in line with the revised Declaration Policy.
Updates since the Board Declarations were last received in March 2017 are highlighted in bold.
BOARD DIRECTOR SPONSOR: Deborah Lawrenson, Company Secretary REPORT AUTHOR: Deborah Lawrenson Company Secretary
APPENDIX: Appendix 1 – Board Declarations as at 25 May 2017
Page 1 of 6 Appendix 1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD DECLARATION OF INTERESTS – AS AT 25 MAY 2017
Name Interest Organisation details Gifts, Hospitality and Sponsorship Sue Davis (Chair) Director of lobbying West Midlands Constitutional None organisation Convention
Vice Chair NHS Providers Association
Chair of Joint Audit West Midlands Police Committee
*Husband Councillor - *Birmingham City Council Billesley Ward
*Husband Lay Manager *BSMHFT of BSMHFT Nephew and Niece (by marriage) employees of BSMHFT
John Short (Chief None None Received Executive) Brendan Hayes None None None (Chief Operating Officer and Deputy Chief Executive)
Sue Hartley None None None (Director of Nursing)
Hilary Grant None None None (Medical Director) In post from April 2016 Barry Henley Birmingham City Council Councillor None (NED) Service Birmingham Director
King Edwards Schools Governor
Joy Warmington Chief Executive Officer BRAP None (Non- Executive Director and Steering Group Member WRES Deputy Chair) (stepped down September 2016)
Page 2 of 6 Trustee (Stepped down National Voices in July 2016)
Member Birmingham and Solihull social economy consortium
Secondment on special NHSE projects working in the public, patient and participation team from 1st September until March 2017
Trustee Migrant Voice – appointed Feb 9th 2017
Dr Nerys Williams Member of Independent Solihull MBC and WMCA Received (NED) and Senior Remuneration Panels Independent Director Honorary Associate University of Warwick Professor
Speciality Doctor – left Heart of England NHS Trust Dec/January 2015/16
Examiner PLAB Fitness General Medical Council to Practice Instrument Development and Associate advisor on reasonable adjustments for examination candidates
Pilot OSCE writer and ACME at UCL assessor
Editorial Assistant and Editorial Board of Society of Editorial Board member Occupational Medicine Journal
Occupational Physician PWC Advisor, Clinical Advisory Group advising PWC on clinical audit of HML delivery of FFWs (from Nov 2015 until October 1 2016. As at October 2016 working as an External Consultant for PWC
Lectures on occupational AWP health and articles
Page 3 of 6 Waheed Saleem Trustee & Non-Executive NACRO Received (NED) Director (Stepped down in March 2017)
Trustee (Stepped down NACRO Pension Fund in March 2017)
Owner / Director WS Associates Midlands (Dormant Company) Limited
Ambassador Caring Minds Charity
Director and Registered Sahaara Care Limited (social Manager – ended care provider) October 1st 2016
Trustee (resigned Amirah Foundation (anti- Febuary 2017) domestic violence charity)
Non-Executive Director Officer of the West Midlands Police and Crime Commissioner
Non-Executive Director Paycare
Integrated Project Public Health England Manager – from September 5th 2016 – ended 1st December 2016
Managing Director Walsall Alliance Limited (Walsall Alliance has business relationships with a range of pharmaceutical companies in the form of sponsorship and grants for services. A list of pharma companies has been provided to the Company Secretary Gianjeet Hunjan College Finance University of Birmingham None (NED) Manager
Chair – West Midlands ACCEA
Governor Oldbury Academy
Governor Ferndale Primary School Russell Beale Director, shareholder – CloudTomo None (NED) from security company pre- January 1st 2017 commercial
Founder and minority BeCrypt
Page 4 of 6 shareholder – computer security company
Director, 100% azureindigo shareholder – company undertaking work on behaviour change, education and other health activities amongst others
Professor University of Birmingham
*Spouse is a consultant *BCH in Paediatric A & E and a co-director of azureindigo
Journal Editor, Interacting with Computers Interacting with Computers
Governor Hodnet Primary School
Honorary Race Coach Worcester Schools Sailing Association
Non-Executive Director Walsall Healthcare NHS Trust
External Examiner University of Southampton
PHD examiner Various UK and International Universities
Member EPSRC
Evaluator Various international government or research organisations
Dave Tomlinson 95 % shareholder and DEAT Consulting Limited None Director of Director which has previously Finance provided services to the NHS
Deborah Company Secretary Summerhill Supplies Ltd None Lawrenson (Company Gifts, Hospitality and Secretary) Sponsorship
Page 5 of 6
Page 6 of 6
Item 9.7
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31st MAY 2017
DECLARATION OF INTERESTS Strategic or Regulatory Requirement to which the paper reports – • NHSI Well Led Framework • Constitution
ACTION: The Board is ask to note the contents of the updated Declarations of Interests for Board members and confirm any changes ISSUES
In accordance with the Trust’s Constitution a register of interests is maintained in respect of interests of Board and Governors. The updated register of interests for the Board of Directors is provided below. The Governors declarations of interest will next be updated in September 2017.
Board members have been providing updated declarations throughout the year (which includes compliance with the Fit and Proper Persons Test) and have completed the new forms in line with the revised Declaration Policy.
Updates since the Board Declarations were last received in March 2017 are highlighted in bold.
BOARD DIRECTOR SPONSOR: Deborah Lawrenson, Company Secretary REPORT AUTHOR: Deborah Lawrenson Company Secretary
APPENDIX: Appendix 1 – Board Declarations as at 25 May 2017
Page 1 of 6 Appendix 1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD DECLARATION OF INTERESTS – AS AT 25 MAY 2017
Name Interest Organisation details Gifts, Hospitality and Sponsorship Sue Davis (Chair) Director of lobbying West Midlands Constitutional None organisation Convention
Vice Chair NHS Providers Association
Chair of Joint Audit West Midlands Police Committee
*Husband Councillor - *Birmingham City Council Billesley Ward
*Husband Lay Manager *BSMHFT of BSMHFT Nephew and Niece (by marriage) employees of BSMHFT
John Short (Chief None None Received Executive) Brendan Hayes None None None (Chief Operating Officer and Deputy Chief Executive)
Sandra Betney Director NHS Trading Summerhill Supplies Limited Received (Director of Resources) Audit Committee British Horse Society (Charity) member
Finance and General NHS Providers Formally known Purposes Committee as FTN Foundation Trust member Network)
Director from June 2016 FTN Trading Limited Sue Hartley None None None (Director of Nursing)
Hilary Grant None None None (Medical Director) In post from April 2016 Barry Henley Birmingham City Council Councillor None
Page 2 of 6 (NED) Service Birmingham Director
King Edwards Schools Governor
Sukhbinder Singh- Chairman Mayfair Capital LLP NA Heer (NED) (Left the Trust in June Non-Executive Director Hadley Industries Plc 2016 declarations correct as at the Member Chairman’s Birmingham Symphony time of departure) circle Hall
Chairman SSH Associates Ltd
Chairman Premium Hotels Limited
Chairman Aviramp Limited
Chairman Selwyn Lloyd Bespoke Limited
Non-Executive Director Birmingham Community (from Nov 1st 2015) Healthcare NHS Trust. Joy Warmington Chief Executive Officer BRAP None (Non- Executive Director and Steering Group Member WRES Deputy Chair) (stepped down September 2016)
Trustee (Stepped down National Voices in July 2016)
Member Birmingham and Solihull social economy consortium
Secondment on special NHSE projects working in the public, patient and participation team from 1st September until March 2017
Trustee Migrant Voice – appointed Feb 9th 2017
Dr Nerys Williams Member of Independent Solihull MBC and WMCA Received (NED) and Senior Remuneration Panels Independent Director Honorary Associate University of Warwick Professor
Speciality Doctor – left Heart of England NHS Trust Dec/January 2015/16
Examiner PLAB Fitness General Medical Council to Practice Instrument Development and Associate advisor on
Page 3 of 6 reasonable adjustments for examination candidates
Pilot OSCE writer and ACME at UCL assessor
Editorial Assistant and Editorial Board of Society of Editorial Board member Occupational Medicine Journal
Occupational Physician PWC Advisor, Clinical Advisory Group advising PWC on clinical audit of HML delivery of FFWs (from Nov 2015 until October 1 2016. As at October 2016 working as an External Consultant for PWC
Lectures on occupational AWP health and articles
Waheed Saleem Trustee & Non-Executive NACRO Received (NED) Director (Stepped down in March 2017)
Trustee (Stepped down NACRO Pension Fund in March 2017)
Owner / Director WS Associates Midlands (Dormant Company) Limited
Ambassador Caring Minds Charity
Ambassador (Stepped Sahaara Care Limited (social down in March 2017) care provider)
Director and Registered Manager – ended Amirah Foundation (anti- October 1st 2016 domestic violence charity)
Non-Executive Director Officer of the West Midlands Police and Crime Commissioner
Non-Executive Director Paycare
Non-Executive Director Public Health England (resigned in November 2016)
Integrated Project Walsall Alliance Limited (Walsall
Page 4 of 6 Manager – from Alliance has business September 5th 2016 – relationships with a range of ended 1st December pharmaceutical companies in 2016 the form of sponsorship and grants for services. A list of Managing Director pharma companies has been provided to the Company Secretary Gianjeet Hunjan College Finance University of Birmingham None (NED) Manager
Chair – West Midlands ACCEA
Governor Oldbury Academy
Governor Ferndale Primary School Russell Beale Director, shareholder – CloudTomo None (NED) from security company pre- January 1st 2017 commercial
Founder and minority BeCrypt shareholder – computer security company
Director, 100% azureindigo shareholder – company undertaking work on behaviour change, education and other health activities amongst others
Professor University of Birmingham
*Spouse is a consultant *BCH in Paediatric A & E and a co-director of azureindigo
Journal Editor, Interacting with Computers Interacting with Computers
Governor Hodnet Primary School
Honorary Race Coach Worcester Schools Sailing Association
Non-Executive Director Walsall Healthcare NHS Trust
External Examiner University of Southampton
PHD examiner Various UK and International Universities
Member EPSRC
Page 5 of 6
Evaluator Various international government or research organisations
Deborah Company Secretary Summerhill Supplies Ltd None Lawrenson (Company Gifts, Hospitality and Secretary) Sponsorship
Page 6 of 6 Item 10.1
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
INTEGRATED QUALITY COMMITTEE REPORT FOR MAY 2017
Strategic or Regulatory Requirement to which the paper reports: Providing assurance to the Board on the work undertaken by the Committee. Putting Service Users at the Heart of everything the Trust does.
ACTION: The Board is asked to note the contents of the report.
Executive Summary The Integrated Quality Committee last met on 24th May 2017 and discussed the following: • Solar update presentation and discussion – The Committee received a presentation on the work of the Solar service. • Assurance of Local Governance Arrangements - The Associate Director of Governance raised the key issues from the Trust Clinical Governance Committee. IQC discussed the initial results of the prone restraint audit and requested that a deeper dive into the data. The Committee requested that the Executive Team review the issue of the experience of PICU’s given the numbers of one to one observations and the additional staffing requirements • Risk Register – The Committee discussed the possible inclusion of three additional risks to the register. IQC also asked for the scoring of the risk on the delayed recruitment of Mental Health Act Administrators to be reviewed. • Integrated Quality Report Q4 2016-17 – The report was presented to the Committee to enable members to understand the progress the Trust was making in delivering its quality priorities. The Committee discussed the issue of new psychoactive substances (NPS) and the effect these are having on the Trust and service users. • People Plan – The Deputy Director of Workforce and Inclusion discussed the progress of the key deliverables within the plan, and outlined the actions concentrating on the 3 key issues emerging from the Staff Opinion Survey. • Integrated Patient Experience & Recovery Report – the Head of Patient Experience and Recovery updated IQC on the progress that had been made on the recovery goals. The Committee requested that the key themes deriving from the Friends and Family Test are included in the next report to IQC • Clinical Senate Report – The Committee received and update of the work carried out through the Senate and had a lengthy conversation on the Prevent agenda and questioned how the Trust could better engage with the programme.
Items for Escalation:
• None raised
BOARD DIRECTOR SPONSOR: Joy Warmington Non-Executive Director
REPORT AUTHOR: Dan Conway, Board Support Officer
PREVIOUSLY DISCUSSED: NA
Page 1 of 1
Item 10.2
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
FINANCE, PERFORMANCE, AND PRODUCTIVITY COMMITTEE REPORT Strategic or Regulatory Requirement to which the paper reports: Providing assurance to the Board on the work undertaken by the Committee. ACTION: The Board is asked to note the contents of the report. Executive Summary The FPP last met on 24th May 2017 and discussed the following in detail: • Acute and Urgent Care Service Area Presentation • Additional acute beds – the committee was updated on discussions with commissioners around potential options • Finance report – was discussed in detail prior to the May Board. This demonstrated a strong position at the outset of the financial year. It was noted that consideration was being given to future format and content of the report. • Capital Programme (including disposals) – The year to date capital expenditure were discussed and noted. An updated plan, to include the DoH funding of £5m over three years for the digital exemplar project, will be received at the next meeting of the committee. • Agency Spend – excellent progress with agency spend in month was noted. The committee have agreed to have a deep dive on this issue at a future meeting. • Performance Report – The performance and actions in relation to the national, commissioner and local key performance indicators were presented and discussed. • Savings Project Board – An update to the current projects was received by FPP and the strong position at the outset of the financial year was commended – discussion took place on schemes under development • Estates Strategy – was discussed and approved for recommendation to the Board • Procurement Strategy Annual Review – an update on delivery of the strategy was received and accepted and the committee noted the end of the joint arrangements with BCHC • Corporate Records Management Strategy – was received and approved • EPMA Evaluation Report – in discussion with the committee it emerged that there is a risk of end of support for EPMA before the end of the economic life of software. The committee felt that this posed a risk that this might lead to possible system failure and the Trust writing off its investment. • NHS Cyber Attack – An update on the Trust response to the recent cyber attack on NHS systems was discussed. It was noted the Trust had been cited as one of the most effectively responsive to the situation.
Items for Escalation: • Estates Strategy was approved for recommended ratification at Board • A risk related to EPMA was raised by the Chair of the Committee at the Audit Commtitee
The minutes of the meeting will be circulated to Board members. BOARD DIRECTOR SPONSOR: Barry Henley, Non-Executive Director and Chair of FPP REPORT AUTHOR: Deborah Lawrenson, Company Secretary
Page 1 of 1 Item 10.3
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
TRUST BOARD TO BE HELD ON WEDNESDAY 31 MAY 2017
AUDIT COMMITTEE REPORT Strategic or Regulatory Requirement to which the paper reports: Providing assurance to the Board on the work undertaken by the Committee. ACTION: The Board is asked to note the contents of the report which provides an update on discussions at Audit Committee in May 2017 Executive Summary Summary of discussions at the meeting held on 24th May 2017: • Head of Internal Audit Opinion - The Core Internal Audit - significant assurance confirmed as there is a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. • External Audit (PWC) - The Committee received the report on the Annual Accounts, – unqualified opinion and unmoderated report was given by the auditors. • The Committee approved the Annual Accounts. • Report on the Quality Account (PWC) – The Committee received the report on the, Quality Account – unqualified opinion and unmoderated report was given by the auditors
• The Committee amended and approved the Annual Report 2016-17 including Quality Account and Annual Governance Statement. • The Committee amended and approved the letters of representation for Quality Report. • The Committee approved the letters of representation for the Financial Statements. • The Committee approved the Directors Statements and Certificates.
• The Committee received the Corporate Risk Register and agreed that the potential three new high level risks discussed at the IQC in May should be reviewed for inclusion, and approved the BAF for presentation to the Board. • The Committee formally thanked Internal Audit for their work and External Audit, Finance, Communications and the Governance teams for their work on the annual report and through the review process. • The updated terms of reference are attached for approval
Items• for Escalation: • None
BOARD DIRECTOR SPONSOR: Gianjeet Hunjan, Non-Executive Director and chair of the Audit Committee meeting REPORT AUTHOR: Daniel Conway, Board Support Officer
APPENDIX: PREVIOUSLY DISCUSSED: NA
BIRMINGHAM AND SOLIHULL MENTAL HEALTH FOUNDATION TRUST
AUDIT COMMITTEE
TERMS OF REFERENCE
1 Authority
1.1 The Audit Committee is constituted as a Standing Committee of the Trust Board of Directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future Board of Directors meetings.
1.2 The Committee is authorised by the Trust Board to request the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary.
2 Purpose
2.1 The Committee is authorised by Trust Board to carry out any function within its terms of reference.
2.2 The Committee shall request and review reports and positive assurances from directors and managers, on the overall arrangements for governance, risk management and internal control and will provide assurance on these to the Board.
2,3 The Committee is delegated and authorised by the Board to:
• Investigate any activity within its terms of reference. • Seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. • Obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. • Recommend the annual accounts and report (including the Quality Account and Charitable Funds Accounts) to the Board for approval
2.4 They may also request specific reports from individual functions within the organisation as it may deem appropriate to provide assurance on overall governance arrangements.
3. Duties
3.1 Governance, Risk Management and Internal Control
3.1.1 The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical) that supports the achievement of the organisation’s objectives.
3.1.2 In particular, the Committee will review the adequacy of:
• All risks and controls related to disclosure statements (in particular the declarations of compliance with the CQC regulations and requirements for the Annual Report and Accounts and the Annual Governance Statement), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to approval by the Board • The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements • The policies and procedures for all work related to fraud and corruption as set out in Secretary of State directions and as required by the Counter Fraud and Security Management Service
3.1.3 The Committee will ensure that the process for managing risks is sound and will recommend top risks to be included in the Board Assurance Framework received by the Board.
3.1.4 In carrying out its work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the overarching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it
3.1.5 The committee will have delegated authority from the Board to receive and approve changes to the Standing Orders, Standing Financial Instructions and Scheme of Delegation.
3.2 Internal Audit
3.2.1 The Committee shall ensure that there is an effective internal audit function appointed in line with the scheme of delegation and that it meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by:
• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation dismissal; as well as agreeing the adequacy of the procurement process • Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation including those identified in the Assurance Framework • Consideration of the major findings of internal audit work (and management’s response), and ensure co-ordinationbetween the Internal and External Auditors to optimise audit resources • Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation • Annual review of the effectiveness of internal audit
3.3 External Audit
3.3.1 The Committee shall review the work and findings of the External Auditor and consider the implications and management’s responses to their work. This will be achieved by:
• Consideration of the appointment and performance of the External Auditor, in order for a recommendation to go to the Council of Governors, whose role it is to appoint the external auditors • Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensure coordination, as appropriate, with other External Auditors in the local health economy • Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee • Review all External Audit reports, including receipt of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses • Consider any non-audit work to ensure external audit retain independence
3.4 Other Assurance Functions
3.4.1 The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health arms-length Bodies or appropriate regulators/inspectors.
3.4.2 In addition, the Committee will review the work of other committees within the organisation, whose work can provide relevant assurance to the Audit Committee’s own scope of work. This will particularly include the Clinical Governance Committee, and any Risk Management committees that are established, as well as receiving or seeking assurances as appropriate, from the other board sub committees.
3.4.3 In reviewing the work of the Clinical Governance Committee, and issues around clinical risk management, the Audit Committee will wish to satisfy themselves on the assurance that can be gained from the clinical audit function.
4. Membership
4.1 The membership of the committee will be: • Chair – Non-Executive Director • Deputy Chair – Non-Executive Director • At least two other non-Executive or Associate Non-Executive Directors • 4.2 Others required to attend the committee will be: • Executive Director of Finance • Company Secretary
4.3 Invitations for attendance of others will be issued by the Chair of the committee in line with the requirements of the agenda.
4.4 The Chief Executive should be invited to attend, at least annually, to discuss with the Audit Committee the process for assurance that supports the Statement on Internal Control. Other Non-Executive Directors who are not members of the committee may attend with the agreement of the Chair of the committee. The Trust Chair will attend at the invitation of the Chair of the committee.
4.5 All members will have one vote. In the event of votes being equal the Chair of the committee will have the casting vote.
4.6 Appropriate Internal and External Audit representatives shall normally attend meetings, although are not entitled to vote. However at least once a year the Committee should meet privately with the External and Internal Auditors.
5. Quoracy
5.1 A quorum shall be two members of the committee.
6. Declaration of interests
6.1 All members and attending officers must declare any actual or potential conflicts of interest in advance. These must be recorded in the minutes. Members must exclude themselves from any part of the meeting where a potential or actual conflict of interest may occur.
7. Meetings
7.1 Meetings shall be held not less than three times a year. The External Auditor or Head of Internal Audit may request a meeting if they consider that one is necessary.
7.2 Meeting dates will be agreed annually in advance by the members of the committee.
7.3 To include as a standing item on every agenda the Committee should review how effectively it has discharged its business.
8. Administration
8.1 The meeting will be closed and not open to the public.
8.2 The Company Secretary will ensure there is appropriate secretarial and administrative support to the committee.
8.3 An Action List and minutes will be compiled during the meeting and circulated within 7 calendar days of the end of the meeting.
8.4 Any issues with the Action List or minutes will be raised within 7 calendar days of issue.
8.5 The Company Secretary will agree a draft agenda with the committee chair and it will be circulated 7 calendar days before the meeting.
8.6 Any issues with the agenda must be raised with the committee chair within 4 working days.
8.7 All final committee reports must be submitted 7 calendar days before the meeting.
8.8 The agenda, minutes and all reports will be issued 6 calendar days before the meetings.
9. Reporting
9.1 The committee will report to Trust Board at the next meeting reporting on any significant issues.
9.2 The committee will review their effectiveness on an annual basis, reporting the outcome of the review to Trust Board.
9.3 The committee Chair will present to the Council of Governors annually a report on the work of the committee
Received at the May 2017 Audit Committee for approval Item 11
Birmingham and Solihull Mental Health NHS Foundation Trust Minutes of Public Trust Board meeting Wednesday 26th April 2017 at 9.30am Plymouth room, Uffculme Centre, Moseley, Birmingham Present Sue Davis Chair (SD) John Short CEO (JS) from item 2 Brendan Hayes Chief Operating Officer and Deputy CEO (BGH) David Tomlinson Executive Director of Finance (DT) Sue Hartley Executive Nursing Director (SH) Barry Henley Non-Executive Director (BSH) Nerys Williams Non-Executive Director (NW) Waheed Saleem Non-Executive Director (WS) Gianjeet Hunjan Non-Executive Director (GH) Russell Beale Non-Executive Director (RB) Joy Warmington Non-Executive Director (JW) Hilary Grant Executive Medical Director (HG) Robert Pickup Deputy Finance Director (RP)
There were no apologies
In attendance Deborah Lawrenson Company Secretary (DL) Dan Conway Board Support Officer (DCC) Alison Simpson Head of Service User Involvement (for the patient story) (AS) Louise Butler Head of Communications (LB) Esperance Makiese PA for Dave Tomlinson (EM) Shane Bray SSL (SBr) for item 15
Governors Maureen Johnson Carer Governor (MJ) Hazel Kench Public Governor Solihull (HK) Anthony Brookes Carer Governor (AB) Peter Brown Service User Governor (PB)
Patient Story
The Board received a presentation from a service user who had spoken to the Board, two years previously . He outlined support he had received both within inpatient and community services and spoke about his voluntary work with the Trust through the Recovery College for which he was hoping to become a Peer Support Worker.
1. Questions from Governors and members of the public 1.1 MJ stated that an issue had been raised with her through a Solihull GP practice with her with regard to difficulties they had experienced in connecting with individuals in CHMTs and they had asked if it were possible for there to be named links. BGH explained that all Solihull GPs have been given a named practitioner, and following the upcoming service changes this would be further supported by the planned appointment of an IAPT person in each practice.
1.2 MJ noted that she had heard from constituents that it was their experience that LD and MH services were not ‘talking to one another’ with regard to providing support to people with dual assessments. SD confirmed that there had been a recent consultant appointment in the area
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which would support improvements in this.
1.3 PB informed the Board that service users had raised some concerns with him with regard to trusting and bonding with both agency and bank staff in inpatient units which was noted.
2. Apologies 2.1 No apologies were received.
The Chair welcomed Dave Tomlinson to the Board noting that he was undergoing a period of induction and would be taking on the full role of Director of Finance from May 1st 2017. She also welcomed Rob Pickup who was present as Acting Director of Finance and Esperance Makiese newly appointed PA who was attending the meeting as part of her induction and to support learning for covering Board minute taking at the May Board.
3. Declarations of Interests 3.1 None declared
4. Chair’s Report 4.1 None raised
5 Chief Executive’s Report 5.1 None raised
6. Director of Nursing Report 6.1 SH presented the Quality of Clinical Services highlighting the following from her report:
• Improvements achieved in the vast majority of our quality goals when compared to the 2015/16 outturn position. One standard was showing deterioration against 2015/16 outturn position which related to the number of physical assaults on staff on inpatient wards.
• The Trust had increased the number of individuals trained in Level 2 smoking cessation and now have at least 2 trained individuals on each inpatient site.
• The Trust Policy states that e-cigarettes are not to be supplied to service users and they may only be used on section 17 leave or by informal patients. She confirmed the Deputy Director of Nursing was looking at the approach at other Trusts on this issue and a further update will be given in due course.
• key statistics relating to overall levels of activity for 2016/17 through the Customer Relations Department:-
o 157 complaints were registered in 2016/17 showing an increase in comparison to 131 received for 2015/16.
o 885 PALS resolutions were recorded in 2016/17 showing a reduction in comparison to 949 for 2015/16.
• There were a total of 93 deaths reported in March 2017. Nine will receive a full RCA review, nine were downgraded as they were not previously known to the Trust and 73 will receive a management report (natural causes). From next month, the mortality review process will go live and further deaths may be subject to a mortality case note review.
6.2 With regard to e-cigarettes BSH noted the issue had been raised in his visit to Mary Seacole and added that the CQC report on the unit in January had been critical about the management of the smoking ban, he noted that staff had suggested that had e-cigarettes been available the management of the ban would have been smoother.
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6.3 ACTION: SD and SH to discuss when the report on the use of e-cigarettes should come back to Board. (tbc)
6.4 NW asked what had changed if anything with regard to assaults on staff, if there were any emerging trends and if there was anything further which could be done to prevent them.
6.5 HG explained that the Positive and Proactive Care Group were looking at the detail and work had been taking place with the police to progress the agenda around response when assaults take place. She confirmed that the work around safe wards will be audited and staff had improved in terms of reporting. JS asked for confirmation when a report on the impact of safe wards could be expected. It was agreed HG will advise when this could be received at IQC.
6.6 ACTION: HG to identify when the Positive and Proactive Care Group Safewards report will come through IQC and Board. (TBC)
6.7 JS informed the Board that the final draft NHS England report on the actions following the death of Christina Edkins and support provided to Phillip Simelane had been received by the Trust and was due to be published on 3rd May 2017. He confirmed he was confident actions assigned to the Trust have been completed and the Board formally apologised to the family in 2014. He noted that it was his intention to ensure the Board is informed in advance of final publication.
6.8 WS congratulated the positive efforts of the complaints team but noted that there were common themes around basic issues on wards and asked how the Board and the organisation will be looking at these in order to effectively share learning.
6.9 GH asked if the themes were the same as in previous years and if so what action had been taken. SH commented that with the volume of the contacts seen by the Trust the numbers of complaints coming through was not disproportionate and all complaints are reviewed and followed through, She added that common issues were being addressed through the People Plan
7. Medical Director’s Report 7.1 HG talked through the report highlighting the following:
• Recruitment in psychiatry remains a national challenge with vacancies often occurring because trainees are choosing other specialities. • HR is currently undertaking a review on internal locum pay rates to look at options for varying existing pay rates in order to fill short term gaps on rotas without relying on agency.
• Trainees on existing contracts in the Trust, will remain on these until the end of their tenure unless they request to move to the new contract before the end of their current tenure. In line with the requirements of the 2016 Contract, the Trust is required to ensure that any doctor who is employed on the 2016 contract is working on a rota which complies with the 2016 contract rules.
• The positive and proactive care workstream has begun by identifying priority areas such as restrictive practice and identifying benchmarking data and information that will enable further evaluation to take place. The Safewards programme forms part of this workstream and all inpatient wards have now had initial information delivered to enable them to enact all modules of the Safewards approach.
• The first Excellence in Psychology event was held on March 17th bringing together psychologists and psychological therapists from across the trust to share their skills and knowledge through a series of workshops followed by showcase presentations and an awards ceremony.
• Following discussion and agreement by the executive team and the Chair of Mental Health Legislation Committee (MHLC), it was agreed that the responsibility for the MHA
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administrators will move to a new reporting structure, consultation is underway with staff involved.
• There has been a delay in completion of Year 2 of the new job planning process which had been due for completion by 31st December 2016, in order to await completion of the restructuring of Clinical Directors roles and responsibilities.
7.2 JW asked how the Trust are managing the Junior Doctors contract issues and if there was an impact on individual services. HG explained that the main issue was around gaps in on-call rotas as doctors move across to the new contract but that mitigation plans were in place to deal with this.
7.3 NW asked, in relation to the psychology excellence day, if this approach would be replicated across other services. SH confirmed there were a range of celebrations taking place within the professions but that it may be helpful to consider putting in place a multi-disciplinary excellence day in the future.
7.4 JS commented that with regard to the number of vacant medical posts, the Trust was undertaking a significant recruitment drive. He noted that the challenge would be around ensuring services continue to be safe and appropriately staffed, despite the NHSE target regarding restriction on use of locums. Discussion took place whether it would therefore be appropriate for the Trust to choose not to comply with the locum target.
7.5 ACTION: HG to review if a proposal to not accept the locum target was acceptable and include the detail in the May 2017 Medical Director’s Report. HG
8. Chief Operating Officer Operational Escalation Report 8.1 BGH provided an updated on the following issues from his report:
• All Urgent Care staff are now undergoing a period of consultation, due to complete by the end of May 2017, to align their shift patterns.
• The Acute & Urgent Care service area has been successful in securing some dedicated funding to enable testing and piloting of the Red2Green approach in mental health. Whilst this has been implemented widely the acute sector it is in the early pilot stages in the NHS and the Trust is one of three sites chosen to pilot this.
• Although there has been an improvement in some of the older service users Delayed Transfers of Care, concerns have been raised in relation to the local authority SPROC NET system. This is a system where patents needs are placed on a database by the local authority and nursing homes bid to provide a placement. At times no nursing homes come forward and it adds delays to the process of discharge.
• The newly updated Ardenleigh Houses are to be renamed Rookery Gardens.
• National Offender Management Service (NOMS) have now confirmed agreement to share the second draft report of the formal inquiry into December’s prisoner riot at HMP Birmingham, by the end of April 2017.
8.2 SD informed the Board that she had spoken to the chair of the CQC on issues around prison care and was informed that CQC is aware of national concerns in this area; the CQC Chair was planning his own prison visits to look at conditions ‘on the ground’.. 8.3 ACTION: It was agreed a Board seminar should take place on the Red2Green patient flow tool. BGH (TBC)
8.4 SH added that she had received the draft prison NOM’s report and shared this with the Chief Executive. She added that the Trust would need to feedback on factual accuracy of the findings. WS asked if the Trust had received the report on the riot itself. SH confirmed that this had yet to
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be received. 8.5 JW questioned if the partnerships on addictions services needed strengthened. BGH stated that a conversation had been held with the partners and it had been agreed a workshop would be facilitated to discuss issues and agree actions required. 8.6 ACTION: BGH to include detail of the partnership workshop in respect of the addictions service, in the next report. (May 2017) 8.7 JS confirmed that NHS England have confirmed they will not be commissioning the CAMHS PICU beds as originally expected. RB asked whether this decision was challengeable. JS said that it was but it would not be any benefit for the Trust. RP added that NHS England had indicated in their letter that there would be a future tender process. HG noted her concerns for the staff in the service given the uncertainty there had been. 9. People Report 9.1 BGH drew attention to the following issues from his report:
• The Trust agreed three High Impact changes in response to the Staff Opinion Survey Results. The first of these “High Impact Changes” was to address Health and Wellbeing. To address Health and Wellbeing, an Annual Plan for 2017/18 had been developed. The other two, Bullying and Harassment and Team Working will be addressed at the May and June Board of Directors meeting respectively.
• Agency performance for March 2017 was strong, and culminates much work by many during the year. The monthly spend in March 2017 was £548,330, which is £120k below the NHSI target. The annual position was £9.22m, which is £1.1m over the NHSI target for 2016/17. The Audit Committee raised concerns on the e-rostering system and discussions are underway to improving this.
• There are currently three live suspension cases. Since the previous report to the Board, four cases have been concluded. The outcomes in relation to these are that one employee has been subject to a downgrading from their position alongside a final written warning being issued, one case is pending a hearing outcome and the employees in relation to the other two cases have resigned during the course of the disciplinary investigation. However the investigations were completed despite this in line with safeguarding obligations and the appropriate professional bodies notified. Recruitment analysis and team brief will be launch shortly.
9.2 WS raised that recruitment analysis was showing lower figures for certain areas and asked what the actions to rectify this are. BGH stated that meetings had been set up to look at the obstacles staff are facing in not just recruitment but also achieving internal promotions.
9.3 The Board agreed that the WRES report does not show the Trust in a good light. BGH confirmed that as part of the Listen Up process an ongoing staff survey would be included in the future.
9.4 ACTION: WRES report data report to come to Trust Board for discussion (May 2017) BGH
9.5 The Board asked why there are ongoing issues on the e-rostering audit. BGH said that initially it was due to lack of a skill set, capacity and performance management of the process and agreed a revised PMO report should be produced shortly. 10. Resources Report 10.1 RP talked through the resources report and highlighted:
• The consolidated position at the end of month 12 is a surplus of £2.8m after the ‘£ for £’ incentive funding of £846k which will be received along with the bonus incentive funding of £872K.
• Healthcare Income has under recovered by £910k against plan. The under recovery is
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mainly due to under performance on FCAMHS of £1.3m and cost and volume contracts of £667k.
• The Trust, in negotiation with the landlord, has surrendered the lease on Miller Street early, at a cost of £200k, this is £90k less than the contractual value.
• The Consolidated Single Oversight Framework (SOF) was a 3 at month 12. This was due to the override rule as capital servicing rating has deteriorated to a 4. This was due to a worse EBITDA position as a result of savings delivered through capital financing schemes. This would return to a 2 for 2017/18.
• The Trust has been selected as one of Seven Mental Health Global Digital Exemplar sites to pioneer world class digital services to improve care for patients experiencing mental health issues. The award comes with a £5m investment to be utilised over the next 3.5 years.
NW asked if the costs of transferring 0 – 25 services to Forward Thinking Birmingham was 10.2 known and what level had been recovered. RP confirmed that in 2016/17 £3.6 m non recurrent funding had been identified to support of the transfer but the transfers had taken longer than expected.
10.3 RB asked if, on reflection, there were areas which should not have been cut through the savings programme and now require re – investment BGH confirmed that this may be the case with support around the e-rostering programme and in CMHTs JS suggested that re-investment be picked up as part of discussion with commissioners.
10.4 GH asked if the Trust had received confirmation the NHS Exemplar funding would be received as there had been some conflicting press coverage on this nationally. JS confirmed NHS England had indicated it was but it was subject to Treasury Approval.
10.5 ACTION: DT to check if the Mental Health Global Digital Exemplar funding was secure and confirm with the Board by email. (May 2017)
11. Update on Strategic Partnerships 11.1 MERIT
11.2 The Board received and discussed the quarterly report from MERIT. It was felt that the report needed to at a higher level in future with key issues drawn out clearly.
11.3 JS stated that the standard report highlights the progress made and the additional supporting report was the evaluation report. He added that there remained some issues the partnership was working through for example around sharing information about bed availability and the Chief Executives were planning to meet to discuss this issue.
11.4 WS informed the Board that the MERIT NED assurance meeting would be taking place in July 2017. He noted that it had been agreed the same CEO will attend each time.
11.5 SD added that the Chairs have not met since the start of the year.
11.6 NW was concerned that the report was only reporting activity and was not drawing out outcomes sufficiently which she felt would be improvement in terms of future on-going funding.
11.7 BSH asked when the agreed joint software for bed management would be completed and in place. JS stated that this was expected shortly but that there were some cultural issues which needed to be addressed first.
REACH OUT
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11.8 JS confirmed that the first Reach Out Board has met and new TORs were being worked through.
13. R & I Annual Report 13.1 The R & I Annual report was received and noted. This had been discussed at FPP.
HG informed the Board that the Head of Department is in the process of consulting on an organisational restructure to ensure the department offers career progression and longevity.
14. Use of the Trust Seal 14.1 The report was noted 15. SSL quarterly report [SBr joined the meeting]
15.1 SBr highlighted the following details from his report:
• The period from April to March 2017 has seen revenue achieved of £7.8m, with total expenditure of £8.3m resulting in a loss of £495k. The loss has increased over the past 3 months as result of the purchase of Ardenleigh & Juniper which is principally due to the depreciation and interest paid by SSL to the Trust over and above the lease charges received from the Trust.
• During the reporting period SSL had 49 externally reportable incidents out of 149,961 items dispensed. No service users were harmed as result and all had been dealt with and resolved promptly
• SSL are in discussion with the CCG regarding potential to provide contract cleaning services to some of their LIFT properties.
• SSL are in discussions with Amey regarding potential staff that may need to TUPE across to SSL.
15.2 ACTION: The Board requested that the SSL Quarterly Report to Trust Board in July 2016 to include a 5 year forward view. SBr
15.3 NW questioned what the value of the translation services opportunity was. SBr commented that the Trust currently pays £900,000 a year for the services from a third party and BGH added that the services are currently spot purchased and this gives the Trust the opportunity to centrally manage this process through one provider in SSL.
16. Q4 Business Plan 16.1 The Q4 Business Plan was received and noted
RP updated the Board on progress with achieving the 2016/17 goals confirming that out of 390 goals, 346 of these were green and 44 were red, which means 89% had been completed during the year an improvement on the previous year where the completion was 86%.
17. Integrated Quality Committee report 17.1 The report was received and noted
18. Finance Performance and Productivity Committee report 18.1 The report was received and noted
19. Audit Committee report 19.1 The report was received and noted.
GH informed the Board that the updated Terms of Reference would come back to the May 2017 19.2 meeting for agreement.
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19.3 SD commented that the Audit Committee should have been consulted on the recent tender process for internal audit and GH confirmed that the committee had asked management to provide a report on the process at the next Audit Committee meeting.
20. MHLC report 20.1 The report was received and noted.
20.2 WS informed the Board that the committee had discussed the Trust’s preparation to respond to the
20.3 Police & Crime Act which will amend S136 of the MHA. He noted that the committee had extended its membership to include a police representative and a trainee medic. The Terms of Reference were approved by the Board
21. Minutes of the last Board – March 2017 21.1 The minutes of the meeting held in March 2017 were agreed. 22. Matters Arising (not on the Agenda) 22.1 None raised
23. Board forward planner 23.1 Noted
24. Any Other Business 24.1 None raised
Next Board meeting: Wednesday 31st May 2016, 9.00, the Uffculme Centre, 52 Queensbridge Road, Moseley, Birmingham
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BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST PUBLIC BOARD - ACTION SHEET – April 2017 FOR May 2017 BOARD
Agenda Topic Action Agreed Exec Original Revised RAG Comment Item No. Timescale Timescale
Mar 17 Medical Director’s Report Item 7
7.5 HG to include on an update HG May 17 Complete – on the timescale for within report psychologists job planning in the May 2017 Medical Director’s Report. Mar 17 People Strategy Item 14
JW to support the review of BGH, May 17 Completed the Equality and Diversity MR & discussions Policy to bring in line with the JW underway People Strategy. April 17 Director of Nursing Report Item 6
6.6 HG to identify when the HG TBC September 2017 Positive and Proactive Care for ICQ & Board Group Safewards report would be produced and to come through IQC and Board. April 17 Medical Director’s Report Item 7
7.5 HG to review if a proposal to HG May 17 Complete – not accept the locum target within report was acceptable and include the detail in the May 2017 Medical Director’s Report. April 17 Chief Operating Officer Operational Escalation Item 8 Report
8.3 The Board agreed to receive a BGH TBC On the forward Seminar Session on the planner for a Red2Green patient flow tool. seminar session April 17 Chief Operating Officer Operational Escalation Item 8 Report
8.6 BGH to include detail of the BGH May 17 COMPLETED partnership workshop in detail in the respect of the addictions report service, in the next Chief Operating Officer Operational Escalation Report April 17 People Report
9.4 WRES report data report to BGH May 17 On the forward come to Trust Board for planner for a discussion (May 2017) BGH seminar session April 17 Resources Report
Agenda Topic Action Agreed Exec Original Revised RAG Comment Item No. Timescale Timescale
10.5 DT to check if the Mental DT May 17 COMPLETED Health Global Digital email sent to the Exemplar funding was secure Board members and confirm with the Board by email. April 17 SSL quarterly report
15.2 The Board requested that the SBr July 17 SSL Quarterly Report to Trust Board in July 2016 to include a 5 year forward view.
Board Members/Attendees – Abbreviations
John Short (JS) Sue Davis (SD) Joy Warmington (JW) Dave Tomlinson (DT) Brendan Hayes (BGH) Dr Nerys Williams (NW) Sue Hartley (SH) Barry Henley (BSH) Hilary Grant (HG) Waheed Saleem (WS) Nerys Williams (NW) Russell Beale (RB) Deborah Lawrenson (DL) Gianjeet Hunjan (GH) Mark Ratley (MR) Shane Bray (SWB) Dan Conway (notes) (DCC ) Mark Ratley (MR)
RAG Red – overdue Green – Resolved Blue – Not yet due BSMHFT Board Forward Plan 2017 – 2018
Updated 25 May 2017
• There are currently no Board meetings planned for August and December • All meetings begin with a patient story
Key
• Items in red are either updates required from the last board or items added or moved since the planner was last received at Board.
Note to be added when dates are known
• BCC and Solihull suicide prevention strategies when approved • E & D reports following discussion at IQC timing to be confirmed • Add a group Board visit to the new Rehabilitation Services at the refurbished Ardenleigh Houses when they are completed. (possible July 2017) from March Board • Schedule a seminar on the WRES – BGH to advise on timing • Schedule a seminar on Red2Green – BGH to advise on timing • Schedule a seminar on Staff networks – BGH to advise on timing
Month Afternoon seminar Standing Items Quality and performance Strategy Policy Governance Board Committee Chair session Reports (minutes are circulated separately 28 June There will be an away • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) 2017 day session with the • Action log (DL) (SH) Partnerships (JS) • Annual Board self- • FPP (BSH) Governors in the • Matters arising • Quality Report certification (DL) • CFC (NW) afternoon • Declarations of • Serious Incident Report • Report from the Freedom to • Rem Com (SD)
interests (All) • Safe Nursing Staffing Speak Up Guardian (DL) terms of reference • Outcome of General • Chair report (SD) Numbers six month report • Report potentially from the Election and • CEO report (CEO) Medical staff Guardian potential impact on • Board forward plan • Complaints Annual Report health (DL) Medical Directors report (SH) policy/operationally
• Opportunities for Collaborative Chief Operating Officer Operational working in STP – Escalation Report (BGH) SD and JS to lead • Combined Authority and Mental Health – People Report (BGH) Sean Russell • Emerging HR Issues • Discussion on • findings and next Whistleblowing report steps from the stakeholder Resources Report (DT) engagement work • Finance report • Joint working with the Children’s Hospital – JS
11th July 2017 – TRUST AGM
26 July 2017 • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) • Action log (DL) (SH) Partnerships (JS) • NHS Improvement • FPP (BSH) • • • Matters arising Quality Report Information Strategy declaration and Q1 sign off • Audit (GH) • Declarations of • Serious Incident Report (DT) (DT) interests (All) • Emergency Planning Core • Chair report (SD) Medical Directors report Standards submission
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Month Afternoon seminar Standing Items Quality and performance Strategy Policy Governance Board Committee Chair session Reports (minutes are circulated separately • CEO report (CEO) • Medical Revalidation Annual 2016/17 (SH) • Board forward plan Update and Audit • Infection Prevention Control (DL) Committee annual report Chief Operating Officer Operational (SH) Escalation Report (BGH) • SSL quarterly report (Shane Bray) • Possible Changes to the People Report (BGH) Constitution following the • Emerging HR Issues AGM (DL) • Whistleblowing report
Resources Report (DT) • Finance report
There is no planned Board in August currently
• Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) 27 Sept 2017 • Action log (DL) (SH) Partnerships (JS) • BAF (DL) • FPP (BSH) • Matters arising • Quality Report • Progress report on • MHLC annual report • Declarations of • Serious Incident Report Trust Strategy (DT) (HG/WS) interests (All) • Q1 Business planning • Chair report (SD) Quality Improvement Programme quarterly monitoring update • CEO report (CEO) (SH) (DT) • Board forward plan • Internal Safeguarding (DL) Medical Directors report annual report (SH) • Six monthly review of • NHS Improvement Q1 Homicides feedback (DT/JS) • R & I update • Health and Safety Annual Report (SH) Chief Operating Officer Operational Escalation Report (BGH)
People Report (BGH) • Emerging HR Issues • Whistleblowing report
Resources Report (DT) • Finance report 25 Oct 2017 • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) • Action log (DL) (SH) Partnerships (JS) • Patient experience and • FPP (BSH) • Matters arising • Quality Report recovery Annual Report • MNLC (WS) • Declarations of • Serious Incident Report (SH) • Audit (GH) interests (All) • Mental Health Community • NHS Improvement Q2 submission (DT) • Chair report (SD) Service User Survey Results • • Report from MERIT NED CEO report (CEO) 2017 • Board forward plan assurance group (WS )
(DL) • SSL quarterly report Medical Directors report (Shane Bray)
Chief Operating Officer Operational Escalation Report (BGH)
People Report (BGH) • Emerging HR Issues • Whistleblowing report
Resources Report (DT)
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Month Afternoon seminar Standing Items Quality and performance Strategy Policy Governance Board Committee Chair session Reports (minutes are circulated separately • Finance report 29 Nov 2017 • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Risk Management • Use of Trust Seal (DL) • IQC (JW) • Action log (DL) (SH) Partnerships (JS) Policy annual review • Q2 Business planning (DT) • FPP (BSH) • Matters arising • Quality Report (SH) • BAF (DL) • • Declarations of • Serious Incident Report interests (All) • Chair report (SD) Medical Directors report • CEO report (CEO) • Board forward plan (DL) Chief Operating Officer Operational Escalation Report (BGH)
People Report (BGH) • Emerging HR Issues • Whistleblowing report
Resources Report (DT) • Finance report
There is no planned Board in December currently
31 January Seminar: • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • SSL Quarterly Report • IQC (JW) 2018 • Action log (DL) (SH) Partnerships (JS) (Shane Bray) • FPP (BSH) Finances 2018/19 (DT) • Matters arising • Quality Report • Declarations of Interest • MNLC (WS) • Declarations of • Serious Incident Report (DL) • CFC (NW) interests (All) • Use of Trust Seal (DL) • Chair report (SD) Medical Directors report • CEO report (CEO) Board forward plan (DL) Chief Operating Officer Operational Escalation Report (BGH)
People Report (BGH) • Emerging HR Issues • Whistleblowing report
Resources Report (DT) • Finance report 28 February Joint session with the • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) 2018 Governors in the • Action log (DL) (SH) Partnerships (JS) • BAF (DL) • FPP (BSH) afternoon • Matters arising • Quality Report • Well Led Update (DL) • Audit (GH) • Declarations of • Serious Incident Report • Birmingham and Solihull interests (All) Safeguarding Board • Chair report (SD) Medical Directors report annual update (SH) • CEO report (CEO) • Q3 Business Planning Board forward plan update (DT) (DL) Chief Operating Officer Operational Escalation Report (BGH)
People Report (BGH) • Emerging HR Issues • Whistleblowing report
Resources Report (DT)
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Month Afternoon seminar Standing Items Quality and performance Strategy Policy Governance Board Committee Chair session Reports (minutes are circulated separately • Finance report 28 March • Minutes (DL) Quality of Clinical Services Report • Update on Strategic • Use of Trust Seal (DL) • IQC (JW) 2018 • Action log (DL) (SH) Partnerships (JS) • Business Planning • FPP (BSH) • Quality Report • Matters arising • Annual progress 2018/19 (DT) • Declarations of • Serious Incident Report report on Trust • Budget setting 2018/19 interests (All) Strategy (DT) (DT) • Chair report (SD) • Declarations of Interest Medical Directors report • Annual progress • update (DL) CEO report (CEO) report on People
Board forward plan Strategy (BGH)
(DL) Chief Operating Officer Operational • Escalation Report (BGH) Annual progress report on Communications and Marketing Strategy People Report (BGH) (DT) • Emerging HR Issues • Annual progress • Whistleblowing report report on the Quality Strategy (SH) Resources Report (DT) • Finance report
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Item 16
BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST
PRIVATE TRUST BOARD MEETING TO BE HELD ON 31st May 2017
ESTATES STRATEGY Strategic or Regulatory Requirement to which the paper reports:
• Achieve long-term financial sustainability, deliver service strategies and ensure compliant premises. ACTION: For the Trust Board Meeting to receive and endorse the Estates and Facilities strategy incorporating the Capital Development Proposals Key supporting Strategies requiring development: • Agreement of a detailed service strategic plan, determining service effects on premises, costs and key milestones. • Agreement of a funding strategy including; a detailed cost plan, financial plan and funding strategy. Executive Summary This Estates Strategy focuses on the 2017-22 period. The format of the strategy is consistent with Department of Health guidance which poses the questions: Where are we now, Where do we want to be and How do we get there. Section 1:“Where are we now?” by comparing the profile and performance of the Trust’s estate April 2008 and April 2015 (previous Estate Strategies) significant improvement in the profile of the estate have been achieved primarily because of the continued targeted capital and non-recurrent revenue investment made in inpatient facilities and the rationalisation of the community estate. This provides a new baseline against which the 2017-22 strategy can be monitored. Subject to investment, the priorities for securing further improvements in the alignment of premises to service development, key investment areas and performance of the estate has been confirmed. Sections 2 & 3:“Where do we want to be?” and “How do we get there?”: An estate which efficiently, effectively and economically supports the delivery of safe, high quality services and addresses the Trust’s service, business and financial strategies and plans”. The Trust’s operating environment for the period of the strategy is acknowledged. Clear service, business and financial emerging strategies and detailed plans need to be developed in response. The development of Inpatient Cluster sites and Community Hubs will shape the future configuration of the estate, and recognising that limited resources will require investments to be prioritised an initial schedule of priority development areas consistent with this configuration has been developed. The continued management, investment and performance of premises, estates services and facilities operations is a key priority with the Trust aiming to achieve top 10% status of all Trusts nationally in cleanliness, catering and estates condition. This should be set against costs nationally in the lower/median quartile, thereby delivering true value for money. Subject to endorsement of this strategy, approval of individual schemes will approval via the development of robust business cases to confirm their affordability, that they meet clinical/service requirements and are deliverable within given parameters. BOARD DIRECTOR SPONSOR: David Tomlinson, Executive Director of Finance REPORT AUTHOR: Neil Hathaway, Associate Director of Estates & Facilities APPENDIX: 1. Premises Condition Facet Review (commercial in confidence under FOI S43 (2) in the Reading Room) 2. Premises Condition Facet Ratings (commercial in confidence under FOI S43 (2) in the Reading Room)
3. 4. Capital Development Proposals (commercial in confidence under FOI S43 (2) in the Reading Room) 5. Facilities / Hotel Services, Estates, DoH – Premises and Estates and Facilities returns and Private Finance Initiatives (commercial in confidence under FOI S43 (2) in the Reading Room) 6. Estates Strategy Major Projects Summary (commercial in confidence under FOI S43 (2) in the Reading Room)
PREVIOUSLY DISCUSSED: This 2017-2022 Estates Strategy was received and endorsed at the Finance Performance and Productivity Committee on 24th May 2017 and was developed as an update to the 2015-2020 Estate Strategy taken to the Planning and Development Committee April 2015. The strategy and supporting documents have been consulted upon with Deputy CEO/Director of Operations, the Clinical Service Operational Associate Directors and Executive Director of Finance.
Estates & Facilities Strategy 2017 - 2022
Ref: NH/CG/Estates Strategy 2017-22 April 2017 1
Estates and Facilities Strategy 2017 – 2022
Contents Page
Content Page
Introduction 3
Section 1: Where are we now? 3
Section 2: Where do we want to be? 4
Section 3: How do we get there? 8
Appendices
Appendix 1: BSMHFT Premises Schedule denoting core and non-core premises plus Estatecode categorisation as at April 2017
Appendix 2: Trust Premises Condition Facet Review, and Statutory Standards/Backlog Maintenance Programme Development April 2017
Appendix 3: Capital Development Proposals
Appendix 4: Facilities and Hotel Services, Estates, DoH Premises and Estates & Facilities returns, Private Finance Initiatives
Ref: NH/CG/Estates Strategy 2017-22 April 2017 2
Introduction
This Estates Strategy focuses on the 2017-22 period. The format of the strategy is consistent with Department of Health guidance which poses the questions: • Where are we now? • Where do we want to be?, and • How do we get there?
The Trust’s previous Estates Strategies covered the 2008-17 period, focussing on: • Service investments planned for South Birmingham as part of the Birmingham New Hospitals project, and the expansion of Male Medium Secure services. • Rationalisation of the community estate, much of which was not fit for purpose and provided a barrier to service improvement & integration. In many cases the cost of refurbishing parts of the estate would not have provided a value for money investment. • Delivery of national and local targets.
Over the period: • A capital investment of circa £135+m (including PFI developments) was made in the estate. • The estate reduced from 105 to 43 operational properties, whilst maintaining the same area (square meterage) and bed numbers • All national/local targets were either achieved or are currently on target to be achieved.
This resulted in a measurable improvement in the profile and performance of the Trust’s estate, noted within Appendix 2.
SECTION 1: WHERE ARE WE NOW? (2017)
Section 1: responds to the question “Where are we now?” by updating the profile and performance of the Trust’s estate from April 2008 against the current 2017 estate. This provides a new baseline against which the 2017-22 strategy can be monitored. This is important as subject to investment, the priorities for securing further improvements in the profile and performance of the estate have been confirmed at the Finance Performance and Productivity Committee on 24th May 2017 and the April 2015 Planning and Development Committee but will be subject to further review and confirmation of new funding strategy. This investment is being made largely to ensure that the Trust remains compliant with regards to statutory legislation and regulatory standards and to support the delivery of high quality and fit for purpose clinical services.
The improvement made over the 2008-17 period has been significant. However the strategy was prepared and delivered, in part, at a time of substantial investment in the NHS.
Since 2011, the Trust and wider NHS has undergone political, structural, economic and organisational change. This has created the challenging environment which now exists, and which will continue for the foreseeable future. An environment which is characterised by a need to: • Re-design services and develop new ways of working, within reduced resources. • Operate in an increasingly contractual and performance driven environment. • Align resources, e.g. the estate to service needs and to maximise its margin. • Make informed decisions which improve the performance of the Trust and its estate. • Work within a defined capital funding environment • Deliver challenging Cost Improvement Plan (CIP) savings, to support the financial sustainability of the Trust. • Consider new ways of working in terms of collaboration and partnerships 3
Against this background a new Estates Strategy is required to enable the Trust to manage its services over the medium term, 2017-22 and to secure the maximum contribution the estate can make in supporting the needs of clinical services and the delivery of the Trust’s Service, Business and Financial strategies and plans.
SECTION 2: WHERE DO WE WANT TO BE?
“An estate which efficiently, effectively and economically supports the delivery of safe, high quality services and addresses the Trust’s service, business and financial strategies and plans”.
The Estates Strategy needs to respond to the Trust’s emerging operating environment and service plans.
The development of detailed service strategic plans will provide a robust service blue print and definition of what we mean by safe, high quality, effective services.
This will identify ways in which the estate contribution can be maximised, and support the Trust in managing its operating environment.
Achieve the best standards of the time making a difference to people’s lives
Operationally the estate needs to:
• Support the delivery of safe, high quality, effective services in an environment which is responsive to the needs of service users & staff. • Support the re-design of services and development of new ways of working including the Reach Out Programme. • Perform at a good level when measured/benchmarked against other comparable service providers in the NHS and in other sectors through ERIC (Estates Return Information Collection), PAM (Premises Assurance Model) and Market Testing as appropriate. • Contribute at a good to excellent level to service user, carer and staff experiences, confirmation of this being evidenced via PLACE (Patient Led Assessments of the Care Environment) and CQC inspections, plus service user and staff surveys. • Provide flexibility to respond to service changes
Strategically the estate needs to be:
• Managed and reviewed on an annual and project by project basis as an “Asset” ensuring that commercial opportunities which may exist have been identified, and where appropriate developed to ensure the Trust is an enabler in any partnership development. • Designed to enhance the reputation/credibility of the Trust and confidence of key stakeholders. • In line with the emerging STP and CCG agendas again to ensure the Trust is a key player.
Emerging themes can also be identified in terms of the structure and design of the estate, which suggests that the Trust estate will be developed around:
• A number of “Inpatient Cluster” sites and “Community Hubs” each delivering safe, high quality services, supporting, the redesign/integration of services and teams. 4
• “Core” estate (for which a medium/long term need exists), and “Non-Core” estate (for which no more than short term need exists). • A desire to work in partnership more effectively with service partners, promoting the possibility of services being provided from their estate rather than the Trust’s and other such initiatives which may enable more effective community services to be developed. • New ways of working, specifically mobile working for community staff. This will require Estates and ICT investment strategies, to be aligned, to provide a technically and environmentally functionally suitable Estate/ICT infrastructure. • Greater evidence based assurance with regard to the performance of the estate and its ability to meet and support the needs of services, service user and staff will be required to support effective management of the estate and ensure assessment criteria standard of regulators are met. • In addition the Trust also provides services out of sites not listed in Appendix A - these being for example the Addictions sites in Wolverhampton and Stoke, The RAID services and prison services and other community partnership ventures such as the SIAS team in Solihull. • Strategically the Trust as a whole needs to be better and more consistently informed of where its services are being delivered from and where its staff are working. During 2017/18 work will be undertaken to identify such gaps and where necessary to 'regularise' such agreements. • Out of the 48 sites (43 operational), 26 sites are freehold, 13 sites are leasehold / licence and 9 sites are PFI. Strategically moving forward the Trust needs to consider carefully and where possible avoid entering into extended or new leases with commercial landlords as by the very nature of the commercial arrangements the landlord’s sole objective is to make the highest financial return for its funders - this being at the risk of quality and effectiveness. Indeed a disproportionate amount of time is expended at sites where the landlord is a commercial landlord. Strategically where the Trust needs to provide a service and does not own a suitable property then every effort should be made to either buy a property freehold or to lease a property from other NHS organisations or from the Local Authorities. • Strategically the number of sites that the Trust provides its service from has reduced considerably (over half) over the past 7 years from over 100 sites. There will come a point when the Estate is as small as it needs to be and where the sale of properties or sites is not perhaps the right decision from a commercial or service delivery perspective. Premises as well as being a financial liability are also an asset of an organisation and as such this estates strategy needs to be aligned (vice versa) with service strategies and long term financial planning when making decisions over premises.
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• More specifically in terms of the leased buildings we have breaks / opportunities to break as follows:-
Property Lease Break Date Lease Expiry date
Adams Hill No break provision 16/05/2088
15/11/2019 to break 15/11/2020 (Break clause refers to payment of £1,000,000 on B1 break) 14/11/2030
Bishop Wilson and Under development in line
Freshfields with commissioning / service requirements
Callum Lodge 24/12/2017 24/12/2017
5 year lease negotiated to 2020. Option to Grove Avenue 04/09/2020 break every 12 months
Orsborn House (Main 26th April 2026 (having given 3 months’ 24/04/2031 Building) notice)
New Lease being negotiated in line with Phoenix day centre Commissioning requirements / Service requirements
Statutory Tenancy in place rolling over Yewcroft previous lease due to insurance claim post 01/06/2016 fire incident
Lease not at this point agreed with Local Middlewood / Bridge Authority. Statutory Tenancy in place
Lease needed in line with Commissioners requirements once head lease William Booth for property within Salvation Army established
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• By far the most significant of these is the option for the Trust to break the B1 Lease in 2020. An options paper will be developed to explore this opportunity. • Where leases are being renegotiated one of the challenges is to ensure that the leases are either directly aligned in terms of duration with the commissioned service contract or that they have options to determine aligned to service requirements
The vacation of leased premises requires controlled demobilisation project managing:-
• Dilapidation costs/proposals • Ensure lease – contractual conditions are achieved • Ensure no breaches are created in the leaving of service user files, medicines or needle sticks.
Premises sales will be progressed in line with Business Cases and approved through CRG and FPP as appropriate. Sales potentially will include; Hillis Lodge, Main House, Holly Hill, Ross House and Newington.
Estimates have been developed for the Minor and Major works being identified from the initial planning undertaken. These can be added to the investment needs identified previously to ensure that the physical condition of the estate is brought up to a Category B standard and compliant with regards to statutory legislation and regulatory standards.
This work highlights that the investment needed in the estate needs to be reviewed thoroughly with detailed cost plans, financial plans and funding strategies established. This will involve investment decisions prioritised. Major projects can have long lead times in terms of planning, approvals and procurement. Each project will be developed in detail to respond to the constraints, the service strategies and financial plans.
The priorities for 2017-22 are summarised below:
1 Re-provision of standalone inpatient sites and utilisation of existing Trust estate to accommodate the inpatient adult acute services, including development of the Highcroft site. 2 Hillis Lodge re-provision. 3 Solihull re-provision – to move services from the leased property in Solihull 4 Upgrade/Replacement of Reaside (Medium Secure) Forensic Facility 5 Service redesign including developments within ECT, Neuropsychiatry and Place of Safety.
The development of the accommodation to support the above five service themes is considered in Appendix 3, which considers the themes, a limited number of options for each plus the costing profile per option.
The premises sales proposals will follow the development timescale.
The cost profile again will follow the development timescale, therefore determining the business case and closing the option appraisals per theme needs to be a key priority.
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Where do we want to be? Conclusion: The Trust wants to be in a position where it has “An estate which efficiently effectively and economically supports the delivery of safe, high quality services, and the Trust’s corporate, service, business & financial strategies and plans”.
Responding to its operating environment will present challenges and opportunities for the Trust and the management of its estate. The challenge to make sustainable, far reaching/stretching improvements in the efficiency, effectiveness and economy of the Trust, its services and resources will demand different approaches as to how the estate is designed and managed in the future.
Further investment is needed to bring the “Core” estate up to the same standards of the developments undertaken over the 2008-17 period. The scale of investment required is such that over the 2017 -22 period, the Trust needs to work within constraints however where possible consider alternative funding services to achieve more flexible premises, better service provision and affordable outcomes.
In practice parts of the core estate; the Reaside Hospital, parts of the Eastern Birmingham estate and parts of the North Birmingham estate over the next 10 years will reach the end of their design life.
It is important to be mindful of the need to plan for beyond 2022 especially where major investment programmes/projects are planned on the same or adjoining sites/properties, this involves considering Development Control Plans (DCPs) for the major sites.
Those parts of the estate that may be of a design or condition that are not economically able to be improved, made compliant with legislation or regulation, or meet accreditation standards of regulators or commissioners- need to be managed to closure and rationalisation, as safely and as quickly as possible. Avoiding large investment in such properties needs to be reflected in the investment plans.
Facilities Management, PFI Management, Sustainability and Department of Health Returns have been reviewed and included within Appendix 4, a part of the continued performance and quality management of the premises Estates and Facilities services.
SECTION 3: HOW DO WE GET THERE?
Responds to the “How do we get there”, question by identifying key steps which need to be taken to progress the development and delivery of the estate needed by the Trust: These include:
• Ensuring that the Estates Strategy and its implementation is informed by and reconcilable to clear service, business and financial strategies and plans. • Ensuring the above is carried through in terms of scope and scale of development briefs. • Development control plans for individual programmes and projects. Being clear on responsibilities delivery programmes, critical path and key interfaces. • Reviewing, the Non-Core Estate to be able to advise re investments which may be required whilst and should the estate continue to remain operational. • Development of a 5 year 2017-22 capital investment programme which maximises the benefit from the investment and its impact on the profile and performance of the Trust’s estate. The table above summarises the major projects identified. • Preparation of business cases to confirm affordability, deliverability, financial and non-financial benefits to be secured, funding source and secure approvals as required for programmes and individual projects.
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• Securing financial and non-financial benefits, and improvements in the performance (the efficiency, effectiveness and economy), of services and resources. • Reviewing vacant properties and plans for disposal and depending on findings considering alternative use of the property and income generation potential. • Building relationships with key service provider partners and stakeholders.
From an operational/general management perspective there also needs to be a greater scrutiny of the existing estate in terms of:
• Progression of the necessary actions which will secure the scope for further improvements in the profile and performance of the estate identified in Section 1 by the use of ERIC and other performance indicators. • Plans for generating income from the alternative use of the estate, e.g. Retail outlets, Advertising boards, out of hours use of premises etc. • Reviewing the utilisation of the estate across the Trust, the intention being to release space for more effective use. Consider the development of criteria/standards to apply to allocate actual use space and challenge poor practice. • The functional suitability of the estate to ensure it meets the service needs and enhances the experiences of service users and staff. • Development of an effective working partnership arrangement with the Trust’s PFI partners. • Development of more appropriate performance indicators for the estate specifically in terms of viewing and measuring the estate in a commercial /asset management context. • Undertaking a review of estate land and property to identify scope for rationalisation and disposal to avoid on-going revenue expenditure and generate sales receipts. • Updating Development Control Plans (DCPs) for the “Core” estate to inform site investment plans and programmes. • Maintaining knowledge of local conditions to ensure awareness of changes to market conditions and opportunities. • Utilising market testing and approved frameworks to influence procurement strategies and negotiations. • Maintaining accurate and up to date risk registers.
Measures of Success
To enable effective monitoring of the impacts of investment made, a range of “measures of success” performance indicators will be developed and reported on annually. These will include a number of existing performance indicators, e.g. the number of physical condition of properties as well as new indicators relating to levels of space utilisation and functional suitability promoting the estate in a greater asset/commercial context.
This Estates Strategy reflects the emerging themes from the service and business plans which are being prepared by the Trust in response to its operating environment. Once these plans have been confirmed and further developed, any impact on the strategy will be considered.
The strategy does not capture or included any information with regard to the estate associated with the independent/private sector Respite Care beds the Trust has contracts for or HM Prison-Birmingham.
The service, commercial and financial planning currently being undertaken in the Trust has informed the preparation of this strategy. Reference has also been made to the following guidance:
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• Department of Health (DH) -Estate-code. • (DH) Capital Investment Manual and HM Treasury Business Case Guidance • (DH) Developing an Estates Strategy. • (DH) Annual Estates Return Information Collection (ERIC). • Monitor Guidance re: Protection of Assets for NHS Foundation Trust, and • Care Quality Commission Inspection – Standards.
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