Board Meeting
A virtual meeting will be held Wednesday, 29 July 2020 commencing at 1:00pm
If you are unable to attend please notify Keith Eales on 01202 277008.
Yours sincerely,
Andy Willis Chairman
PART 1 Lead Paper Time
1 Apologies AW Verbal 1:00
2 Declarations of interests in relation to agenda AW Verbal items
3 Patient Story TP Paper
4 Minutes: 24 June 2020 - to approve AW Paper
5 Matters Arising – to review progress AW Paper
6 Chairman’s Report - to receive an update. AW Verbal
Strategy Items
7 Fit for the Future Programme KD Paper
To note the report.
Current Affairs and Operational Performance
8 Chief Executive’s Report EY Verbal 1:45
To note the update.
9 Trust Board Integrated Corporate Dashboard KD Paper 2:00
To note performance for June.
10 Trust Finance Report for June 2019 MM Paper 2:15
To the report.
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11 Dorset Care Record Update MM Paper 2:30
To note the report.
Regulatory and Governance Matters
12 Reports from Committee Chairs 2:40
a) Appointments and Remuneration AW Verbal Committee: 8 July 2020
b) Mental Health Legislation Assurance SM Paper Committee: 8 July 2020
c) Audit Committee: 15 July 2020 TP Paper
d) Quality Governance Committee:15 DB Paper July 2020
13 Annual Report of the Mental Health SM Paper 2:50 Legislation Assurance Committee 2019/20
To note the report.
14 Appointment of a Senior Independent AW Paper 3.00 Director
To make an appointment.
Other Matters
15 Questions from Governors on matters on the AW Verbal agenda
What went well, what could be better?
15 Next Meeting: 1.00pm, Wednesday 30 AW Verbal 3:20 September 2020
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Agenda Item 3
Patient Story
Part 1 Board Meeting 29 July 2020
Author Janine Coletta, Patient Experience Facilitator Purpose of Report To consider the patient experience of our service Executive Summary
The report is being submitted to the Board for consideration, reflection and to highlight the positive experience of care received from Langdon Ward (now Colmers Ward) at Bridport Hospital, and how this has impacted both the patient and the patient’s family.
The Board is asked to consider and discuss the report and agree any Recommendation follow up actions as required.
The service user was assisted in providing the story by Janine Coletta, Patient Experience Coordinator.
Jen’s Story – A Family Perspective After our many experiences of the NHS throughout my Mother’s 91 years, I wanted to highlight the wonderful level of care that she received at Bridport Community hospital, and the reasons why I felt that care was vastly better than any other NHS facility that we have visited over the years.
In November 2019, my mother was now very frail, had dementia and could hardly see. After a big fall, she was taken to the local District General Hospital and, due to lack of beds, was on the acute ward for a couple of weeks, then moved onto Bridport Community Hospital in December 2019.
Whilst at the local District General Hospital there were issues around illegible handwriting and a lost “This is Me” document which caused us some concern and lost time with my mother. I will reflect on this at the end of my summary of the care she received.
When I arrived at Bridport Hospital, I was greeted by a senior member of staff who was friendly, kind and approachable. She invited me into a side room, made me a drink and sat me down asking me to tell her all about Mum and her needs. It was clear from the start that they were treating the family and not just the patient at Bridport. She also asked me to complete another ‘This is Me’ document, as the previous one had been lost whilst in transit from the local District General Hospital. However, this time I was permitted to complete my documents electronically and email it back to her. She then ensured this emailed version was shared with all staff who would be involved in Mum’s care. Whilst it was frustrating to have to spend more time filling in forms when I could have been spending that valuable time with Mum - and especially after having to fill in the document at the local District General Hospital, which was subsequently lost - I was encouraged by this one being electronic.
They then did a handover of staff really thoroughly, giving all information about Mum accurately. This meant I didn’t have to keep repeating myself and also gave me confidence in Mum’s care. I also noticed the mood of the team was very positive and motivated, with it being very clear from the start that there was strong leadership on the ward. The staff always had a smile on their face and nothing was too much trouble for them. As they knew I came from Reading, they allowed me to come in earlier than the visiting hours and they made me feel really at home; telling me I could make myself a cup of tea whenever I wanted and just generally making me feel very much part of the team caring for Mum.
Mum remained in Bridport Community Hospital for a further 3 weeks, before she moved to a Care Home. During those 3 weeks, we could not have asked for better care. The communication across the whole team was excellent and I felt all staff members were encouraging and helpful to Mum at all times. The food was wonderful and the physiotherapy staff tried their hardest to get Mum up and walking for as long as they could (in a kind, gentle manner) until it became apparent that Mum’s care had sadly become palliative and rehabilitation wasn’t going to be possible.
The doctor at Bridport was also very knowledgeable and professional, but had such a manner that you felt she was approachable and easy to discuss matters with. This made a big difference to our experience of Mum’s care.
One memorable event at Bridport was when the staff organised Christmas songs to entertain patients on the ward. The nurses took the patients in to hear the singing, but sadly Mum was unable to get herself in there as she was very unwell by this stage. So the nurses went out of their way to move Mum into the room (still in her bed) so she could hear this singing and be part of the experience. Everyone was smiling and laughing and the mood was so warm and happy – I keep thinking what a lovely thing it was of them to do for us. They went to huge amounts of effort to make sure this could happen, with four of them moving Mum’s bed and making sure she could be there. It is a really lovely memory.
Sadly, Mum passed away in the Care Home she was moved into after leaving Bridport Hospital, but the care and compassion we both received at Bridport was very positive and I wanted to say thank you to all of the team there for that. It is very clear that the strong team understood the importance of looking after the family as well as the patient.
Can I just say, in this time of crisis, that I felt that every individual in both hospitals were giving ‘their all’, and we could not ask for anymore from them. It’s just the structure that surrounds these wonderful individuals that struck me, so I wanted to point out areas that could be improved for everyone’s benefit.
Summary of care and suggested areas of improvement The areas that came across that were different at Bridport were:
• Leadership, staff morale, teamwork and communication • Attentiveness to the family, not just to the patient • Attention to not only medical needs, but also social & mental needs
I also wanted to highlight our experience, as a family, of an area that could be improved, which would benefit all the NHS facilities and give massive benefits to staff, patients, family experience, and, more importantly, patient outcomes. If paper-based processes were automated using simple electronic forms, so many problems that I have highlighted could be solved, and huge benefits realised. And, with the added crisis that we find ourselves in, with fear of infection and the need for accurate information, there is a massive need to cut out paper & hand-written inaccuracies. The need for the NHS to put simple e- forms in place that streamline process & remove inaccuracies could not be more paramount.
Feedback from Bridport Hospital Matron, Ellen Holmes
This really lovely story is fantastic to hear and is testament to each of the amazing team members at Bridport, who work together so well to support not just the patients in our care but their families too.
We had received a Thankyou card from this family member soon after the patient’s discharge – but it is really special to hear their full account of the patients stay from the family member’s perspective.
We will also of course take on board the area of improvement highlighted and work together with our wider NHS colleagues to improve this.
Bridport Hospital – Feedback Department/Ward/Unit: Langdon Ward (now Colmers ward) Triangulation data: 01/04/2019 – 31/03/2020
Friends & 94.4% would recommend the service. Family Test
Complaints 6
Compliments & categories
The most frequent category of compliment was general praise.
*compliments can cover more than one category. Survey Examples of comments Comments Sentiment Analysis
The majority of comments are positive. Survey Comment Themes
79 free text comments were themed. All were positive. Of the positive comments “Staff Attitude” is the most common theme. There were no negative comments themed (please note, not all free text comments are themed). Service No service developments have been recorded during 2019/20. Developments and improvement due to patient feedback. (YSWD)
NHS Choices Nil. Reviews/ Online Comments
Agenda Item 4
Minutes of a virtual meeting of the Board of Directors held at 1pm on Wednesday, 24 June 2020
Present:
Andy Willis Chair Eugine Yafele Chief Executive Heather Baily Non-Executive Director David Brook Non-Executive Director John Carvel Non-Executive Director Sarah Murray Non-Executive Director Steve Peacock Non-Executive Director Tristan Phillips Non-Executive Director Belinda Phipps Non-Executive Director Dawn Dawson Director of Nursing, Therapies and Quality Kris Dominy Chief Operating Officer and Deputy Chief Executive Matthew Metcalfe Director of Finance and Strategic Development
In Attendance:
Sudipto Das Acting Medical Director Keith Eales Trust Secretary
Apologies:
Nicola Plumb Director of People and Culture
64/20 Welcome and Apologies
The Chairman welcomed Board members and reported the apology received.
65/20 Declarations of Interests in Relation to Agenda Items
There were no declarations of interest in respect of agenda items.
66/20 Minutes: 20 May 2020
The Board approved as a correct record the minutes of the meeting held on 20 May 2020.
67/20 Matters Arising
The Trust Secretary submitted a report on matters arising from previous meetings.
Minute 05/20: Dorset Care Record (DCR)
The Board requested an update on the DCR at the next meeting. It was recognised that operational matters in respect of the DCR were the appropriate remit of the Programme Board.
The Board:
(a) Noted the report; and
(b) Agreed that a progress report on the DCR would be submitted to the July meeting.
68/20 Chairman’s Report
The Chairman advised that his recent priorities had included:
• A visit to the Yeatman Community Hospital in Sherborne;
• A number of meetings in respect of system working;
• Discussions with Governors about the future development and working of the Council of Governors; and
• Reflecting on the future working of Board Committees.
The Board noted the report.
69/20 Chief Executive’s Report
The Chief Executive gave a verbal report to the Board on key issues.
The Chief Executive provided an update on the response to the Covid-19 pandemic:
• In total 3295 Trust staff had been tested for antibodies and had received results. A further 400 staff were awaiting results. An administrative error had resulted in 18 staff being sent the wrong results. This had been rectified;
• 10% of staff had tested positive for antibodies;
• There remained a low level of infection locally;
• The discharge to assess model remained in place with the aim of taking patients out of the acute hospitals. It was not yet clear how this model would continue into the longer-term;
• A local outbreak plan was in place;
• There had been no inpatient deaths within Trust establishments in the last two weeks. There had, however, been a local outbreak of the infection, with nine staff and two patients being tested positive;
• An assessment had been made of the potential loss of bed capacity from social distancing in Trust sites. The likely loss was 19 mental health and 22 community beds. The current low level of occupancy would facilitate the
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reduction in community beds. However, the loss of mental health beds was more challenging;
The Chief Operating Officer and Deputy Chief Executive gave an update on the work of the system-wide care recovery cell. Three meetings had been held to date, with the initial focus being on scoping a work programme. Consideration was being given to the development of a system-wide waiting list.
An assurance was sought that action was being taken to minimise the loss of mental health beds and options for their replacement. The Chief Operating Officer and Deputy Chief Executive advised that work had commenced on a range of initiatives to ensure appropriate provision. The bed provision would not be reduced without clarity in respect of the implications of this.
Clarification was sought on the action being taken to seek the views of patients on the changes made to Trust services.
The Chief Operating Officer and Deputy Chief Executive advised that a six week programme of work had commenced being taken forward through four workstreams. Questionnaires had been developed as part of this work seeking the views of patients and staff. The Executive Committee would be considering the outcome of this work the following week. It was confirmed that the views of those who had not accessed Trust services would be sought.
The Chief Executive updated the Board on other developments and activities:
• National planning guidance was expected in July. It was anticipated that trusts would continue to be funded nationally, on a block basis and being funded to breakeven, for some time. The Director of Finance and Strategic Development advised that the Trust working assumption was to reach a cost base consistent with the original plan for the year;
• There was a growing recognition of the mental health impact of the Covid-19 pandemic. A cross-governmental review had commenced;
• There had been some discussion nationally of integrated care systems being given statutory powers. This would take forward what was already an increasingly stronger focus on system planning and working;
• The Care Quality Commission would be recommencing its inspections;
• An independent safeguarding review had been commissioned following the court case involving a former Trust consultant;
The Board noted the report.
70/20 Board Integrated Corporate Dashboard
The Chief Operating Officer and Deputy Chief Executive submitted the dashboard for June 2020, drawing on data for May. Executive Directors highlighted key aspects of the dashboard.
Executive Directors drew attention to:
• During May there were 37 patient on staff violent incidents, 15 of which had resulted in an injury to staff;
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• Bed occupancy levels remained low, at 55% in community hospitals and 71.2% in mental health units;
• There were 54 incidents of supine restraint in May, which was a noticeable increase on the previous month. The reasons for this were noted;
• 89.9% of patients with a care programme assessment had received a 12 month review (an improvement from 88.2% in the previous month);
• Falls assessments were above the threshold but there continued to be challenges in mental health units;
• The performance in respect of the target of a maximum of 18 weeks from point of referral to treatment had fallen further to 51.8% (against a target of 92%). This reflected the suspension of clinics in accordance with national advice;
An assurance was sought that the increase in supine restraint did not reflect a practice of patients being secluded as a result of the Covid-19 pandemic. The Director of Nursing, Therapies and Quality advised that patients were excluded on admission pending the result of being tested for Covid-19 but not as a matter of practice beyond this. Results to these tests were being received within two hours.
Clarification was sought as to whether the Trust could, given the position in respect of waiting lists, be withdrawn from patient choice options. The Chief Operating Officer and Deputy Chief Executive undertook to investigate this. It was noted that all waits were being mapped.
An assurance was sought that the Trust was assessing the impact of the lengthening waiting lists on patients. The Chief Operating Officer and Deputy Chief Executive confirmed that this was the case.
It was noted that limited information had been included in the dashboard on learning disability services. Clarification was sought on the approach that would be taken to bring matters of concern to the attention of the Board. The Director of Nursing, Therapies and Quality advised that any mattes of concern would be escalated from the Clinical Governance Group.
It was recognised that this reflected a broader issue of ensuring that smaller Trust services continued to have visibility at Board level. The Chief Operating Officer and Deputy Chief Executive undertook to give consideration to this.
The Board:
(a) Noted the dashboard for June;
(b) Agreed that the Chief Operating Officer and Deputy Chief Executive would confirm whether or not the Trust could be removed from patient choice options given the current level of waiting lists; and
(c) Agreed that the Chief Operating Officer and Deputy Chief Executive would give consideration to approaches for ensuring Board visibility of smaller Trust services.
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71/20 Trust Finance Report
The Director of Finance and Strategic Development presented the Finance Report for May 2020.
The Board noted that, at the end of the month, the Trust was in a breakeven position in line with the interim plan provided to NHS Improvement (NHSI). A retrospective top-up payment of £128,000, to bridge the year-to-date deficit to a breakeven position, had been accrued.
It was noted that agency expenditure was £665,000 which was favourable to the NHSI plan by £491,000 and to the Trust target by £92,000.
The Board noted that £4m of the £12.3m cost improvement plan had been banked year-to-date.
The Board noted that capital expenditure was £1.2m year-to-date against a plan of £2.2m.
The Board discussed the merit in undertaking financial scenario planning as the Trust re-started services and implemented the fit for the future programme. There would be merit in including within this the implications of, for example, addressing the lengthening waiting lists.
The Board noted the Finance Report for May 2020.
72/20 Reports from Committee Chairs
As part of the short-term changes to the Board governance structure, which included the suspension of Committee meetings, Chairs were invited to escalate to the Board any matters of concern or which merited wider awareness.
No matters of concern were raised.
The Chair of the Mental Health Legislation Assurance Committee referred to the reappointment of Mental Health Act Panel Members prior to the next Board meeting. It was agreed that the decision in respect of reappointing any Panel Members prior to the next Board meeting would be delegated to the Director of Nursing, Therapies and Quality, in liaison with the Chair of the Mental Health Legislation Assurance Committee.
The Board agreed that the decision to reappoint any Mental Health Act Panel Members prior to the next Board meeting would be delegated to the Director of Nursing, Therapies and Quality, in liaison with the Chair of the Mental Health Legislation Assurance Committee.
73/20 Renewal Contract Approval-Electronic Patient Record: SystmOne
The Director of Finance and Strategic Development submitted a report seeking approval for the Trust entering into a contract renewal with The Phoenix Partnership for the continued use of SystmOne.
SystmOne was used for storing patient records primarily in physical health services.
The Director of Finance and Strategic Development advised that the cost of the licence was £743,562 plus VAT per annum with an overall contract value of
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£5,204,932 plus VAT over seven years. The contract exceeded the £5m delegated limit of the Chief Executive.
The Board discussed the length of the contract, the merit of entering into a contract of the length proposed, penalties for exiting the contract early and whether or not the Trust had maximised the benefit to the organisation from committing to a seven year contract.
The Chief Executive commented that, strategically, SystmOne was pivotal to the Trust’s commitment to building closer links with primary care. The Director of Finance and Strategic Development confirmed that there was a financial benefit to the Trust from entering into a seven year contract.
The Board:
(a) Agreed, in principle, to the Trust entering into the contract;
(b) Agreed that a briefing note would be distributed to Board members responding to the matters discussed at the meeting; and
(c) Requested that the Audit Committee review delegated limits to Directors.
74/20 Infection Prevention Control Self-Assessment Against National Framework
The Director of Nursing, Therapies and Quality submitted a self-assessment in respect of the nationally published infection prevention and control board assurance framework.
The Board noted that the framework contained 10 overarching themes, each underpinned by key lines of enquiry. The evidence gathered in respect of each was noted.
The Director of Nursing, Therapies and Quality highlighted the areas of the self- assessment where, on the basis of the evidence collected, it was considered that further action was required in the Trust. The Board endorsed the action proposed.
The Board noted that the actions proposed would be monitored by the Clinical Governance Group and escalated to the Quality Governance Group where appropriate.
The Board noted the self-assessment against the infection prevention and control board assurance framework.
75/20 Membership of Board Committees
The Trust Secretary submitted a report setting out the revised membership, and chairing arrangements, of Board Committees.
Since the despatch of the agenda is was proposed to add Sarah Murray to the membership of the Audit Committee. This would require a change to the terms of reference to allow for a larger membership.
The Board agreed the revised membership of Board Committees, the Chair of each and the amendment to the terms of reference to allow a membership of five Non-Executive Directors.
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76/20 Questions from Governors
There were no questions from Governors.
77/20 Review of the Meeting
No matters were highlighted for consideration.
78/20 Next Meeting
The next scheduled, virtual, meeting of the Board would be on Wednesday, 29 July 2020 at 1.00pm.
Signed: Date:
Andy Willis, Chairman
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Agenda Item 5
Matters Arising
Part 1 Board Meeting 29 July 2020
Minute Topic Action Lead Deadline Response 51/19 Board The Board agreed to authorise the Chief Executive to sign, in EY ASAP Completed, contract Briefing consultation with the Chairman, the contract for the provision signed. of children and young person’s public health services.
73/19 Board That the Executive develop an ambitious and challenging MM Sept 2020 Scheduled for Briefing sustainability policy and a programme of appropriate actions September 2020 which are aligned with the core purpose and activities of the Board meeting. organisation.
92/19 Trust Five The Board agreed: Sept 2020 The strategic Year framework, including Strategy (a) That the enabling strategies in respect of digital MM the supporting and estates be discussed at the Board workshop strategies, will be in November; submitted to the September 2020 (b) A report on actions and milestones for delivery be NP Board meeting. submitted to the January 2020 Board meeting.
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Agenda Item 5
101/19 Workforce The action plans would be updated in the light of the review of NP Sept 2020 Scheduled for Race the data and feedback from focus groups with staff. September 2020 And Equality Board meeting. Report It was considered that the revised data and action plans 05/20 should be submitted to the May Board meeting.
102/19 Workforce The action plans would be updated in the light of the review of NP Sept 2020 Scheduled for Disability the data and feedback from focus groups with staff. September 2020 And Equality Board meeting. Standard It was considered that the revised data and action plans 05/20 should be submitted to the May Board meeting.
114/19 Sustainabilit Agreed that the Finance and Investment Committee would MM Sept 2020 To be incorporated in y consider the actions that could be taken as part of the 73/19 above. transformation programme which would also have the effect of reducing the Trusts’ CO2 emissions
12/20 Review of Agreed that the Executive should give further consideration to DD Sept 2020 Scheduled for CAMHS the approach and timescale for providing the Board with the September 2020 Staffing assurances sought. Board meeting.
47/20 Trust Agreed that the Executive would consider the continuing need EY July 2020 The Executive will Finance for the Finance and Investment Committee and advise the report to the Report Board accordingly. September meeting on the possible remit of a Committee.
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Agenda Item 5
67/20 Dorset Care Agreed that a progress report on the DCR would be submitted MM July 2020 Item on the agenda. Record to the July meeting.
70/20 Integrated (a) Agreed that the Chief Operating Officer and Deputy KD July 2020 The Trust cannot be Dashboard Chief Executive would confirm whether or not the Trust removed from patient could be removed from patient choice options given choice options as for the current level of waiting lists; and some patients; the Trust is the only provider to meet their need.
(b) Agreed that the Chief Operating Officer and Deputy KD July 2020 The dashboard format Chief Executive would give consideration to is currently under approaches for ensuring Board visibility of smaller review and this Trust services. includes how to give greater visibility to smaller services.
72/20 Reports from The decision to reappoint any Mental Health Act Panel DD/ July 2020 To be confirmed. Committee members prior to the next Board meeting would be delegated SM Chairs to the Director of Nursing, Therapies and Quality, in liaison with the Chair of the Mental Health Legislation Assurance Committee.
73/20 Renewal (a) Agreed that a briefing note would be distributed to MM July 2020 Completed. Contract Board members responding to the matters discussed Approval- at the meeting; and Electronic 3
Agenda Item 5
Patient Record: (b) Requested that the Audit Committee review delegated HB July 2020 Completed. Report SystmOne limits. requested by the Audit Committee.
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Agenda Item 7
Fit for the Future Programme Part 1 Board Meeting 29 July 2020
Kristin Dominy, Chief Operating Officer, Deputy Chief Executive, Lauren Leete, Business Manager, Colin Hicks, Author Service Director, Jane Elson, Service Director and Kate Harvey, Service Director Purpose of Report To report the findings of the Fit for the Future stocktake following the Trust actions in response to COVID-19 Executive Summary
This paper details the outcome of the stocktake undertaken over a 6 week period to determine the impact of the Trusts actions in response to COVID-19.
4 work streams were established to review all aspects of Trust activity related to the delivery of patient care, the staff who were impacted, the change to the nature and type of care delivery and both the cost of these changes as well as the impact on the Trust financial plan for 2020/21.
The report sets out the impact on services, the impact on staff and details recommendations related to each work stream. The paper also acknowledges there is more to do in respect of staff and service users, patients and their carers who did not or who have not yet commented on their experiences to date. The report also identifies that some service users and patient groups did not present to services and in some cases have still not done so as a result of fear or anxiety related to the pandemic. The paper also identifies that the Trust is part of a wider system programme of care and recovery and details the areas that the Dorset System consider to be priority.
The Board is asked to note that this paper is a high level summary that draws on the outcomes of the workstreams and an extensive range of supporting information is available on key aspects highlighted in the report to Board members on request. Recommendation The Board is asked to note the review its findings and the next steps being taken forward by the Executive Background
1.1 This paper outlines the findings, learning, cost implications and direction of travel from the rapid 6 week scoping phase of the Fit For the Future Programme (FFTF). This paper will contain the findings from the following work streams; • Care & Recovery (Led by Jane Elson) • Digital (Led by Colin Hicks) • Finance (Led by Kris Dominy) • Workforce (Led by Kate Harvey)
1.2 The FFTF programme and individual work streams were instigated in response to the significant efforts made to respond to the COVID- 19 pandemic at speed, ensuring the safety of our patients and staff whilst continuing to provide high quality care within services.
1.3 It must be remembered that, whilst this report outlines the work of the Trust as described above, we are also part of a wider care and recovery programme at a systems level and as such are required to contribute fully through the priorities set by that programme.
2 Proposal
2.1 Each work stream was asked to do a stock take of the Trusts response, identify changes to services and current ways of working, identify new ways of working, review current practices and capture the experience of staff and people who use our services
2.2 Each work stream project group had representatives from across the relevant areas which included all 3 Operational areas, People and Culture, Estates, Business and Performance, IM&T and Nursing and Quality. This agile, cross-team project approach enabled rapid stocktake and assurance of key elements and position across operational services.
2.3 A significant amount of information was collected and synthesised as detailed in each of the full work stream reports.
2.4 This paper will bring together the high level findings from each of the work streams under the following headings;
Part 1: Impact on Services • New models of care • Service Recovery, including cost and requirements • New ways of working • Redeployment • Digital impact
Part 2: Impact on staff • New ways of working • Digital impact • Review of staff metrics (Training, AL, Supervision etc)
Part 3: Recommendations
2.5 Where appropriate this paper will also outline the requirements, timeframe and cost of recovery.
3 Part 1: Impact on Services 3.1 New Models of Care The COVID-19 pandemic has had an unprecedented impact on health care services in terms of the rapid introduction of new models of care aimed at both containing and responding to surges in the spread of the virus.
Significant new models of care were introduced in response to COVID-19, along with the next steps/ evaluation of these models. These include the following services;
3.1.1 Discharge to Assess: NHSE/I mandated that systems must use a modified discharge to assess (D2A) model to discharge all patients who have been confirmed by a consultant as no longer meeting the criteria for acute care. The national expectation is that D2A models remain, recognising that further improvements and a more sustainable model is required. This will require system sign up and providing a fundamentally different way of working, and shift of resources (staff and financial).
A ‘Home First’ Programme Board and Operational Group has been established with partners across Health and Social Care to both strategically and operationally direct the work required.
3.1.2 UTC/ MIU Model: MIUs/ UTCs have moved to a telephone triage and bookable appointments model. The review found the following;
• Attendance across MIUs/UTC has reduced significantly compared to the same period last year (as is the case nationally across Urgent care services) • Noticeable that most minor ailment (urgent primary care) work has stopped, whereas minor injury work continues. • High numbers of patients being managed with telephone or video assessment, advice, prescribing and discharge. • Under new ways of working, national standards have been consistently met. • Staff feedback has been extremely positive • Improved staff resilience across a reduce number of sites and no lone working • Minors ED attendance reportedly increased due to GP/ MIU/ UTC bookable appointments only.
There is a National drive for 111 to be the point of access for direct booking into services outside of urgent care with the aim to remove waiting rooms and reduce face to face contact as part of BAU.
This in turn will support the aligning of MIUs/UTCs with the IUC Service under a single leadership model.
3.1.3 Mental Health Emergency Assessment Units (MHEAU): MHEAUs were set up to temporarily support the acute hospitals by finding a different way to manage patients with mental health issues who present at ED.
Liaison services were based off site and provided an in-reach service. The EAU was a joint venture between adult and child mental health teams to develop an all-age service for face to face assessments.
Since the EAUs opened in early April they have received 621 assessments, a reduction of 21% on the number received in the same period the year before. This fits with the wider picture in Dorset whereby demand for mental health service was significantly reduced during the lockdown period. The MH Integrated Programme Board will be receiving the full evaluation report when completed and considering the impact of the learning on future developments and the Trust is currently working with the Acute Trusts to enable psychiatric liaison services to return fully to the acute setting.
3.2 Smaller developments within teams but still of note are the following;
3.2.1 Pain Management Service: The team converted face-to-face pain management programmes to virtual programmes. Group programmes have, for the first time, been delivered online with clinical content rewritten to make it suitable for remote delivery. This includes both clinical and peer led groups and the development of a website for self-directed and peer support.
3.2.2 Podiatry: The national directive was to only offer urgent podiatry appointments, the caseload of nearly 10,000 patients was triaged to ensure the 1000 patients at greatest risk could be seen and managed, mostly through provision of domiciliary care.
With over 8000 patients put on hold, the service rapidly implemented a telephone support line as a safety net to patients who could be quickly assessed if their foot condition deteriorated. Patients were also signposted to self-management videos for support.
3.2.3 Dermatology: The service has implemented new virtual working arrangements through the introduction of photographs shared by the patient of their skin condition prior to their appointment. This enables the clinician to review the photo and determine if a virtual appointment and advice can be offered rather than a face to face appointment.
Support and guidance on how to take and send the photos is provided and this has already reduced the number of face to face appointments required.
3.2.4 Orthotics and Audiology: Both the Orthotics and Audiology services deal with the fitting of aids/ appliances, with the fitting normally carried out in a clinic setting face to face.
The orthotics service has introduced appropriate equipment being delivered direct to the patients doorstep (supported by Podiatry Assistance during this time) enabling patients to receive appliances without delay and self-fit. Similarly, following changes by the British Audiology Association, audiology is in the process of sending approx. 1000 hearing aids via the post for ‘self-fit’ to avoid delays.
3.3 Further Opportunities Further service transformation opportunities were identified and are currently being taken forward including:
Diabetes education - shift from 3 face to face sessions to working with other providers pan Dorset to offer one virtual group programme for the county. Once the programme is agreed pilot programmes will commence in July.
Pulmonary Rehab –Delivering via virtual means including the use of Attend Anywhere for assessments, MyMHealth App with monitoring, Virtual group programme and face to face where required.
Community Stroke Beds – discussions are now taking place about the potential to designate 10 beds within a community hospital to become specialist Stroke/Neuro beds and support earlier discharge from Acute services.
3.4 All service changes are being reviewed via the quality impact assessment process and this remains ongoing.
3.5 Service Recovery This section of paper gives a snapshot of the current position and plan for each of those services that were suspended and will be subject to change as new guidance is issued, social distancing guidance changes and / or any subsequent surge in COVID-19.
The trajectories in this report are based on a point in time, and are subject to change. Referrals rates to a large number of services will also be impacted as primary care steps back up as well as the phasing of acute services coming back. As best as possible this has been factored into trajectories.
The services are divided into 5 categories
• Those requiring a system wide approach • Those requiring investment to recover • Those requiring collaboration between services to recover (e.g. secondment of additional staff). • Slow stream recovery • Recovery with minimal impact.
3.5.1 Services that require a system wide approach
Overarching service Services included Consultant Led RTT Services Cardiology Ear Nose and Throat Elderly Medicine General Surgery General Medicine Urology Gynaecology Ophthalmology Oral Surgery Rheumatology Diagnostic Services Endoscopy
3.5.2 Services that Require Investment
Service Current position Podiatric Surgery Podiatry Surgery relies upon increasing surgical capacity as part of the overall RTT pathway and is likely to start mid/ late July (subject to risk assessment of environment, equipment, staffing and local IPC procedures in place).
Podiatry Podiatry has been suspended with the exception of treating high risk active foot ulceration and specialist hospital services e.g. diabetes and rheumatology. As the service looks to step up, patients will be prioritised by ‘foot risk’ rather than length of wait.
As with many services productivity is impacted and is anticipated to by 60% Dermatology Dermatology Services is a service with fixed capacity, and options to recover will need to include a combination of increase internal session and also outsourcing to an alternative provider subject to them having capacity.
Medical and Minor op resumed from June 2020 with minor ops being at 50% normal capacity allow for temperature testing and clinical cleaning. Medical support will be provided virtually wherever possible. Both elements are co-dependent.
Pain Management In line with national guidance Pain services suspended medical interventions but continued with virtual appointments and self - Services management activities for all other patients.
Intermediate Care ICRTs stopped providing long term therapy during COVID-19, but continued with intermediate care. The demand for Intermediate Teams care did not rise as expected enabling the team to address long waiters for long term therapy with the exception of Portland & Weymouth team who already had a number of long waiters due to long-term staffing challenges
An additional Physio has now been recruited to the team and started mid-June.
School Aged School Aged Immunisations were stopped during lock down. Immunisations (NHSE Restarting of the immunisation programmes requires use of clinics as schools are not available with potential development of drive Commissioned) through options to increase throughput.
Alongside this, the scale of the flu programme (starting Sept) has increased to include an additional year group and a greater cohort size.
3.5.3 Services Requiring Additional Staff Deployment or Collaboration to Recover / Continue During the COVID-19 period, 226 staff were redeployed within DHC. Most of the Nursing and Quality Directorate 102 from the CYP Directorate (speech and language therapists, health visitors, school nurses, LAC nurses, business support and sexual health nurses) and 124 from the ICS Directorate (nurses, physios, speech and language therapists).
Redeployment was led and coordinated by the Workforce Cell, with input from operational directorates, nursing, therapies and quality, payroll, HR, occupational health, psychology and the learning and development team. The focus of this phase of redeployment was business continuity and resilience in community hospital and district nursing teams.
Many of the redeployed staff have now returned to their substantive roles however the following services will need additional staffing or collaboration between services to recover, plans are in hand to support this.
Service Overview Anti- coagulation Continued during COVID-19 with reduced productivity due to social distancing and a shift to home based visiting for the majority service of patients due to non-availability of primary care venues and supporting shielding patients at home. As the service has continued there is no backlog/ waiting list and all new patients continue to be seen in 7 days.
In providing a continued service to patients at home the service has been supported by two redeployed Health Care Assistants. Leg Ulcer Service Provides different level of care, • Level 2 – provides ongoing treatment of complex leg ulcers and has continued during COVID-19 but with a shift from clinic towards home base visiting • Level 3 Pan Dorset - a one off specialist assessment which stopped The level 2 service required a full time nurse and HCA to be seconded for six months to recover. New Born Hearing Service was stopped in the community, with delivery shifted to acute sites. Screening As at the beginning of May there were 747 babies overdue for screening
The new born community screening programme recommenced in early June and is being supported in recovery by the secondment of audiology staff during July.
Slower Stream Service Recovery
There are a number of other services / function that were suspended that will have a slower recovery. These includes the following services:
Service Recovery Period Indicative month for full recovery Dorset MSK 31 week recovery Feb 2021
Orthotics 27 week recovery Jan 2021
Pulmonary Rehab – 30 weeks assessment Jan 2021
Courses 36 weeks Feb 2021 Oncology (genetic screening 6 week recovery end August 2020 element)
Heart Failure 10 weeks recovery mid-August 2020
Diabetes Education 12 weeks recovery end Sept
Stroke Reviews 7 week recovery end July
B&P LT Therapy 5 weeks recovery early August
LAC 12 week recovery end August
Wheelchairs 16 week recovery Sept
MAS 16 week recovery Sept
CYP & Paediatric SaLT TBC
3.5.4 Recovery with minimal impact The following services/ functions were also suspended however there are no significant recovery issues and will be a quick catch up or review of existing caseloads • Physio MSK O/P • Brain Injury • Community Neuro • Continence • Sexual health
3.5.5 System Recovery The mechanism for system recovery is via The Care and Recovery Programme which is a fortnightly meeting with Chief Operating Officers and the CCG. The priority action from a health care perspective is RTT recovery with an urgent focus on 52 week waits. The focus is as follows:
Type Lead Organisation Endoscopy PGH and RBH Orthopaedics DCH Oral Surgery and ENT PGH Ophthalmology RBH General surgery All Audiology CCG, DCH, DHC
The wider system recovery matrix is as follows:
3.6 Services with underrepresented demand Across MH & LD services there has been a significant reduction in demand resulting in between a 20 and 60% decrease in referrals (activity for current patients has remained consistent). This is reflective of the national picture. As part of forward planning, consideration is being given to addressing this under representation to ensure equality of access along with any anticipated surge in COVID-19 related demand.
3.7 Digital Impact on Services
3.7.1 Attend Anywhere Adoption of Attend Anywhere software by services within Dorset HealthCare vastly increased during the initial days of the pandemic, building upon existing good use of Attend Anywhere in some service areas. Before the coronavirus pandemic, the Trust had already rolled out virtual consultations using Attend Anywhere across 24 sites. During the pandemic this was expanded to include inpatient and community services across an additional 60 waiting areas.
Prior to coronavirus our average calls per day to patients were 40 calls per week, this is now averaging approx. 500. As another rapid response to coronavirus the Attend Anywhere platform was used for our Virtual Visiting Project which has enabled our patients to have a video call with family/friends while an inpatient at our Hospitals.
Figure 1 Usage of Attend Anywhere (number of calls per week) within Dorset HealthCare from 8th January 2020 to 4th May 2020. Pre-pandemic dates are displayed in red and during the pandemic in blue. The trend line shows the expected growth before the Coronavirus pandemic.
3.7.2 Other applications Other applications such as Go To Webinars, Go To Meetings, WhatsApp and Facebook have also been used during the crisis to resolve issues in areas that required a more bespoke solution. The full report contains this feedback.
3.7.3 The experience of people who use our services An online survey was added to the Attend Anywhere platform that people accessing virtual visiting or clinical appointments were asked to complete at the end of their session. Feedback was for the period 13/05/2020 and 27/05/2020. The survey used was co-designed with Dorset Mental Health Forum to ensure a service user voice was present.
193 people responded to the survey out of a potential cohort of 2,265 giving an overall response rate of 8.5%, when the information was further analysed for those people using the system for specific virtual visitation calls this response rate increased to 51.4%.
On average:
• 61.1% rated the service as very positive • 30.9% rated the service as positive • 5.65% were unsure • 1.6% responded negatively • 0.8% responded very negatively
Those who indicated they were attending for a clinical appointment were also asked if they felt heard or listened to, including their body language being picked up. Of 123 respondents 98.4% answered that they did; with only 1.6% answering that they did not.
3.7.4 Overall experience of Attend Anywhere Users for both clinical appointments and virtual visits were asked if they would choose video appointments in the future. Of the 123 responses 78% answered “Yes”, with the remaining 22% answering “No”.
The overall experience of users was positive with 88.6% rating their experience as either very good or good
3.7.5 Feedback from Staff A section in the care & Recovery questionnaire was included to capture experience of using a range of digital platforms both with other professionals (in and outside of Dorset HealthCare) and with patients/service users. Thirty eight team responses were received with thirty three of them reporting to have used Attend Anywhere.
A similar questionnaire was subsequently put onto Gather to collect similar feedback from support/corporate services. The survey was open between Monday 18 May and Sunday 31 May and received 111 individual responses.
A significant amount of positive feedback was received across teams with comments about it being easy to use, reducing travel time, patients seeming to value it, and in particular anxious patients seeming to engage well.
Negative feedback revolved around connectivity issues initially getting set up with a couple of teams, comments on finding it quite exhausting to be working using AA as opposed to face to face for their clinical work, and work life balance issues. Several challenges were identified regarding undertaking clinical work online including:
• Difficulty assessing a patient’s environment, clothing, hygiene and other indicators of wellbeing • Privacy issues for patients • Lack of observation opportunity when walking into consulting rooms • Need for white board if wanting to sketch something out
The vast majority of teams who were using Attend Anywhere reported that whilst they would like to reintroduce face-to-face contact they would seek to continue to roll out/expand the use of Attend Anywhere for appointments
3.7.6 Hidden Impact A limitation of this stocktake has been that patient feedback has only been sought from people who have engaged in Attend Anywhere (mainly due to time constraints). However it is recognised that some people will choose not to, or be unable to, engage with services through a digital platform. Feedback from service users who have not used or been able to use Attend Anywhere or other video consultations is equally as important to ensure that discrimination is not inadvertently perpetuated through this period.
• Limitations Several limitations have been identified as part of this stocktake which will need further consideration in the continued rollout of the digital/flexible working programme. These broadly fit into two areas: • Clinical effectiveness and safety Whilst this report has captured some information around usage and experience what is missing is any data regarding clinical outcomes and impact on the quality of the service delivered. Several teams highlighted concerns regarding effective safeguarding when working remotely with patients when you have limited access to other information regarding the patient and their environment.
• Access to digital services and the risk of increased inequality Digital poverty’ is a term being used to describe how lack of access to the internet may impact on people’s healthcare during this period. Further analysis will be needed to ensure that particular patient cohorts are not being inadvertently discriminates against with a greater proportion of services being offered through digital means.
Digital poverty remains a significant concern, evidence from the ONS suggest that the SW has a significant proportion of the population who are unable or unwilling to access the internet.
4 Part 2: Impact on Staff
4.1 New Ways of Working The COVID-19 period enabled rapid change in views and implementation of agile working. Employees of the trust have had to adapt to mobile / digital options made available to ensure they continue to deliver a service with aims of safe, effective care leading to a good patient experience.
The IM&T department were very fortunate at the outset of the coronavirus outbreak to have already implemented sturdy foundations which enabled the Trust to have a proactive response to the crisis. The scale of the workforce being asked to work from home caused initial issues with laptops being in short supply and the bandwidth being strained leading to poor connectivity but on both accounts this was resolved within a couple of weeks.
The most common reason that staff started working from home was in response to a request from line managers to support social distancing (56% of responses). Other common reasons were shielding themselves, a service need and shielding others (including caring responsibilities). Feedback from clinical teams on the use of digital can effectively be summarised into three key areas as below;
Area Feedback
Home / remote working Team Working Virtual MDTs/ Handovers/ 1:1’s/ Clinical Supervision/ Team meetings Virtual training materials/ workbooks e.g. Dysphasia training Mobile video conferencing Use of digital photography WhatsApp as a means of informal communication Telephone assessments and also staff welfare calls Virtual interviews Emailing correspondence to GPs rather than sending by post (CAAS)
Multi agency Efficient use of time and ways of working in relation to multi-agency working meetings becoming virtual. Virtual meetings, training and patient reviews with care home Virtual advice clinic for GPs.
Working with Telephone triage/ assessment before undertaking visits Patients Self-directed help and supporting family/ carers to undertake basis care Signposting to other resources Use of Apps and software for services Virtual appointments, Attend Anywhere or via telephone Telephone reviews Virtual groups and carer support Zoom stroke peer support meetings
4.2 Digital Impact All bar one of the operational services reported used MS Teams and all bar two of the responses from corporate services. Most usage was for internal and external meetings, talking to colleagues, appraisals and a small number of people said they are using MS teams to share and update documents.
Uptake has been rapid with an average over an eight week period of 2,700 users per day generating 900+ calls and 1500+ meetings. Over 200+ ‘Teams within Teams’ have been created where an average of 400+ team chat updates occur per day notwithstanding the 11,500+ private messages. The Trust has held its position in the Top 10 NHS.net Organisations using MS Teams since it was implemented early April.
The feedback was generally very positive from operational services and 86.2% of corporate services respondents were very or extremely positive about using MS Team with 79% said they would frequently or always use MS Teams in the future.
Theme Positive comments Challenges of platform
Accessibility I find the meetings more Managing meeting structure and accessible than other online methodology for hearing impaired systems. staff.
Time Higher levels of meeting The new ever-presence of MS management attendance with greater flexibility Teams has been a challenge for for teams with a lot of part time some as they are relentlessly staff. available, are drawn into parallel Made meetings more efficient. chat steams whilst being simultaneously in other meetings Using chat function for quicker which can be difficult to avoid responses / reducing the amount when they can see decisions are of emails / speedier responses. being made at pace. Anecdotally Saving travel time and this may be more problematic for consequently improves staff working across teams or productivity. within different services as they Saves problems finding/booking a appear to different teams meeting room. available at all times.
Technical Connectivity issues including lag. Challenge of initial set-up. Access to laptops. Willingness of some staff to use video function.
Theme Positive comments Challenges of platform
Communications Able to share documents for Selective use. people without access to shared Managing the cultural change of folder structure – improves cross using MS Teams. functional information sharing and Missing people. collaboration. Missing some of the conversation Improved record keeping as richness. group chat records remain available. Need to ensure all details are included in the meeting. Reduced team isolation and encouraged people to contribute Lose ability to have informal chats to meetings (those who don’t with individuals at start/end of speak much in team meetings). meeting.
4.3 Access to digital services and the risk of increased inequality It is also of note that there is a great variance amongst staff as to their skills and ability to use digital options. We have some evidence within the Trust from uptake although no detailed evaluation of IT skills or the broader digital skill set and understanding has been undertaken.
4.4 Review of staffing metrics 4.4.1 Training, supervision, appraisals and annual leave Training and supervision rates in operational teams did not significantly change during the COVID-19 period.
In contrast, a decision was taken in the early part of the COVID-19 period to suspend appraisals and completion rates can be seen to have fallen across all operational directorates in April and May 2020, with the largest decrease in Mental Health Services (-3.38%). Appraisals were stopped and some catch up is now required. Ongoing assurance processes have been reintroduced via DMG meetings.
The FFTF project group recommended that appraisals should be maintained in the ongoing COVID-19 period and in any future major incidents or pandemics.
4.4.2 Sickness absence management There was little change in sickness absence during the COVID-19 period but considerable increase in special leave and other COVID-19 related absences.
We cannot be confident that this will be maintained through further demands due to the prolonged demands on the workforce. Sickness and other absence varied across different staff groups in line with national data and evidence based risk assessments and guidance.
Significant capacity was lost through staff who were fit to work but unable to work remotely in their substantive role; this may also have had an impact on the health and wellbeing of these staff. This is now being looked at by a working group to look at effective deployment of staff fit for work but unable to work in their substantive role.
4.4.3 Workforce wellbeing needs and support In preparation for COVID-19, a staff well-being plan was designed to support staff during and after the pandemic, with a strong focus on prevention of needs and prevention of escalation of emotional distress.
Despite considerable investment, the demand and uptake of the in-house mental health and emotional wellbeing support is lower than previously expected.
Values driven behaviour was visible in all groups of staff and warrants further understanding and support to ensure that this is not depleted in the face of considerable ongoing pressure and demand
4.4.4 Additional Recruitment and Redeployment A new redeployment process was implemented at pace and considerable scale. Two key themes emerged from the review as successful redeployment was found to be linked to clear and consistent communication and support to prevent staff feeling isolated. The new process has now been developed and coordination remains complex, requiring considerably more time than arranging usual bank staff placements.
The major areas of COVID-19 related effort resulted in relatively small numbers of new starters, highlighting the importance of longer term workforce planning with all operational teams. 5 Summary Costings
5.1 Service Recovery Summary Costings The following table provides a summary of costs which have been agreed.
Service Cost £ (000) Increase CCG AQP Total £ (000) cost £ (000) Podiatric Surgery 13 13 Podiatry 54 54 Dermatology 31 82 113 Pain management 50 50 Intermediate care 10 10 School Aged 49 49 Immunisations Total 207 82 289
5.2 Digital Summary Costings The table below indicates the indicative costs associated with maintaining the current provision. The annual revenue cost from 21/22 onwards would be circa £1.3m. This covers licenses and fees and an increase in the depreciation of laptops if the renewal cycle was reduced. Any additional IM&T support needed to sustain this programme is excluded.
20/21 21/22 22/23 23/24 24/25 Software Costs: Details £ '000s £ '000s £ '000s £ '000s £ '000s Office 365 (Teams) Variety of different levels 740 740 740 740 Dependent on national negotiations - potential for new systems to be Attend Anywhere* developed. Need clarity on 2020/21. Max 6 per meeting 200 300 300 300 £3 per month per person - could give to admin set up and then no cost Teams add on (assumes 50% of Admin need this) 32 32 32 32 Life-size Large room conferencing - we have a couple of units 20 20 20 20 20 Go To Meetings Used mainly in Steps - based on spend in 2020 16 16 16 16 16 Other Remote working service increases line & firewall 26 26 26 26 26 Hardware Costs: Additional Laptops Increase in programme and change from 7 year to 4 year roll out 95 191 191 191 191
Total Costs 157 1,225 1,325 1,325 1,325 Inflation ** 2% 25 51 78 104 Total with Inflation 157 1,250 1,376 1,403 1,429
* Currently unknown if this will be commissioned centrally by NHSE. The price range for this is from £200k to worse case £528k. The figures above are based on negotiations that happened ealier this year **Cumulative Inflation
6 Part 3: Summary, Recommendations and Next Steps
6.1 Whilst preparedness, responding and recovering services has bought its unique challenges, it has also demonstrated that service transformation at pace is possible. It is clear that the impact of the coronavirus pandemic on services and the people that use them has been significant but they have been at least in part mitigated but the flexibility of services across the organisation to mobilise and adapt at speed whilst continuing to provide safe, effective and quality care.
6.2 The ability to introduce new ways of working and digital approaches within services has often been challenging. However, with many services temporarily suspended, clinicians have been provided with time to reflect on the model of service and how this can be adapted.
6.3 In stepping back up services the plans should include a time limited period for lead clinician to undertake a review of the service model and maximise on the opportunity for starting up a new BAU model going forward including consideration of what does not add value and stopping these functions.
6.4 DHC has only scratched the surface of the capability surrounding digital health services. Services can continue to expand their digital offer, both patient facing though developments such as the patient portal, clinically though the implementation of EPMA and the maximising of the use of Video consultation and Apps.
6.5 Both MS Teams and Attend Anywhere appear to have been the most adopted platforms and received positive feedback. Regardless of system, there remain areas where additional planning and training would be beneficial, such as accessibility for people with sensory impairment (hearing, visual) and adequate training and support regarding functionality.
6.6 The experience across individuals, teams or services during COVID-19 varies and there is a requirement for highly personalised support as part of ongoing change management. Staff will require regular engagement and cyclical feedback loops (including a brief FFTF summary output)
6.7 The FFTF programme has taken an agile, cross-team project approach to stocktake and assure the current position across operational services. This cross-team approach is suggested to be key in effectively delivering the FFTF recommendations. It is now important that as part of thinking toward the future the Trust considers how to capture the learning from this period and use this to accelerate its transformation agenda at pace.
6.8 It is of note that the provision of datasets for this report proved challenging and demonstrated that this data is not readily available particularly from S1. As a consequence it is not currently possible to set up a system to regularly refresh this data and report across service lines against the trajectories set out in this report
6.9 Immediate Next Steps: Clearly these changes will require a quality impact assessment.
Care & D2A model: Identify quick wins prior to winter Recovery MIU/ UTC model: Better align the MIU/UTC and the 111 Service.
Support the stepping up and recovery of services in line with National Guidance.
Digital Continued roll out of Attend Anywhere in line with National Programme.
Support roll out of Office 365 (include MS Teams)
Develop standard framework
Understand individual team needs for both digital input and training requirements. • Additional resources will be required to take these areas forward.
Workforce Prepare a FFTF summary to go back to staff and share with partners and agreeing the work that non-operational Directorates will deliver to ensure catch up in mandatory training, appraisals, supervision and annual leave.
A number of recommendations relate to governance and pre- planned changes and these are being implemented via existing programmes of work.
Longer term change and transformation programmes will progress the remaining actions through longer term recovery and reset work
Ongoing assurance processes have been reintroduced via DMG meetings for training, appraisals, supervision and annual leave.
Kristin Dominy Chief Operating Officer, Deputy Chief Executive Agenda Item 9
Integrated Corporate Dashboard July 2020 (Based on June 2020 data)
Author Kristin Dominy, Chief Operating Officer Kyoko Monk, Business & Performance Corporate Business Partner Purpose of Report To provide the Board with insight and foresight concerning Trust performance. To support effective decision making, highlighting key areas of exception and good practice. Executive Summary
June metrics continue to be affected by the Coronavirus Pandemic (services stepped down, data collections suspended and changes to operational practice). The trust has carried out an assessment of services that were stepped down and is planning service recovery.
Falls – The number of falls has been above the long term average since January. There were 58 falls in June (39 no ham and 19 minor harm). There has been a national increase in Covid-19 patient falls and staff have not been able to respond as promptly as usual due to having to don PPE before responding. More detail is in the main report.
Bed occupancy – Planned acute hospital activity has resumed leading to an increase in bed occupancy in community hospital wards. Mental Health bed occupancy remains low due to inpatient services carefully managing the Covid-19 risk through creating single occupancy and isolation rooms.
Integrated Community Services Delayed Transfers of Care – This figure increased since May and is over the threshold (7.6% against 7.5% threshold). However performance standards were suspended by NHS England on 19th March 2020.
CPA 12 month review – Although compliance was below the 95% threshold it has improved over the last three months (90.51% for June). Improvement work is ongoing.
Risk assessments (95% threshold) – Falls assessments were above the threshold. Venous thromboembolism (VTE), pressure ulcer and MUST assessments were all below threshold.
Assessment Type Trust Total Community services Mental Health (95% threshold) Services Falls 96.0% 97.6% 87.0% Venous Thromboembolism 91.3% 100% 78.3% Pressure ulcer 93.0% 98.3% 65.2% MUST 93.2% 100% 56.5%
Further details on the breaches and actions being taken to improve compliance with these assessments are in the full report.
Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate – patients on an incomplete pathway. The RTT figure has further reduced to 25% (against 92% threshold) due to the suspension of clinics in line with national COVID guidance. Further detail is included within the body of the report.
Maximum 6-week wait for diagnostics - Diagnostics has improved from last month (May 7.9%) to 31.6%. This metric has been below the 99% threshold due to services being suspended during the COVID-19 outbreak. A slow recovery over the next 6-9 months is anticipated.
Steps to Wellbeing /Talking Therapies - proportion of people completing treatment who move to recovery. The Steps to Wellbeing service has been affected by COVID; this metric achieved 43.5% in May against a threshold of 50%.
Recommendation To note the report Contents
Section Page No 1.0 Integrated Corporate Dashboard Analysis 1-17 2.0 National Reporting Frameworks 2.1 CQUINS (Quarterly) N/A 2.2 External Benchmarking (as appropriate) N/A 2.3 Nationally reportable concerns (as appropriate) N/A 2.4 Research and Development Metrics (Quarterly) 18 2.5 Mental Health Act Metrics (Quarterly) N/A 2.6 Learning From Deaths Report (Quarterly) N/A 2.7 Data Quality Assurance Activity Summary (Quarterly) N/A 2.8 Inpatient Nursing Staffing N/A Integrated Corporate Dashboard Analysis – July (based on June 2020 data)
This paper summarises key messages from workforce, finance, quality and performance domains, set out by key lines of enquiry.
Many of the metrics have been affected by prioritisation for the current Coronavirus Pandemic. For example, some services have been stepped down, data collection has been suspended, some data is unvalidated or there have been changes to operational practice. Where this is the case ‘C-19’ is cited in the Data Quality column of the metric tables. Where services or data collection are suspended ‘no data’ is in the ‘In Month’ column.
Are We Safe By safe, we mean people are protected from abuse and harm. This covers medicines management, enough staff of the necessary skill mix to provide good care and infection control management and practise.
Three metrics were outside normal limits during June within the Are we Safe key line of enquiry. The rate of falls has now been above the long term average since January. Due to the Trusts Covid-19 response community and mental health bed occupancy remains below the lower control limit.
Integrated Community Service Recovery – The Trust has carried out an assessment of services that were stepped down in line with national guidance as part of our Covid preparedness response to understand the number of patients waiting and trajectories for service recovery. There are a number of factors that could impact on service recovery which has been added to the Trust Risk Register as follows:
• Fixed service capacity requiring an additional investment • Prioritisation of surgical/diagnostic activity in line with national guidance and supply of specialist staff under the SLA to support stepping back up services
1 • Loss of staff through track & trace • Local outbreaks /second wave impacting staffing /service provision • Changes in national guidance
Reported patient safety incidents have remained within the Statistical Process Control (SPC) measures for the quarter. Twelve patients were appropriately transferred to acute care following physical health deterioration. Three of these patients had received a diagnosis of Covid-19. A further three incidents included patients that had only been in our care for a few hours following step down from acute hospitals. Acute hospitals have been asked to investigate and feedback their findings to the trust.
There was a delay in obtaining blood results after the blood sample from a care home resident was collected from the different resident in error, local learning from this incident has been identified and implemented.
There were four reported incidents involving self-harm in mental health services. All patients returned to the care of mental health services after assessment in acute care.
Controlled drugs were found to be missing from a community patients’ home, this has been reported to the police and the safeguarding team are involved in the patients care.
During June 58 falls were reported with 39 patients not harmed and 19 sustaining minor harm. Twenty-four falls were reported within community hospitals and 34 in mental health hospitals. Five patients sustained three falls each within the month.
Nationally there has been a reported increase in falls where Covid-19 patients were experiencing hypoxia and the impact this had when patients started to mobilise. It has also been noted that staff not able to respond to patients needs as promptly as usual due to having to don Personal Protective Equipment (PPE) before entering the patient area. Further review of local data is required to assess the Covid-19 impact on the number of inpatient falls.
The Falls Lead was redeployed into Infection Protection Control (IPC) team from 23 March 2020 and therefore quality of falls support, case review and training has been impacted. The plan is to restart falls monthly dashboards in July with data and learning being shared.
One C difficile case was reported from Colmers Ward, Bridport hospital. A Root Cause Analysis (RCA) is underway currently to establish whether any lapses in care have occurred. The patient had received antibiotics whilst an inpatient at the acute trust and developed loose stool on the ward at Bridport. Antibiotics are a predisposing factor for the development of C difficile infection.
Other significant healthcare associated infections - There was a diarrhoea and vomiting outbreak on Haven Ward. Two patients and four staff were affected. No causative organism was found.
Physical health bed occupancy has risen during June as predicted last month, due to the resumption of some planned acute hospital activity.
2 Mental Health bed occupancy - Mental Health adult acute bed occupancy remains below the 85% Royal College of Psychiatrists threshold at 73.9% in June, an increase on May's position of 70.8%. Bed occupancy has remained low due to inpatient services carefully managing the Covid-19 risk through creating single occupancy and isolation rooms.
3 Are We Effective? By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. This enquiry line includes patient choice, appraisals, training, ongoing referrals, consent to care and treat, restraints, nutrition and tissue viability.
The percentage of Patients with delayed transfers within physical health is now above threshold. Fewer than 95% Venous Thromboembolism (VTE), Pressure Ulcer and Malnutrition (MUST) risk assessments and percentage of patients with CPA 12 month review did not meet the 95% target.
Mental Health Services Delayed Transfers (DToC) - The Trust has tracked below the threshold of 7.5% for Delayed Transfer of Care (DToC) in the quarter and has maintained an improving trajectory which equates to 307 delayed bed days. At the end of June there were 9 people delayed which is a significant reduction on previous months.
April May June 7.32% 6.92% 5.78%
In response to Covid-19 DToC remains on the Daily Risk Report, local authorities continue to provide support with sourcing care for patients to be discharged safely and daily bed management calls take place identifying patients ready for discharge.
Integrated Community Services Delayed Transfers (DToC) - The percentage of days lost to DToC increased in June at 7.6% against a target of 7.5%, which was an increase from May (5.3%). This figure is not validated as the validation process by the local authorities has been suspended nationally in response to the Covid-19 situation. The routine reviewing of DToC is now part of the Central Coordination Team (Discharge to Assess) which includes social care and brokerage.
Current performance standards on DToC monthly reported delays was suspended by NHS England (NHSE) on 19th March 2020.
4 The NHSE guidance for Covid-19 Hospital Discharge and Admission Avoidance has led to a new Central Coordination team being set up. A Pan-Dorset Programme Board has been established to oversee the further development and embedding of Discharge to Assess and a ‘Home first’ approach.
Percentage of patients with CPA 12 month review - The Trust compliance against a threshold of 95% was 90.51%, an improved position on May’s 89.9%. Learning Disabilities achieved 100% compliance and the Child and Adolescent Mental Health Teams maintained an upward trajectory.
June Completed reviews Adult CMHT 91.2% 624/684 Older People CMHT 90.9% 210/231 CAMHS 93.3% 50/60 Learning Disabilities 100.0% 26/26 Specialist Services 89.0% 186/209
The Task & Finish Group have met twice to discuss improving compliance and work is ongoing. The Head of Community Services and Lead Consultant meet regularly to review and support work on increasing performance against this Key Performance Indicator.
Falls assessment within 24 hours - The Trust achieved 96% against a threshold of 95%. Community Hospitals achieved 97.6% against a threshold of 95% (3/126 breaches)
Mental Health Inpatient Services achieved 87% against a threshold of 95% (3/23 breaches) an improved position on the previous month of 70.6%. Seaview 1/13 patient's physical presentation prevented assessment, same day transfer to another ward and assessment completed. Melstock 1/3 completed, electronic patient record not updated, this has been followed up with the member of staff. Psychiatric Intensive Care Unit (Male) 1/1 patient agitated on admission, completed outside of target time.
Venous Thromboembolism (VTE) assessment within 24 hours- The Trust achieved 91.3% against a threshold of 95%, 18/207 breaches. Integrated Community Services were compliant at 100%.
5 Mental Health Inpatient Services achieved 78.31% against a threshold of 95%, 18/83 breaches.
Reasons for the breaches: • 6 patient presentation on admission - 4 completed outside of the 24hr target time, 1 patient transferred out of area same day, 1 not completed. • 5 assessment completed, electronic patient record not updated/incorrect date used. • 2 completed outside of target time. • 2 no Senior House Officer (SHO) available and 1 locum SHO not aware of process (Pebble Lodge). • 2 not completed.
Actions: • All breaches are reviewed by Ward Managers, raised at team meetings and in individual supervision. • Pebble Lodge - a general nurse has been recruited and a process is now in place for locum SHOs to follow assessment checks. • Training is being rolled out and 'Guidance at a Glance' shared with managers at the Inpatient Business Meeting to disseminate to teams. • VTE assessments will be added to the E-Obs project to enable by the bed screening.
Quarterly Narrative: Community Hospitals: Compliance for VTE assessments was achieved in Q1 with 97.9% against a target of 95% assessments completed within the 24 hour target. Compliance was achieved in each month in the Quarter.
Mental Health: Improved quarterly compliance for VTE Assessment - 80% compared to 79% in the last quarter.
Breaches April 77.5% 20/89 May 85.5% 12/83 June 78.3% 18/83 Totals 80.4% 50/255
Specialist Services continue to embed the VTE assessment and have updated admission checklists to reflect the procedure and 24hr target time. In mid-June physical health checks were added to the Matrons weekly audit for their individual wards to support an increase in compliance.
Pressure ulcer assessment (Purpose T) within four hours - The Trust achieved 93% against a threshold of 95%, 10/143 breaches. Integrated Community Services were compliant at 98.3% against a threshold of 95%.
Mental Health Inpatient Services achieved 65.2% against a threshold of 95%, 8/23 breaches.
Reasons for the breaches: • 2 completed outside of 4hr target time.
6 • 5 patient presentation on admission - 3 completed outside of target time, 2 not completed. • 1 assessment completed, electronic patient record not updated.
Actions: • All breaches are reviewed by Ward Managers, raised at team meetings and in individual supervision. • Purpose T assessments will be added to the E-Obs project to enable by the bed screening.
MUST assessment within 24 hours - The Trust achieved 93.2% against a threshold of 95%, 10/146 breaches. Integrated Community Services were compliant at 100%.
Mental Health Inpatient Services achieved 56.5% against a threshold of 95% (10/23 breaches), a declining position on the previous month of 58.8%. Seaview 6/13, 5 completed outside of target time due to Covid-19 swabbing delaying assessment, 1 completed but the patient electronic record was not updated, this has been raised with the member of staff. Herm 1/5 patient presentation on admission, assessment completed outside of target time. Melstock 2/3, 1 patient presentation on admission, assessment completed outside of target time, 1 electronic patient record was not updated, this has been raised with the member of staff. Where patients were isolating awaiting swabs, it was not possible for them to be taken to the clinical room missing the 24hrs target time. Mobile equipment has been purchased to enable by the bed testing.
Are We Caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.
Patient Satisfaction Metrics – As advised by NHS Digital, data collection has been suspended due to Covid-19.
Compliments – data collection/reporting has also been suspended.
7
Are We Responsive? By responsive, we mean that services are organised so that they meet people’s needs.
Measures taken as a response to Covid 19 continue to impact on reaching metric thresholds within the Are We Responsive key line of enquiry. The 18 week from referral to treatment, 6 week wait for diagnostic procedures, and the steps to wellbeing patients completing treatment who move to recovery metrics have each failed to reach threshold since the pandemic response began.
Out of Area Placements (OAPs) - There were four Child and Adolescent Mental Health (CAMHS) Out of Area Placements (OAPs) in June. Two Acute, one Eating Disorders and one Psychiatric Intensive Care Unit placement, with a total of 36 occupied bed days.
New Placements in Month In bed at month end Apr May Jun Total Apr May Jun Adult Acute Out of area placement 0 0 0 1 0 0 0 Adult MH Specialist Out of area 0 0 0 0 5 4 4 placement Learning Disabilities Out of area 0 0 0 0 13 13 13 placement Forensic Out of area placement 0 0 0 0 32 31 31
CAMHS Out of area placement 0 1 4 1 13 13 10 Rehabilitation Out of areas CCG rehab data currently recorded on RiO – TBC placement OOA Incidents 0 0 0 0
Total 0 1 4 2 63 61 58
8
The two Acute OAPs were due to Covid-19 and bed availability in the CAMHS acute unit, availability has been reduced from 10 to eight in line with discussion with NHS England South West to manage risk associated with Covid-19 and social distancing, the unit is currently managing the associated risk with nine beds.
It is anticipated that CAMHS Acute OAPs will continue as building work will commence on 20th July for 26 weeks reducing bed availability to eight.
Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate – patients on an incomplete pathway – As reported previously, a number of community services have been suspended since mid-March in line with national guidance. As a consequence all of the services that contribute to the Trusts RTT position have been suspended and there has been an expected corresponding month on month deteriorating position against the target.
Given the emphasis on urgent and priority care nationally there will be a phased approach to being able to step up all RTT activity where the Trust is dependent on the supply of specialist staff from our acute partners. However waiting lists are being regularly triaged and virtual appointments where possible are taking place, and any urgent cases being transferred to acute partners to be seen. Some specialties are working towards stepping up clinics in late July/August including Rheumatology and Ophthalmology.
The Trust is working closely with its acute partners and taking account of national guidance which sets out four priority levels for the recovery of surgical activity along with a traffic light assessment of readiness and the expectation of a geographical i.e. system approach to waiting list management. Surgical recovery in Dorset is currently focused on priority groups 1 and 2, the surgical specialties within community hospitals fall within priority 4. There is the potential should General Surgery not be able to recommence in August that three patients may breach 52 weeks wait in September.
In relation to Podiatric Surgery which is not dependent on our acute partners, plans are progressing with a view to restarting in August, although additional capacity needs to be secured to enable the service to recover.
Across the RTT pathway (Outpatients and Theatre), it is estimated that ‘productivity’ will be reduced by 50% taking into account the requirements for air disposal and IPC requirements and cleaning between procedures.
The RTT position within the Trust will therefore continue on a downward trajectory at this time, equally as the outpatient element of the pathways restart the numbers waiting for surgical intervention will increase.
9
Maximum 6-week wait for diagnostic procedures - Diagnostics has improved from last month (May 7.9%) to 31.6% with 1039 people waiting at the end of June, 711 of whom were waiting longer than 6 weeks.
There are a number of specialties contributing to the target. Of note:
Ultra Sound have cleared the backlog and this has contributed in part to the improved position. Sustained recovery will be dependent on the number of referrals as primary care steps back up which could impact on continued improved performance.
Audiology is the biggest contributor to the diagnostic target. The improved position in this service actually reflects increased referrals under the 6 week target offsetting the overall position. The waiting list has increased from 665 to 772. There have been recent changes to national guidance allowing hearing aids to be posted rather than patients needing to come in for fittings. Whilst this does not impact the diagnostic target it will create increased staff capacity albeit that IPC measures have impacted through-put.
Endoscopy is reliant on the supply of specialist staff under Service Level Agreements from Poole General Hospital (PGH). The Trust is working closely with PGH and taking account of national guidance and prioritisation which directly impact on the ability to step up within the community hospitals in the same way as outlined for RTT services. Any urgent cases in are being transferred with agreement to PGH at this time. There is currently no start date for Endoscopy.
It is anticipated that the diagnostic position in the Trust will remain below target, with a slow recovery over the course of the next 6 – 9 months assuming the service doesn’t need to be suspended in a second surge or significant loss of staff.
10 Steps To Wellbeing / Talking Therapies - The Covid19 pandemic has generated a high(er) level of depression and anxiety in clients currently within treatment, which has understandably impacted on their outcomes in treatment (and the recovery rate). The service has also experienced a higher dropout rate than usual in the pandemic, and is about to start a piece of work to try and re-engage patients who have recently dropped out of treatment. The drop-out rate has a negative impact also on the recovery rate. The service is involved in promotional work to try and increase access rates, for example lots of media coverage for mental health awareness week and a social media campaign. Teams are proactively engaging in local and national CPD training and webinars to improve their delivery of interventions remotely, and with increased supervision; fine tuning their communication to patients about how to (and benefits of) accessing digital treatments such as webinars and computerised CBT; and are preparing to re-open bases for face to face treatments, for those patients that require this.
Children Young People & Families – New Services Significant mobilisation is underway to adjust and implement the following new services following recent competitive tenders: the CYP PH service (contract started October 2019); the new School Aged Immunisation Service (contract starts August 2020) and the new Integrated Sexual Health, GUM and HIV service (contract starts October 2020).
11 Are We Well-Led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality, person-centred care, supports learning and innovation, and promotes an open and fair culture.
Finance update - As part of the Fit For the Future stocktake the finance workstream has identified and clarified all recurrent CIP delivery for 20/21 to date. A CIP assurance process has been developed and currently assurance documentation is being completed. This will be reviewed through the monthly Finance and Performance meeting between each directorate and the Chief Operating Officer.
The capital expenditure target for 2020/21 is £19.3m per the draft annual plan (including £301k of Covid related spend). Capital expenditure is 55% of month 3 target; spending in month and YTD has been affected by Covid-19. Total capital commitments at M3 are £6,650k of which £3,940k relates to commitments raised last year carried over into this year.
The cash balance is higher due to July contract income (£19.1m) being received in advance as part of the response to Covid-19.
The Trust breakeven position is in line with the NHSI provided breakeven plan which is currently in place until 31st July.
Savings of £331k were banked in July making the total ytd £4,339k.
Agency cost as a percentage of gross payroll cost is 1.75%.
Data Quality Maturity Index (DQMI) – The March DQMI score for the Mental Health Services Dataset (MSHDS) data was 81.7%, 4.7 percentage points lower than the score for February data of 86.4%. Part of this reduction is due to the one off failure to submit complete primary reason for referral data, this error was reported in the June 2020 Board report and has been rectified. Not submitting data for the ‘Clinical response priority type (eating disorder)’ field and a small number of invalid values submitted for the ‘Delayed discharge attributable to’ field account for the rest of the reduction of the data quality score. Dorset HealthCare’s MHSDS data quality score is still well above the national average of 65.5%.
12 Workforce
June 2020 has seen a slight appraisal compliance rate increase from 88.53% in May to 89.09%.
Within patient based services, Children’s Services had the highest compliance rate with 92.20% and Mental Health Services has the lowest with 88.09%.
Within corporate services, Chief Executive has the highest compliance rate of 90% and Org & Devt & Participation/Corporate the lowest with 73.21%.
The job type with the highest compliance rate is Medical and Dental (100%). The lowest compliance rate by job type is Estates and Ancillary (85.35%).
We have now resumed targeted contact with staff to support appraisal completions.
Mandatory training compliance has remained above the 95% target. Face to face training is still on hold due to Covid-19 restrictions. The Learning & Development service is considering how we may be able to deliver 1:1 basic life support assessments to ensure staff can demonstrate competency in this area.
Clinical supervision - Registered clinicians will now be required to receive and record 4 clinical supervision sessions over a set year period, rather than a rolling twelve month period, with a compliance period from 1st April 2020 to 31st March 2021. This will still be monitored on a continuous basis and compliance will be managed on a fixed yearly basis.
The overall staff turnover figure in June 2020 was 8.61%, which represents a further reduction on the position reported in May 2020 (8.83%). Turnover has been on a downward trajectory for the fourth consecutive month and is now at the lower process limit.
There were 29 leavers during June 2020, which is seven less than the previous month (36 in May 2020). This could be attributable to the Covid-19 pandemic, increased uncertainty about moving to unfamiliar employment environments, and an overall reduction in organisations advertising vacant posts. .
Turnover by Service / Directorate for the 12-month period ending June 2020: • Childrens and Young Peoples Services = 10.11% • Integrated Community Services = 8.91%
13 • Medical = 11.23% • Mental Health Services = 6.85% • Support Services = 10.64%
There were 529 leavers during the period July 2019 and June 2020 - the top five reasons for leaving remain the same, albeit with minor changes in numbers: • Retirement Age x 147 staff (28%) • Voluntary Resignation - other/not known x 100 staff (19%) • Voluntary Resignation - work life balance x 85 staff (16%) • Voluntary Resignation - relocation x 53 staff (10%) • Voluntary Resignation - promotion x 36 staff (7%)
It remains that further work is required on the quality of data around leavers to ensure that accurate reasons for leaving are captured and that the volume of 'other/not known' is reduced.
The overall vacancy factor is 5.03%, which equates to 269.71 WTE. Although this represents an increase on the previous month's position of 4.54% and is the second consecutive month that we have seen an upward trajectory, vacancy levels remain within the processing limits and below the mean set at 5.7%.
Across the clinical services, vacancy rates are: • Children & Young Peoples Services = 7.39% • Integrated Community Services = 6.48% • Mental Health & LD Services = 2.37% • Medical = 1.56% • Support Services = 7.01%
WTE vacancies by staff groups - highest to lowest: • Nursing and Midwifery = 105.21 WTE • Admin and Clerical = 104.91 WTE • Additional Professional and Technical = 30.87 WTE • Estates and Ancillary = 22.22 WTE • Medical and Dental = 11.44 WTE
14 Recent initiatives to fill our registered nursing vacancies include: • Participation in a pan-Dorset nursing recruitment campaign via social media Participation in the Dorset-wide Registered Nurse Degree Apprentice scheme, which has received more than 540 applications: 367 for the adult branch and 164 for mental health nursing. Discussions are underway to understand scope for engaging applicants who may be appointable to other positions within the trust.
The overall in-month sickness absence figure for June 2020 is 3.71%. This represents a decrease on May's figure of 3.76% and is showing a downward trajectory for the third consecutive month, having fallen below the lower process limit.
It should be noted however; that the sickness absence figure for the rolling 12-month period ending June 2020 is higher at 4.63%.
The average number of working days lost due to sickness is 10.32.
Breakdown of sickness absence by service: • Children & Young Peoples Services = 3.31% • Integrated Community Services = 4.41% • Medical = 4.07% • Mental Health & LD Services = 3.39% • Support Services = 2.99%
Staff who are self-isolating in line with the Covid-19 guidelines are being recorded as 'special leave' and these absences are not therefore reflected in the sickness absence figures.
Additionally, we have staff who have been shielding due to an underlying health issue that puts them in the high risk group, but they have still be able to work from home.
These factors appear to have had an impact on the decreased levels of sickness absence recorded and work is underway to fully understand the position
The top five reasons for absence in the 12-month period ending June 2020 - in descending order: 1. Anxiety/stress/depression/other psychiatric illnesses 2. Cold, Cough, Flu - Influenza 3. Gastrointestinal problems 4. Other musculoskeletal problems 5. Injury, fracture
15 Keeping our workforce safe – individual risk assessments A range of measures are in place to support staff to stay safe as we continue to work with Covid-19 in our community and meet the need to re-open and expand our service capacity. This includes extensive guidance for all staff and line managers, alongside comprehensive wellbeing, psychological and practical support and initiatives.
A key component of this is working with staff to complete individual risk assessments. The most important thing about individual risk assessments is the quality of the conversation and people feeling supported and safe. From early in the response to Covid-19 we have been asking all staff who are extremely clinically vulnerable and clinically vulnerable to complete individual risk assessments, recognising that those who are extremely clinically vulnerable are shielding at home in line with government advice.
In line with national guidance those considered to be at increased risk from Covid-19 now also includes all of our Black, Asian and Minority Ethnic (BAME) colleagues, and as of 8 July 2020, the national NHS also set out that white Europeans over 60 and all men should also be considered ‘at risk’. We have made individual risk assessments available to all staff throughout this period and encouraged everyone to complete a risk assessment if they feel their circumstances support it; we are now actively asking all staff to complete an individual risk assessment.
There is a combination of direct correspondence to BAME colleagues and extremely/clinically vulnerable colleagues in addition to line manager cascades and supporting corporate communications to require all staff to undertake an assessment. The HR department is working with line managers to prompt and support meaningful risk assessment conversations.
National reporting requirements have been introduced by NHS England and we have been set a target to achieve 100% compliance by 31st July for at least our BAME and vulnerable staff. We have introduced a robust digital system that allows for oversight and assurance of the risk assessment data and process.
As at 17/07/20 the known completed risk assessments are: • Proportion of all staff completing a risk assessment: 11% • Proportion of staff identified as ‘at risk’ completing a risk assessment: 23% • Proportion of staff identified as ‘at risk’ completing a risk assessment, excluding men and white over 60 colleagues: 70%
16 • Proportion of BAME staff completing a risk assessment: 29%
We are maintaining oversight of this position through daily progress reporting as well as capturing the risk in the Trust risk register, this integrated dashboard and should it be appropriate, through the Board Committees and Board Assurance Framework.
Additional Papers: An update on Research and Development Metrics has been included in Section 2.4.
17 2.4 Research and Development Metrics Q1, 2020-21 The following provides details of the Quality Metrics for the Trust’s Research and Development (R&D) activities. Metric In Quarter Current Additional details Status
Time taken to issue All studies received confirmation of capacity and No confirmation of capacity and capability within the agreed timeline of 40 days from exceptions G capability site selected date for Q1.
Recruitment is behind target in Q1 with a total of 42 Recruitment to target 42 G against a target of 704 for the year.
Recruitment of first Green G All studies recruited to time for Q1. participant to the study
Number of incidents 0 G There were no incidents in Q1. Areas/specialities involved in research (target < 2) • Perinatal • Autism Currently active in 25 studies: • Dementia • Cancer 20 open to recruitment (some of these studies are Number of studies in progress 25 - • Eating Disorder • Surgery national studies) • Physiotherapy • Phobia 5 closed to recruitment and in follow-up • Psychosis pathway • Stroke • Sexual Health Number of studies in set-up 6 - 6 studies currently in set-up
Other: Recruitment has been impacted due to Covid-19 and the suspension of our portfolio studies; the focus during the pandemic was on urgent public health studies.
18 Children, Young People & Families – Operational Performance Board Summary June 2020 (M3) CYP&F Services Activity Workforce The vacancy rate for CYP&F Services is 7.39% (+1.5%) which equates to 29.86 (+6.33 WTE since May). The majority of vacancies are within Admin & Clerical 17.5 WTE with a 5.47 WTE increase in Nursing vacancies since the previous month.
The Directorate has a small number of vacancies spread across different teams, (including those related to the CHIS service (4.52 WTE) that is being decommissioned this year). Whilst there has been an Caseload remains steady +0.09% in comparison to M3 19/20. Activity remains reduced against the same period last year -39.7% (-22,311) due to COVID-19 but is slowly improving as teams stepped down to support other clinical services are being stepped back up in line with agreed increase in vacancies this month, this is in part due to the organisational change process to establish a priorities with commissioners which are: standalone school aged immunisations team, 4.52wte vacancies within a team that is being transferred • LAC RHA’s to a new provider in October. Other services impacting on the vacancy rate are: • Health Visiting: New Born Visits, Antenatal Checks and 27 month check • School Nursing 2.99 WTE • New Born Hearing Screening Programme • Paed SaLT: 2.35 Finance: Month 3: (Brackets) = favourable variance • School Aged Immunisations (pending schools return) • Health Visiting: 2.38 WTE Detailed step up trajectories are in place for each service/KPI which is monitored via the DMG. CYP Public Health Service 0-19 New born Hearing Screening Programme
• Prioritisation has maintained antenatal and new birth visits as universal contacts (face to face where necessary, otherwise digital). Antenatal & NBV’s have both exceeded the target uptake in June. The Trajectories have been worked up with The New Born Hearing 27 m check is the universal contact prioritised based on need, via joint Screening Programme (NHSP) to address the backlog as a result of C- planning with local authority colleagues and early years settings. 19. Planned community catch-up significantly increased in May & Trajectories have been worked up and agreed with the Service and are June in line with the additional clinics identified to facilitate catch-up. being implemented. The decline in June is the impact of COVID. Staff have worked flexibly to facilitate dual hospital /community • The new School Aged Immunisations service is now live and screening provision; a 7 day a week Hospital screening service mobilisation underway to commence programmes from September alongside a 5 day a week Community clinic service and exceeded the including a catch-up programme. An extended flu uptake to include trajectory for June. Year 7 at 95% threshold has also been agreed with Commissioners..
Service Director Commentary Paed SaLT Waiting Times The number of looked after children (LAC) remains above that seen last year although the recent increase appears to have In June 819 children were waiting for a 1st assessment (increase of 276 since May). 20 stabilised. The LAC team is applying their demand and capacity model to prioritise activities with commissioners and Local children waited longer than 26 weeks (local CCG target). 80% of children’s 1st Authority partners to ensure that they are able to best meet the needs of their caseload and continue to meet the assessments (117 children) were completed within 18 weeks (local service target. Of the demands of the COVID period. 20 children who waited more than 26 weeks: The business and performance and operational teams continue to plan for catch up, COVID-suppressed activity and new • 16 children were offered non F2F appointments by letter – 12 did not respond & are being followed-up, 3 declined non F2F and preferred to wait, 1 child has an COVID-related needs. This includes understanding access by individual and geographic characteristics with a focus on appointment on 17/7 reducing inequalities that may pre-date or emerge during this period. Further work is underway to understand the drivers • 4 children require ASD (multi agency assessment) and this has been delayed due to for, and solutions to, the small number of waits above 18 weeks for Paediatric SALT services in the context of significant C19 impact catch-up. The average wait for 1st assessment remained static at 13.1 weeks however the longest Significant mobilisation is underway to adjust and implement the new services following recent competitive tenders: the wait increased to 34 weeks.. CYP PH service (contract started October 2019); the new School Aged Immunisation Service (contract starts August 2020)
and the new Integrated Sexual Health, GUM and HIV service (contract starts October 2020).
Integrated Community Services– Operational Performance Board Summary June 2020 Integrated Community Services – Community Nursing and Intermediate Care Service Director commentary
Percentage of bed occupancy has increased in community hospitals and is now averaging 59%. New guidance on COVID bed spacing has reduced overall bed availability with the closed beds still reflected in the numbers. The closed beds will be removed from the overall figures next month. Delays in discharge have increased with a reduction in availability of care and Community Hospital Inpatients placements. Length of stay is still below target levels.
Community Nursing and Intermediate Care Referrals have stayed static and have not yet returned to pre- Annual COVID levels. Team are currently working through recovery plans with full services now being delivered. Budget YTD Face to Face contacts remain low due to a move to Budget YTD digital and remote consultations as well as targeted patient visits. Actual YTD During the month of June, Services were focussed on Variance FOT interim recovery. This included: Variance • Continuation of essential services Financial Summary £m • Recovery of ‘non-essential’ services in line with NHSE 90.5 90.5 89.4 (1.1) recommendations • Assessment of buildings to enable COVID safe status. • Review of the changes made during COVID regarding new ways of working (digital and online/telephone) Workforce • Working with partner organisations in a system wide approach.
Across Community Services and Community Inpatient services, there was an increase in vacancy levels of nursing and midwifery registered staff. Teams have had much better success in recruiting in the last few months so this should start to show a steady improvement.
Mental Health & LD Services – Operational Performance Board Summary June 2020 (M3) Community MH Services: 20/21 Month 3 Workforce
The increasing trend for calls to the Connection has continued during June 20. Call answer rate was 85% (15% terminated the call before it was answered). Calls via NHS111 accounted for 16.5% of all calls received. As at June 20 MH & LD services have 84.2 WTE vacancies. This is a an • MH & LD referral trend continues below the 19/20 position but is on an improving trajectory -41.4% (-3,517). Contacts are -1.0% (-570) against the 19/20 period. At team improvement from the previous month +2.82 WTE. This represents level, the plans to accommodate homeless people in hotels has meant that there has been a 43% increase in referrals to the Homelessness Team. a vacancy rate of 4.30% (-0.14%). There are 2.54 WTE (2.66% medic • S2W referrals are -36.9% compared to M3 19/20, however this is reducing (improving) each month. Contacts are -1% (-469) compared to M3 in 19/20 vacancy rate in MH). Approximately two thirds of the vacancies are due to expansion Inpatients investment/service transformation.
June’s inpatient activity was 17%
lower for admissions against the same period last year (-33 patients) 18% (-35 patients) down for.
Adult acute Length of Stay (LoS) decreased by five days to 45 days in June maintaining the YTD LoS at 45 days as at M3. LoS is calculated at point of discharge The adult acute median LOS reduced to 23 days. Service Director commentary
Adult acute occ. rates increased again in M3 to 73.1% this remains below previous levels but is on an increasing trajectory. • MH bed capacity has been reviewed as part of IPC guidance which has Delayed Transfers of Care (DToC) has further improved with 9 resulted in 19 beds needing to be closed across acute female, rehab and older adult wards. Two further acute female beds need to close people delayed at month end. Compliance is above the 7.5% however they will be re-provided once small scale estates works are threshold at 5.8% which equates to 307 delayed days completed. No one was placed out of area due to a lack of bed availability in • The 15 bedded Linden ward is still temporarily vacant however plans June and no one remained OAP. are being worked through to bring the beds back online (subject to staffing) by September. • All services have completed site risk assessments and are stepping Finance: Month 3 (Brackets) = favourable variance back up routine face-to-face appointments where appropriate. Waiting list backlogs are understood and being addressed. • Uncertainly remains regarding the MH investment standard for 20/21 and additional transformation monies which has been excluded from budgets to date resulting in adverse year to date financial position. Once included in budgets Directorate will report YTD surplus.
Agenda Item 10
Trust Finance Report for Month 3, June 2020
Part 1 Board Meeting 29th July 2020
Author Matthew Metcalfe, Director of Finance and Strategic Development and Michele King, Head of Management Accounts Purpose of Report Financial results June 2020 (Month 3) Executive Summary
Headline results for the three months ended June 2020 are as follows:
The Trust breakeven position is in line with the interim NHSI provided breakeven plan and favourable to our draft plan by £1,858k. The variance to draft plan is due to a reduction in non-COVID activity levels and additional income to fund the Trust to a breakeven position.
The initial forecast for 2020/21 indicates a breakeven position.
The Trust continues to be funded to a breakeven position and this will continue until at least the end of July.
Agency expenditure was £967k, being favourable to NHSI plan by £659k and favourable to internal cap by £168k. COVID related agency and bank expenditure is £156k and £561k respectively. Compared to the same period last year, agency spend is £425k lower and bank spend £774k higher.
Of the overall Trust CIP requirement of £12.3m, £0.3m was banked in June bringing the total banked YTD to £4.3m.
Capital Expenditure was £2.1m YTD vs a plan of £3.9m, with slippage mainly due to COVID-19 restrictions.
The Trust reported YTD expenditure of £3.2m on COVID-19, of which £2.9m was on incremental revenue costs and £0.3m capital. The Trust continues to monitor COVID-19 spend as required by NHSI.
Recommendation The Board is asked to note the report.
Trust financial performance – Month 3 2020/21
Summary G Forecast G Trust level Income Pay Non-Pay Deficit/ Full Year YTD YTD YTD (Surplus)YTD Forecast
£M £M £M £M £M NHSI Plan (71.2) 51.5 19.7 0.0 0.0 Actual (71.8) 55.4 16.4 0.0 0.0 Variance (0.6) 3.9 (3.3) 0.0 0.0
Trust breakeven position is in line with the interim NHSI provided breakeven plan which is currently in place until 31st July.
Service level Full year forecast is in line with the NHSI plan.
Key drivers as follows:
- Income - £2,164k adverse forecast. Mainly due to NCA, Occupational Health, theatre, restaurant and provider to provider income. These are either as a consequence of the current financial arrangements or where COVID is affecting activity.
- Pay - £2,604k adverse forecast. Due to the delay in MHIS funding confirmation, COVID related costs in Corporate Services and Medical staffing.
- Non-pay - £4,768k favourable forecast. Implementation of IFRS16 delayed until 2021/22, MHIS income not yet allocated and With the exception of Community Services non-pay, the majority of contingency not required. Low activity in Community Services with budgets are either broadly in line or overspent as at month 3; in low travel and training costs across many of the Trust’s services particular Mental Health and Corporate Services pay where the majority partly offset by £1.7m of COVID related costs in Corporate Services. of COVID costs are recognised. Further detail is provided later in this Three out of area patients are forecast each month. report and in Appendix 1.
1 Service level performance
Community Services Mental Health Services Income Pay YTD Non-Pay Deficit/ Full Year Income Pay Non-Pay Deficit/ Full Year YTD YTD (Surplus) Forecast YTD YTD YTD (Surplus) Forecast £M £M £M £M £M £M £M £M £M £M Budget (2.6) 18.0 6.9 22.3 89.9 Budget (2.9) 19.9 2.8 19.8 79.0 Actual (2.1) 17.9 6.4 22.2 90.5 Actual (2.8) 20.4 2.7 20.3 80.7 Variance 0.5 (0.1) (0.5) (0.1) 0.6 Variance 0.1 0.5 (0.1) 0.5 1.7
Community Services £0.1m ahead of budget at month 3: Mental Health Services £0.5m behind budget at month 3:
- Income £0.5m adverse, underachievement of NCA income and - Income £0.1m adverse, underachievement of NCA income due IUCS & bowel screening provider to provider income, which is to current financial arrangements. due to the current COVID financial arrangements. - Pay £0.5m adverse, overspends within inpatients, CAMHS and - Pay £0.1m favourable, vacancies with main underspend within Steps to Wellbeing, due to delay in MHIS funding confirmation IUCS, BICS, inpatient wards and Podiatry. and high acuity.
- Non-pay £0.5m favourable, main underspends, arising from an - Non-pay £0.1m favourable, no out of area patients , low impact on core activity, relate to the pain service subcontracted wheelchair service activity and slippage on the Safestop costs and the podiatry decontamination contract together with contract, partly offset by high Steps to Wellbeing low medical supplies, travel and drugs expenditure across the subcontracted costs. Directorate. - The forecast includes the CAMHS Gateway service starting in - The forecast includes Care Recovery Plan costs of £0.3m and an August along with an assumption of three out of area patients increase in non-pay spend as services move back to business as and the reopening of Linden at the beginning of September. usual.
Forecast £0.6m overspend to budget full year. Forecast £1.7m overspend to budget full year.
2 Service level performance
Children, Young People & Families G Corporate Services
Income Pay Non-Pay Deficit/ Full Year Income Pay Non-Pay Deficit/ Full Year YTD YTD YTD (Surplus) Forecast YTD YTD YTD (Surplus) Forecast £M £M £M £M £M £M £M £M £M £M Budget (0.6) 3.7 1.2 4.3 18.4 Budget (2.0) 12.9 4.7 15.6 65.8 Actual (0.6) 3.5 1.1 4.0 17.8 Actual (1.8) 13.5 5.0 16.7 68.8 Variance 0.0 (0.2) (0.1) (0.3) (0.6) Variance 0.2 0.6 0.3 1.1 3.0 Corporate Services £1.1m behind budget at month 3: Children and Young Persons £0.3m ahead of budget at month 3: If COVID related costs were removed Corporate Services would be in line
with budget. - Income in line with budget.
- Income £0.2m adverse, low occupational health activity. - Pay £0.2m favourable, vacancies most notably in School Nursing,
Health visiting, Paediatric Speech and Language Therapy and Sexual - Pay £0.6m adverse, COVID related costs in the emergency planning Health. cost centre (£0.4m) and within medical staffing (£0.2m).
- Non-pay £0.1m favourable, low travel, drugs, provider to provider - Non-pay £0.3m adverse. COVID related costs in the emergency and medical supplies costs partly offset by testing expenditure above planning cost centre of £0.5m, low facilities costs mainly provisions planned levels. and cleaning materials and low travel and training.
Forecast £3.0m overspend to budget full year due to unbudgeted COVID Forecast £0.6m underspend to budget full year. costs.
3 Key Performance Indicators
Temporary staffing
The capital target for 2020/21 is £19.3m per the draft annual plan. Capital expenditure YTD is 55% of the month 3 plan with spending Temporary staffing spend was £5,141K YTD at M3 (£3,499K at M2), of affected by COVID-19. Total capital commitments at M3 are £6,650k of which £967k related to agency, £3,823K bank and £351k substantive which £3,940k were commitments raised last year carried over into this overtime. YTD Agency spend is £425k lower and bank spend £774k higher year. compared to the same period last year. YTD agency spend is below the NHSI ceiling (by £659k) and below the internal agency target (by £168k). Included in these figures are bank and agency costs of £262k and £43k respectively relating to COVID-19 and coded directly to the emergency planning code. Full year agency forecast is £3.3m against a £4.5m internal target and £6.5m NHSI ceiling. Agency trends by staff group
The cash balance at M3 is £57.6m and is higher due to additional July contract income (£19.1m) being received in advance as part of the response to COVID-19. Forecasting assumes the advance payment will continue throughout the year.
4 Key Performance Indicators
Covid-19 Costs Cost Improvement Programme
The Trust reported YTD expenditure of £3.2m at M3 of which Of the Trust’s 2020/21 CIP target of £12.3m, schemes of £9.2m £2.9m was on incremental revenue costs and £0.3m capital. The have been identified, with £0.3m banked in June bringing the total revenue costs are split £1.9m pay and £1m non-pay. banked to £4.3m. The Trust revenue forecast includes estimated COVID related costs of £4.8m due to phased implementation of recovery plans. The Trust is forecasting to achieve savings of £7.6m.
A summary analysis of further CIP scheme detail is shown in appendix 2.
5 Appendix 1 – Financial Performance
INCOME & EXPENDITURE SUMMARY
Month 3 2020/21 CURRENT ANNUAL BUDGET YEAR TO DATE FORECAST VARIANCE @ M3 June Total Budget Actual Variance (Favourable)/Adverse Pay Non Pay Pay Non Pay Income Total Inc & Exp Pay Non Pay Inc & Exp Pay Non Pay Inc & Exp Pay Non Pay Income Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 % £'000 £'000 £'000 INCOME
Baseline Income (258,718) (64,653) (64,568) 85 85 0% R (448) (448)
Integrated Community Services (9,920) (2,549) (2,087) 461 461 18% R 1,596 1,596
Mental Health Services (11,395) (2,871) (2,794) 77 77 3% R 235 235
Children, Young People and Families (2,961) (607) (578) 29 29 5% R 121 121
Corporate Services (6,216) (1,963) (1,811) 153 153 8% R 615 615
Total Trust Income (289,210) (72,642) (71,838) 805 805 1% R 2,118 2,118
EXPENDITURE
Integrated Community Services 73,435 26,293 99,728 17,958 6,946 24,905 17,898 6,444 24,342 (60) (503) (563) (2%) G 77 (1,086) (1,009)
Mental Health Services 78,790 11,141 89,932 19,906 2,754 22,661 20,441 2,666 23,107 535 (89) 447 2% R 1,837 (327) 1,510
Children, Young People & Families 14,578 4,978 19,556 3,697 1,219 4,916 3,545 1,083 4,629 (151) (136) (287) (6%) G (418) (334) (753)
Medical Staffing 17,011 1,049 18,059 4,272 241 4,514 4,555 228 4,783 283 (13) 269 6% R 777 (67) 710
Nurse Executive & Quality 7,050 1,113 8,163 1,753 278 2,031 1,703 244 1,947 (50) (34) (84) (4%) G (63) (150) (213)
Finance & Strategic Development 16,048 15,558 31,605 3,978 3,452 7,430 3,933 3,455 7,388 (45) 2 (42) (1%) G (233) 114 (119)
People & Culture 7,226 1,381 8,607 1,783 366 2,148 1,794 290 2,084 12 (76) (64) (3%) G (26) (235) (262)
Corporate incl. OD 4,555 1,255 5,809 1,137 322 1,459 1,536 789 2,325 399 467 866 59% R 654 1,651 2,305
Total Trust Expenditure 218,693 62,767 281,460 54,484 15,579 70,063 55,406 15,198 70,604 923 (381) 541 1% R 2,604 (435) 2,169
NET INCOME & EXPENDITURE (7,750) (2,579) (1,233) 923 (381) 805 1,346 2,604 (435) 2,118 4,287
Central Budgets 0 3,060 3,060 0 0 0 0 57 57 0 57 57 0% R (4,333) (4,333)
Interest Received (57) (14) (11) 3 3 (24%) R 46 46
Public Dividend Capital Dividend 4,747 4,747 1,187 1,187 1,187 1,187 0 0 0% G 0 0
TRUST (SURPLUS)/DEFICIT 0 (1,407) 0 923 (324) 808 1,407 2,604 (4,768) 2,164 0
Impairments 0 0 0 0 0 0 0 0 0% G 0 0
RETAINED (SURPLUS)/DEFICIT 0 (1,407) 0 923 (324) 808 1,407 R 0 EBITDA 3.7% 3.7%
FORECAST VARIANCE @ CURRENT ANNUAL BUDGET YEAR TO DATE M3 Total Budget Actual Variance (Fav)/Adv. Pay Non Pay Pay Non Pay Total Exp Pay Non Pay Exp Pay Non Pay Exp Pay Non Pay Total £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Total Trust Expenditure post COVID costs218,693 62,767 281,460 54,484 15,579 70,063 55,406 15,198 70,604 923 (381) 541 2,604 (435) 2,169 COVID related costs (1,925) (993) (2,918) (1,925) (993) (2,918) (2,000) (2,750) (4,750) Trust Expenditure pre COVID costs 218,693 62,767 281,460 54,484 15,579 70,063 53,481 14,205 67,686 (1,002) (1,374) (2,377) 604 (3,185) (2,581)
6 Appendix 2 – Cost Improvement Programme
CIP TARGET £12.3m as per financial plan
Proportion Removed Revised Recurrent Total EXEC of Central From Forecast Scheme CIP Plan Value Amount LEAD Schemes Budgets @ & RAG Rating (Feb 2020) (Note 2) Identified (Note 3) M3 £'000 £'000 £'000 £'000 £'000 % £'000 Operational Services Community (excl IUCS) JE 1,051 1,273 513 1,537 1,391 100% 1,537 Children & Young People (excl Sexual Health) KH 467 678 112 579 551 100% 579 Mental Health CH 2,222 1,409 529 2,632 1,012 100% 2,632 Medical Staffing ST 112 113 80 157 146 100% 157 3,852 3,473 1,234 4,905 3,101 100% 4,905 Support Services Nursing & Quality DD 40 90 50 90 76 100% 90 People and Culture NP 0 44 44 44 36 100% 44 Corporate Services KD 114 131 17 131 127 100% 131 Finance & Strategic Development MM 386 1,054 660 1,047 744 100% 1,047 Estates & Facilities MM 22 83 83 105 65 100% 105 563 1,402 855 1,417 1,048 100% 1,417 Central/Transformational Schemes Salary Sacrifice / Tax Efficiencies MM 327 0 327 92 100% 327 Financial Transaction Review and Rebates MM 250 0 200 99 100% 200 Estates Rationalisation/Premises MM 2,200 0 1,100 0% 0 Telephony & Broadband MM 600 600 300 0% 0 League of Friends MM/NP 1,000 0 1,000 72% 717 Corporate Cost Reduction NP 349 0 0 Admin Review 0 Management & Administration Support Review 0 Divestment Schemes ST/KD 0 0 0 0 Investments MM/KD 0 0 0 0 Clinical Consumables/Stock control DD 0 0 0 0 Central Schemes allocated above or removed 1 3,547 8,273 600 0 2,927 190 61% 1,244 TOTAL CIP SCHEMES 2020/21 12,687 5,475 2,089 9,249 4,339 71% 7,566
SHORTFALL against target £3,051
Notes 1. Central Schemes allocated above or removed includes schemes such as car parking 2. The recurrent value for operational and support services where central schemes have been apportioned include the recurrent element of those central schemes - this requires further work 3. Central Schemes allocated to support and operational services include: increase in vacancy factor, procurement, digital 7 communication, travel & transport and unform review
Agenda Item 11
Dorset Care Record update
Part 1 Board Meeting 29 July 2020
Author Stephen Slough, Chief Information Officer Carley Andrews, Head of Projects and Programmes Emily Gadd, Project Manager Purpose of Report To provide an update on the progress of Dorset Care Record (DCR) Executive Summary
This report is to provide an update to the Board regarding progress of the Dorset Care Record (DCR), along with current risks and associated mitigations.
Recommendation The Board is asked to note the report.
Agenda Item 11
Table of Contents
1 Purpose ...... 2 2 DCR Strategic Governance ...... 2 3 Recovery ...... 2 4 Current delivery trajectory ...... 2 5 Strategic Risks ...... 3 6 Costs ...... 3 7 Recommendations ...... 3
1 Purpose SLT
The purpose of this report is to provide an update on the current position and future plans for the Dorset Care Record. This paper responds to a request for an update to the Trust Board DIG on the current position, issues and actions with the DCR Programme.
Partnership Board 2 DCR Strategic Governance
• DCR is hosted and the PMO is at Dorset Council Programme Board • There are 7 partners in the Programme: Dorset HealthCare, Royal Bournemouth and Christchurch Hospitals, Poole Hospital, Dorset County Hospital, Dorset Council, Bournemouth, Christchurch and Poole Council and South Western Ambulance Service. • Working Group Programme Directorship is now being led by two interim positions by Astrid Fairclough, Programme Director for the Wessex Care Record and interim Programme Manager Andy Cowling. • The DCR Programme and Partnership Boards report up to SLT. (see dia.) Partner Teams
3 Recovery
DCR has been in a recovery phase since Summer 2019. A consultation firm, Channel 3, were appointed to lead the DCR through recovery as the Programme was struggling to deliver agreed components. The recovery process implemented a number of governance changes, including the Programme Board reporting directly to the SLT. Channel 3 have now stepped away from the DCR Programme handing over to the Programme Director and Manager as above.
The programme is not officially out of recovery from a governance perspective but a contract with OH is intended to secure a more assured delivery performance in terms of making the functionality needed available when required.
4 Current delivery trajectory
The DCR Programme contains a number of releases, it is currently on release 4 whilst working on completion of release 3 and planning for release 5. Current plans contain 7 releases throughout the Programme. Each release must go through rigorous testing in a Test environment and Pre Production environment prior to being released into the Live environment. Releases are worked on in parallel to one another.
Covid-19 has caused delays for all Partners. However, work has now picked up again except for BCP who have had to place the project on hold (see key risks).
From a DHC perspective, Orion Health still need to deliver:
Agenda Item 11
• a solution for our clinical mental health data (3/8 components) • a solution for our clinical community health data (6/15 components) There are additional work-streams expected of Orion Health e.g. pathways, citizen portal, that are still under investigation. Any further information on progress would need to come from the central DCR Programme Team.
5 Strategic Risks
Key Risk Mitigation / Actions Maintaining partner engagement in the This is being addressed by continuing with the “continuous programme communication” and staggered go-lives for delivery timeframes supportive of partners and supplier resource. Constrained clinical input into the Impacted by COVID-19. DCR are formally recruiting a 0.4WTE programme Clinical Lead for DCR and the re-instigation of a clinical reference group. Ability of Orion Health platforms to meet Reviewing and defining use cases that can be delivered by the the current and future needs (and platforms currently and in the near future. aspirations) of the partners BCP have undergone a merger and de- SLT to advise. prioritised delivery to the DCR Delivery of benefits by DHC These will come with imminent release of the Rio data, and subsequently SystmOne data. Exchange of SystmOne data from the IUCS / 111 module is under investigation now that SystmOne has been installed in this service. DHC Benefit realisation A DCR Programme Board level decision was made to delay benefits investigations until data from all partners is in the DCR. DHC will be benefitting from the DCR with the data already available to us from our partners. This will be further increased with the use of Single Sign On with patient context (click-through) for both RiO and SystmOne. Data sharing and Data Quality There are robust governance structures in place to cover Data Sharing across our partnership. Data Quality is an ongoing work-stream within the DCR.
6 Costs
• Programme Capital expenditure to date is £6.4m. • Total expected Capital expenditure of the Programme is £8.19m. • Total Partner Capital contribution £6,351,260 • DHC contribution to date £1.26m. • This Capital contribution represents c.20% of the total project costs. • Revenue costs of £146k are expected to be incurred for support and maintenance annually by DHC.
7 Recommendations
The Board is asked to note this update.
Agenda Item 12b
Summary Report of the Mental Health Legislation Assurance Committee Meeting on 8 July 2020
Part 1 Board Meeting 29 July 2020
Author Sarah Murray, Chair of the Committee Purpose of Report To highlight key matters discussed at the meeting held on 8 July 2020. Key Decisions and Matters considered by the Committee
Mental Health Legislation Dashboard
The Committee discussed key indicators in the dashboard covering the period January- March 2020, including:
• An increase in detentions under the Act, after a substantial drop during December 2019. This follows a similar pattern to the same time last year. No evidence was available as to why this might be the case;
• One instance of an under 18 being admitted to an adult ward during February 2020;
• The fourth consecutive quarter where no sections were allowed to lapse by mental health professionals;
• Two unlawful detentions recorded during February 2020 (on the basis that the criteria for detention were not met);
• A reduction in the number of MHA panel hearings taking place before the new period of detention commenced. This was attributable to a variety of reasons, the principal ones being doctors on annual leave or having limited availability;
• An increase in the total number of Mental Health Act panel hearings held in the quarter; and
• A sustained improvement in terms of the number of patients awaiting assessment for a standard Deprivation of Liberty assessment.
The Committee discussed the continuing challenge of ensuring that all patients are read their Section 132 rights in a timely and meaningful manner. The Committee believed that a possible solution to this long-standing problem is for this to be included in the package of measures implemented when a patient is first admitted and nursing staff maintain focus on achieving this as best they can The Committee noted that the regulations and code to support the implementation of the new Liberty Protection Safeguards are unlikely to be published before October next year.
Mental Health Act Care Quality Commission (CQC) Inspections Assurance Report Events
The Committee noted that there are currently three active action plans with a total of 14 actions complete, three actions in progress and five now overdue and questioned when they might be completed The CQC has suspended physical visits until September but are undertaking desk-top and telephone assessments.
Mental Health Legislation Assurance Committee Annual Report 2019/20
The Committee approved the annual report for submission to the Board (which is elsewhere on the Board agenda).
The Committee will be agreeing timescales for delivery of its objectives set out in the Annual report , and a work plan for the year, at its next meeting. However work on the plan will start in September
Mental Health Act Panel Members Remuneration
The Committee reviewed a proposed revised scheme for the remuneration of Mental Health Act Panel Members. The Panel Members will now be consulted on the scheme and a report made to the September 2020 Board meeting.
Assurance Statement
The Committee agreed to assure the Board that it continues to acquire and scrutinise assurances that the organisation is operating and will continue to operate in accordance with the law and best practice in relation to the rights of mental health services users.
Committee Chair
The Chair advised that it was her last Committee meeting in this role and wished to thank members of the Executive team, and in particular those who had served on the Committee and worked with her throughout her time as Chair. The Committee noted that Heather Baily will be taking over as the Chair from the end of the month.
Recommendation To note the report.
Agenda Item 12c
Summary Exception Report of the Audit Committee Meeting on 15 July 2020
Part 1 Board Meeting 29 July 2020
Author Heather Baily, Chair of the Committee Purpose of Report To highlight, on an exception basis, key matters discussed at the meeting on 22 January 2020. Key Decisions and Matters considered by the Committee
Counter Fraud Progress Report
The Committee noted the regular report on progress with the delivery of the counter fraud plan for the year. The Chair will be discussing with the Local Counter Fraud Specialist how the impact of counter fraud work in the Trust can be assessed.
Internal Audit Progress Report
The Committee has reviewed the executive summary in respect of three internal audit reports:
• Data security and protection toolkit; • Facilities management; and • Key financial systems.
The Committee reviewed in detail three further audits which had resulted in limited assurance opinions:
• E-rostering; • Violence and aggression; and • Medical device management follow up.
The Committee will be reviewing progress on action plans in respect of each at the next meeting in October.
With regard to violence and aggression, the Committee has concluded that the study raises a number of wider issues that merit further consideration, including:
• Visibility of the level of incidents at Board level; • Ownership of the response to violence and aggression; and • Whether the risk of the level of incidents was appropriately recognised.
The Committee will be discussing these matters further at the next meeting.
Internal Audit Report on Progress with Follow-Up Actions
The Committee has reviewed progress with actions arising from previous internal audits.
The Committee expressed some concern that a medium level recommendation in respect of cyber security (to investigate, test and implement certificate-based Network Access Control) had been delayed further with a target for implementation of September 2020.
To provide further assurance, a report will be submitted to the next meeting on the actions being taken to improve cyber security in the Trust, key areas of risk and setting out a timetable for further action.
Internal Audit Plan 2020/21
The Committee has agreed the revised plan for the year.
Review of Delegated Financial Authorities
Following the discussion at the last Board meeting the Committee has commissioned a report to the next meeting covering, with regard to contract signing, the context for procurement in the Trust, the existing governance processes, information on the number of contracts signed on an annual basis and values, due diligence processes and assessments made of the appropriate length of contracts and other information considered relevant to the review.
The Committee Going Forward
The Chair of the Committee has been in discussion with members and advisers on its future role and ways of working.
Assurance Statement
The Committee agreed to confirm to the Board that it was compliant with its terms of reference and that it continued to review the adequacy and effective operation of the Trust’s overall internal control system.
Recommendation To note the report.
Agenda Item 12d
Summary Report of the Quality Governance Committee Meeting on 15 July 2020
Part 1 Board Meeting 29 July 2020
Author David Brook, Chair of the Committee Purpose of Report To highlight key matters discussed at the meeting held on 15 July 2020. Key Decisions and Matters considered by the Committee
Waiting Lists
The Committee has been advised that Trust waiting lists have, inevitably, lengthened during the Covid-19 pandemic. The reduced capacity in some areas will result in lists growing further. Action has been taken, through the care recovery worksteam, to identify waits in all areas. A trajectory has been developed, and a cross-system approach is being taken, to address waiting lists.
The Committee has expressed concern at the impact on patients of waiting to access Trust services. The cost implications of the additional capacity required to address waiting lists is being assessed and the Committee will be briefed on these in due course. The arrangements for reporting waits at Board level are also under consideration.
Report from the Clinical Governance Group
The Committee received an update on the topics discussed at the recent meetings of the Clinical Governance Group. There was a particular focus on the response to the Covid 19 virus, including services stood down, new services started and the risks associated with these activities. Other topics discussed included, the transfer of the 111 service to the Trust, a number of safeguarding issues and a report on dynamic ligature management in inpatient units.
Significant Incident Report Including Safeguarding Adults and Children Events
The Committee has reviewed the regular report and noted that there were 27 serious incidents requiring investigation reported in the period October 2019 to June 2020. The Trust serious incident reporting process has been maintained throughout the Covid-19 pandemic.
Internal Quality Assurance Report
The Committee reviewed the latest assurance report and, in particular, progress in implementing CQC action plans.
All 45 actions in the plans developed following the 2017 inspection have been completed.
Action plans are in place to address the 19 ‘should do’ recommendations following the publication of the July 2019 inspection report. Eleven actions have been completed and four are overdue. The Committee has noted the action being taken in respect of each of these overdue actions.
The CQC has suspended physical inspections due to the Covid-19 pandemic. Inspectors are carrying out table top inspections where the CQC has concerns.
Internal assurance visits have recommenced. A risk-based approach is being followed with one visit every 14 days to one clinical service area.
Clinical Risks Exceeding the Risk Appetite Threshold
There are currently 44 risks which are at the maximum tolerance level (an increase from 33 in January). Seventeen risks (an increase from four in January 2020) breached this threshold. The increase is attributable to the impact of and the risks associated with responding to the Covid-19 pandemic
Annual Reports 2019/20
The Committee has discussed a number of annual reports- Patient Experience, Complaints, Patient Safety, Freedom to Speak Up, Mortality, Safeguarding and Guardian of Safe Working.
Future Working
The Committee has reviewed how it can enhance it working arrangements going forward. Recovery and the restarting of services will be a standing item on future agendas for the Committee.
Assurance Statement
The Committee agreed to assure the Board that it continues to acquire and scrutinise assurances that the organisation had a combination of structures and processes at and below Board level that equip it to deliver high-quality services.
Recommendation To note the report.
Agenda Item 13
Mental Health Legislation Assurance Committee Annual Report 2019/20 Part 1 Board Meeting 29 July 2020
Lead Director Dawn Dawson, Director of Nursing, Therapies and Quality Purpose of Report This annual report provides the Board with assurance that it is carrying out its duties under the MHA and the MCA with due care and diligence. This report covers the period from 1 April 2019 – 31 March 2020. Executive Summary During the past year there has been an increase in the number of people who have been admitted into a psychiatric bed, within Dorset HealthCare and under the Mental Health Act (MHA), with a 12% increase shown in 2019/20. Detentions under the Act, for those already admitted to a psychiatric ward have decreased by 21%, when compared to 2018/19. This group of patients include those admitted voluntarily or those admitted on a section 2, with a section 3 then put in place whilst in hospital. The use of CTOs in 2019-20 has increased by 41% when compared to 2018-19, where 56 CTOs were implemented during that period. The number of recalls has increased by 25% in the period of 2019-20. Recalls are used when there is clinical need for assessment and treatment in hospital. In 2019-20 there were 306 causes to convene a panel meeting with 197 of those cases having a review completed. The remaining cases were either discharged, transferred out or another section implemented. This represents a 51% increase in the number of panel meetings taking place in the previous year (130). The Mental Health Legislation Assurance Committee has identified improvements in the triangulation of available information relating to Mental Health Legislation. Triangulation of data and information collected from Core Services Reviews, Mental Health Legislation Audit, CQC Mental Health Act inspections, updates coming out of the Strategic MHA Multi-agency Group and reviews of untoward incidents have allowed themes to be clearly identified and shared thereby embedding good practice to improve compliance.
On 8 July 2020 the Mental Health Legislation Committee agreed this report for submission to the Board.
Recommendation To note the report
1
Mental Health Legislation Assurance Committee Annual Report 2019/20
1. INTRODUCTION
1.1 The Mental Health Legislation Assurance Committee is a specialist and discrete committee. It reports directly to the Board and obtains assurance that the Trust is operating in accordance with the law and best practice in relation to the rights of mental health service users.
1.2 The Committee seeks to be assured around the lawful detention and treatment of patients in accordance with the Mental Health Act 1983 (MHA), Mental Capacity Act 2005 (MCA), Deprivation of Liberty Safeguards (Dols) and any associated Codes of Practice.
1.3 This annual report provides the Board with assurance that it is carrying out its duties under the MHA and the MCA with due care and diligence. This report covers the period from 1 April 2019 – 31 March 2020.
1.4 A glossary of terms used within this report can be found at Appendix A.
1.5 To provide a context to the work of the Committee in 2019/20, the next section reviews the use of the Mental Health Act 1983 both nationally and in the Trust.
2. USE OF THE MENTAL HEALTH ACT 1983
National Context 2.1 In 2018/19 according to NHS Digital (NHSD), 49,988 new detentions were recorded under the Mental Health Act in England. This figure represents a small increase of less than 1% on figures recorded in 2017/18. As with last year, it is reported that the overall national totals will in fact be higher as not all providers have submitted data. Trend comparisons are also affected by improving data quality. For the subset of providers that submitted good quality detentions data in each of the last three years, we estimate there was an increase in detentions of 2% from last year.
Detentions under the Act – Dorset HealthCare 2.2 The table below shows the number of times and use of the Mental Health Act where an inpatient stay is required.
1600 Detained Admission 1400 1200 1000 800 600 400 200 0 2019/20 2018/19 2017/18 2016/17 2015/16 2014/15 2013/14
2.3 There has been an increase of 12% in the number of people who have required use of the MHA to instigate an admission to hospital, when compared to the same period in 2018/19. Numbers have fallen in terms of those whose detention or further detention commenced
2
whilst already an inpatient in hospital. A decline of 21% is noted in 2019/20, when compared to the same period in 2018/19.
2.4 This trend follows the national picture, with more people being detained in the community and conveyed to hospital, than being detained once already in hospital if admitted informally. This may suggest that informal or voluntary admission is often refused or not appropriate and there is frequently a requirement for detention under the Act to bring people into hospital.
2.5 The table above in 2.4 illustrates Dorset Healthcare’s use of the MHA and the changes in services over the last 6/7 years. It raises some important questions. As Dorset’s statutory mental health services provider we need to think and reflect on the steady rise in detentions over this period (1200 in 2013 up to 1800 in 2019/20). Consideration needs to be given as to why and how this has happened and what does this trajectory say about our services and the use, purpose and change in use of the MHA? The Committee suggests that these statistics require further consideration and their impact fully understood by the Board.
2.6 The Committee also suggests a table for the same period of 2.4 showing the use of CTOs would be useful to better inform its role..
Community Treatment Orders (CTOs) – Dorset HealthCare 2.7 CTOs allow patients with a mental disorder to live in the community whilst still being subject to powers under the MHA. The power of recall allows the Responsible Clinician (RC) to bring a CTO patient back to hospital if they think that they have become unwell again and cannot be treated/managed in the community.
2.8 Locally in 2019-20, there was a 41% increase in the use of CTOs when compared to the same time period in 2018-19. The use of CTO’s have fluctuated over the last 4 years as seen by the graph below but the trend is still undeniably upwards. The Committee’s workplan for 20/21 will include work to understand exactly how and why they are used; The Committee will look at the context for individuals, people’s experiences and the nature of Recovery Planning and the support that goes around these CTO situations.
2.9 There was also an increase in the number of patients recalled from their CTO during 2019/20 and in turn the number of patients whose CTO was then revoked following recall and detention under s3 or s37 re-instated. Recalls are completed due to clinical need for assessment and / or treatment in hospital. A CTO cannot be revoked without a CTO initially being recalled. During the period 2019/20 patients already subject to a CTO, had this order renewed for a further period on 93 occasions.
2.10 The Committee will also look at this area of CTO data in their workplan for 2021 to MHA legislation. The Committee will also look at the work of the CMHTs and see if there is a relationship between the use of CTOs and the demand on CMHT capacity.
2.11 The following table shows the use of CTOs, recalls and revocations for the Trust over the last seven years:
3
90 85 CTO apps 79 80 CTO recalls 68 70 CTO revokes 56 60 51 53 50 45 44 40 35 31 28 30 21 21 34 18 20 26 21 19 10 16 13 13 0 13/14 14/15 15/16 16/17 17/18 18/19 19/20
2.12 National data shows a total of 4,840 new Community Treatment Orders during 2018-19, a marginal increase from figures in 2017/18 (4,784). This data is however, also incomplete due to coverage / submission issues previously mentioned. Amongst age groups, people aged 35 to 49 were most likely to be placed on a CTO. Amongst broad ethnic groups, CTO use was highest for ‘Black or Black British’ people. This was approximately eight times the rate for the White group. Persons are almost twice as likely to be subject to a CTO if male.
2.13 The MHLAC considers it is a priority to explore what is happening locally within our BAME community. Future reporting to the committee must include ethnicity data to properly understand the trends and effects of mental illness in this community
Overall detention figures – National Context 2.14 Of the 49,978 new detentions that took place in 2018/19, 30,478 took place at admission to hospital, a further 15,834 occurred following admission. 84.5% of people were detained once and 15.5% were detained more than once during this period. Only 2.5% of people were detained more than twice during 2018/19. This suggests that repeated detention for the same people is not a major factor in rising levels of detention in England, but that more people requiring help are coming into the system.
2.15 Known detention rates are slightly higher for males than females and detention rates tend to decline with age. Detention rates for 18-34 year olds are a third higher than those aged 50 to 64, rates rose again slightly for the 65+ age group.
2.16 Detention rates are over four times higher for the Black / Black British group, when compared to the White group, which accounts for the biggest proportion of people living in England, this suggest the Black / Black British group may suffer with poorer mental health.
2.17 Based on Mental Health Services Data Set (MHSDS) returns only, there were 21,196 people reported as being subject to the Act on 31 March 2019, compared to 20, 961 the year earlier; confirming countrywide that just over 200 people more than last year were detained under the MHA as of 31/03/2020.
3. USE OF MENTAL CAPACITY ACT 2005 (MCA) & DEPRIVATION OF LIBERTY SAFEGUARDS (DoLS)
National Context 3.1 An urgent DOLs authorisation is completed when a hospital or care home believes that a person in their care is being deprived of their liberty. The urgent authorisation allows the hospital/care home to hold the person in their care for up to seven days pending
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assessments by the Supervisory Body (usually a Local Authority). An urgent authorisation can be extended to 14 days where there is a delay in the assessments being completed.
3.2 A standard authorisation is an authority granted by a Supervisory Body to continue to deprive a person’s liberty in a hospital/care home as the care and the treatment that the patient needs cannot be managed in a less restrictive way. A standard authorisation can be granted for any amount of time between one day and one year.
3.3 The government has developed a new system to replace Deprivation of Liberty Safeguards, known as Liberty Protection Safeguards. The reforms seek to introduce a simpler process that involves families more, gives swifter access to assessments and be less burdensome on people, carers, families and local authorities. There is no current defined date for implementation of LPS, with October 2020, initially agreed before the covid-19 pandemic. We still await the Code of Practice and Regulations to accompany the legislation and the thinking is that this will now be implemented in 2021.
DoLs Figures for Dorset HealthCare 3.4 The local Supervisory Bodies in Dorset are Dorset County, Bournemouth Borough and Borough of Poole Councils. Bournemouth, Christchurch and Poole have amalgamated to become BCP Council
3.5 The data for DOLs use in the last five years is as follows:
2015- 2016- 2017- 2018- 2019- 16 17 18 19 20 Number of DOLs applications (Urgent Authorisations, Urgent 281 653 590 645 419 Extensions or Standard Requests) Number of Standard Authorisations 29 127 34 18 20 granted by Supervisory Body
3.6 The number of applications made for DoLS during 2019/20 decreased markedly on the three previous years. The majority of DoLS authorisations within Dorset HealthCare are made within Community Hospital settings. It is unclear why numbers have dropped so dramatically.
4. THE WORK OF THE COMMITTEE IN 2019-20
4.1 The work of the Committee in the last year has encompassed the following:
Care Quality Commission Reports 4.2 The Committee received and considered quarterly assurance reports outlining: • Where and when Mental Health Act Inspections have taken place within the Trust • Themes emerging from Mental Health Act Inspections • Current, overdue actions arising from Mental Health Inspections reports
4.3 The Care Quality Commission confirmed that they would not be conducting any physical visits during the covid-19 pandemic, however they could request information relating to a ward / service and conduct a desktop review. The CQC reviewer for Dorset confirmed that he had no particular concerns regarding Dorset HealthCare services, so would only be calling the ward managers of the wards he was due to visit and having a brief chat. To date phone calls have been received at 3 of the 5 sites, with no concerns raised.
4.4 Key themes emerging from visits in the period include:
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• Care planning – Issues included lack of input, incomplete / limited plans or out of date plans. • Information for patients – rights not regularly being revisited or given before discharge. Information not readily available for informal patients. • 1:1 time – limited recording within patient information systems of 1:1 time between nursing staff and patients • IMHA – patients that lacked capacity were not always being referred to the IMHA service. • Capacity and consent – the capacity and consent status of patients was not always recorded in the notes on a regular basis.
Mental Health Legislation Dashboard 4.5 The Committee has reviewed a quarterly dashboard which clearly shows the matters below: • Compliance with the MHA Code of Practice • Deprivation of Liberty Safeguards • Compliance with notifications to the Care Quality Commission
4.6 In depth discussion has taken place specifically on: • Section 132 rights and action being taken to improve giving and recording of section 132 rights, including revisits of rights. • Deaths of detained patients, circumstances were discussed and whether any learning could be taken from these. Specific discussions around physical health and well-being of patients. • Section 136 and reasons why assessments are taking longer than the Code of Practice recommended timescales of three hours, what can be done where delay is down to assessing professionals (section 12 doctors / GP’s) • How to improve compliance of section renewal hearings being held prior to the current period of detention expires and understanding factors that affect this. • The use of paper review hearings: where certain criteria is met, The number undertaken and process required has been carefully monitored at committee meetings. • The use of video hearings, initially raised by the tribunal service and the opportunity for the Trust to be a pilot site.
5. IMPROVEMENT ACTION TAKEN
5.1 The Committee has reviewed themes that have emerged from the CQC Mental Health Act Visit reports, and internal assurance reviews and noted action taken to improve practice in the following areas.
5.2 Section 132 rights • all patients have to have their rights under S.132 commenced within 24 hours of detention; (6 hours for s5(4)). • exception reports are being provided to the Director of MH and service leads to demonstrate whether these targets are not being achieved. • MHL Office continues to provide s132 rights training to nursing staff within inpatient wards. • It is felt that the creation of s132 rights module within RiO, where records can be made direct into the system will aid this process. Feedback from CQC MHA visits have shown an improvement in the giving of rights following admission of patients, 6
however a focus is required to ensure that these are then revisited from time to time.
5.3 Section 136 timescales • Causes for delays in assessments are being reviewed by the Strategic Mental Health Act Multi-Agency Group. • Data report amended to show number of cases which fall just outside of the 3 hour timescale. • Pan Dorset section 12 task and finish group raised, which is hosted by the CCG. GP event attended and opportunity for GP’s to take part in mental health act assessments discussed. Group has viewed several different systems to improve process associated with identifying s12 doctors for MHA assessments, decision awaited on which system will be used.
5.4 Renewals of Sections • Mental Health Legislation Administrators have amended practice to set up panel meetings in the current period of detention and impose dates where Responsible Clinicians have not responded to requests for availability. • Widening of criteria for paper review cases, allows hearings to be conducted in certain circumstances without the professionals present. • The introduction of video hearings has increased flexibility for professionals attending, reducing travel time and the requirement to be available before and after the hearing.
5.5 Independent Mental Health Advocates - IMHAs • Meetings have taken place with the IMHA service to review referral processes to them. • Referrals being made at an earlier stage by wards, for IMHAs where patients lack capacity to request support and this is unlikely to change. • Discussions have taken place regarding IMHA’s having access to RiO and the ability to make progress note entries.
5.6 Care Planning • Piloting of wellbeing plans across inpatient mental health services. • Rolling out of specific well-being plan training with Paul Billen. • Well-being plan event held at Cobham Sports & Social Club
5.7 Working through the Pandemic • The work undertaken with the Tribunal service prior to the covid-19 pandemic, allowed a seamless transition from face to face MHA panel hearings to video hearings. The MHL Office have had not had to cancel any panel hearings, due to the restrictions placed on persons due to covid-19 pandemic. Many NHS Trusts have had to limit the number of panel hearings held or cancel them completely. • The tribunal service initially held hearings via teleconference, before switching to video conference. Due to the number of hearings countrywide and a limited number of teleconference lines, a number of tribunal hearings were postponed. These postponed hearings were re-scheduled for the beginning of June. • The MHL Offices at St Ann’s Hospital and Forston Clinic have managed to keep a presence in both offices throughout the covid 19 pandemic, with the majority of staff home working. A presence in the office has allowed information that continues to
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come in by post to be dealt with in a timely manner. It also ensures phone lines are manned and the printing and distribution of correspondence can continue. • The Retreat service opened back up on Wednesday 27th May 2020. Prior to this staff had been redeployed to the Emergency Assessment Units (EAU) at Seastone House (Westbourne) and Maiden Castle (Dorchester). The EAU was set up to re- direct persons presenting at the General Hospitals with mental health problems to these two sites. The two sites were staffed with support workers, nurses and doctors, allowing assessment under the MHA if required.
6. Care Quality Commission (CQC) - Monitoring the MHA 2018/19
6.1 This report is based on the findings from the CQC’s activities and visits during 2018/19 and also informed by Sir Simon Wessley’s independent review of the Mental Health Act (MHA). During 2018/19 - 1,190 visits were conducted by the CQC with 4,436 detained patients met and spoken with; from these visits 4,477 actions were required from providers. The Second Opinion Appointed Doctor service carried out 14,354 visits to review patient’s treatment plans, 195 notifications were received regarding the death of a detained patient and 923 absences without leave were reported from secure hospitals.
6.2 The independent review conducted by Sir Simon Wessley and published in December 2018 concluded that: “There is a clear case for change: the rate of detention is rising; the patient’s voice is lost within processes that are out-of-date and can be uncaring; there is unacceptable overrepresentation of people from Black and minority ethnic groups amongst people detained; and people with learning disabilities and/or autism are at a particular disadvantage. We are also concerned that we are out-of-step with our human rights obligations.”
Monitoring the MHA 2018/19 highlighted five key areas of concern:
Use of human rights principles and frameworks 6.3 These must be applied and their impact on people continuously reviewed and updated to improve people’s experience, and to make sure that people are protected and respected.
6.4 Within Dorset HealthCare, we currently monitor BME statistics when reviewing s136 presentations and a report is provided bi-monthly to the Strategic MHL Multi-Agency Group (SMHLMAG). We do not however break this down into numbers that go onto being detained, and equally we have not robustly monitored BME statistics when reviewing use of force data. Going forward we will incorporate this into the SMHLMAG group and MH (Use of Force) Group.
6.5 We work proactively to look at ways to promote positive practice in order to bring about ways of working that will reduce restrictive interventions. A key focus of the safety workstream has been around promoting positive practice. We have embedded Quality Improvement in our practices and thinking around restrictive interventions.
6.6 One area in particular has been the development of our Reducing Restrictive Interventions Collaborative, supported by the QI team. This has brought together staff from acute wards at regular intervals throughout the year to learn, share ideas and reflect on what we do and why we do it, underpinned with QI methodology.
6.7 We have refreshed the Safewards initiatives. This was introduced several years ago, but due to staff turnover we have reintroduced the concept of Safewards and the various
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dimensions of this. This work will continue into 2020-21 and due to the Covid outbreak the engagement event is now planned for the autumn.
6.8 The PMVA team are now based at St Ann’s to enable closer working with ward teams, provide visibility on wards, become involved in individual patient reviews and provide real time training to specific wards with higher than normal acuity.
6.9 An area for review that we will continue into 2020-2021 is around the induction and training for staff. It is evident from talking with staff and observing practice on the ward, that there is a strong culture around distraction, de-escalation, and conscious efforts to avoid any form of restrictive practice. It is apparent that the way in which we induct staff does not mirror our aspiration to focus on alternatives to restrictive interventions. We have had some feedback from new staff around their experience of the current induction process and have identified that we could improve the timing and the way in which this is delivered, with an even stronger focus on interventions that should reduce the likelihood of needing any form of restrictive practice. We have commenced a self –assessment process of our PMVA course and will be conducting further surveys to understand new staff’s experience in order to inform a revised induction plan.
6.10 A business case for a pilot project for the use body worn cameras has been submitted for consideration. The primary purpose of the use and activation of Body Worn Cameras is to improve the safety of patients and staff. The concept of BWC has been piloted and evaluated in other Trusts and has been found to be positive for patients, visitors and staff. We aim to initially run the pilot on Health-Based Place of Safety (HBPoS).
6.11 Evidence indicates that the use of video recording devices may reduce the incidence of aggression and violence whilst also providing greater transparency and enabling increased scrutiny for any subsequent actions taken in response to such occurrences. This would enable us to monitor any discrepancies and inequalities in the way in which we manage incidents.
Involvement in care 6.12 People must be supported to give their views and offer their expertise when decisions are being made in their care and treatment. Providers must take this seriously and look for evidence that this is being done across their service.
6.13 Within Dorset HealthCare all patients have a wellbeing plan which includes capturing patient and carer views. It is a collaborative plan which has been designed to focus on the person, their goals, aspirations and how they, their carers/supporters and we as services can support them to achieve these.
6.14 Wellbeing plans are formulated with patients and incorporate sections including:
What is happening? This considers: a. My View (patient view /Carer's and/or Supporter's View /Clinician's view) b. What Is Important? What are my strengths and values? Who is important to me? What would I like people to know about me? My View c. My Personal Plans d. My Early Warning Signs or indications that things are becoming more difficult My view Carer’s view
6.15 Wellbeing plans are reviewed and updated by the keyworker / CCO with the patient on a regular basis. They are updated following incidents and work alongside the risk assessment. 9
6.16 Wellbeing plans are audited by ward team leaders, managers and matrons. Additionally a clinical auditor has been undertaking independent audits and has fed back results to the patient’s keyworker and ward manager.
6.17 Advanced decision making still requires some more work. For patients in acute crisis it can be very difficult to engage patients in future planning. We are encouraging community colleagues to consider advance decisions prior to patients coming into hospital (if already on a caseload).
6.18 Advanced Decisions form part of the Inpatient Innovation and Excellence Collaborative action plan that has been developed by Inpatient Matrons.
People in long-term segregation 6.19 People in long-term segregation can experience more restrictions than necessary, as well as delays in receiving independent reviews. This is particularly true for people with learning disability and autistic people. Too many people with a learning disability and autistic people are in hospital because of a lack of local, intensive community services.
6.20 Within Dorset HealthCare we very rarely place people in long term segregation. Over the past year, there have been only 2 incidents of long term segregation. The current seclusion policy has been reviewed and is up to date. All episodes of seclusion are monitored via the MH (Use of Force) group. Additionally the local DART meetings are being resurrected and chaired by the local security manager, which will review in detail each incident and elicit any learning that can be shared across the service.
6.21 One patient with a learning disability (LD) was placed in long term segregation whilst awaiting an appropriate bed due to lack of inpatient learning disability beds within the county. We are escalating via the incident reporting system each time a patient with a primary diagnosis of learning disability is admitted inappropriately to our wards. This will help to support the rationale to have local inpatient LD beds.
6.22 In adult LD services we have a well-established Intensive Support Team (IST) which works closely with integrated community services, mental health services, commissioners and to prevent admission to hospital and facilitate early discharge. The IST monitors all specialist hospital placements which are out of area as there is no such provision in Dorset. We are working with NHS Dorset to enhance this service in light of the recommendations in the long term plan. DHC carries out regular audit of all clients placed in out of area hospitals and looks specifically at any risks around long term segregation. There is no similar team to the IST for people with ASD and no LD or for in Children's services however responsible MH teams feed in to the audit process as well as through processes such as CPA and CeTR. There is a multi-agency Behaviour and Development Pathway for Children and Young People and there is a plan to review provision for ASD in NHS Dorset's LTP plan.
Access to Care and Treatment 6.23 People are not always receiving the care and treatment they need, with services struggling to offer appropriate options, both in the community and in hospital. There has been a 14% fall in the number of mental health beds from 2014/15 to 2018/19. While this is in line with the national policy, people are not always getting the help they need to avoid crisis situations and hospital admissions, leading to detention under the MHA.
6.24 Within Dorset HealthCare and following the acute care pathway review, Dorset Healthcare are expanding the number of beds offered to Dorset residents. Since December 2019 there have been no acute patients placed in out of area beds. Improvements have been made to support decision making and explore alternatives to admissions thanks to
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collaborative work between the clinical site mangers, matrons, and inpatient / home treatment team consultants.
6.25 Improvements have included: a) Daily bed management calls to understand current bed flow, discharges and barriers to planned discharges b) Daily triage meetings involving community referrers, assessment ward representation, Home treatment Team and matrons to discuss and prioritise all referrals c) SBAR tool to inform decision making and prioritisation considering risk. d) Recruitment of dedicated 24/7 clinical site managers improving consistency and ownership of bed management e) Pilot seconded patient flow lead having oversight of all bed movement, linking with wards, delayed discharge coordinators, Approved Mental Health Professionals, CCG leads, psychiatric liaison and criminal justice diversion team. f) Inpatient consultants on rotation covering s136 assessments which has reduced demand for beds g) DBT informed work for patients with EUPD diagnosis enabling responsive orientation to diagnosis for these patients and time bound short stays to reduce long term risk as per NICE guidance.
6.26 A new s136 suite was built with patient input to create a more welcoming and comfortable environment. Alongside this a dedicated Health-Based Place of Safety (HBPoS) team was commissioned, and this team was given a comprehensive induction. This has enabled better continuity, improved patient experience and elimination of duplication of assessment for the patient. Physical health checks on arrival also signpost patients to acute medical care where necessary and help prevent deterioration. A new HBPoS governance group oversees this. Dorset patients are not unnecessarily detained in police custody, and strong links have been developed between Dorset Healthcare and police colleagues.
6.27 Further work is underway to review the current acute operational policy and fine-tune the referral tool for admissions.
The interface between the MHA, the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards is complex and difficult to navigate 6.28 It is difficult for patients, families and carers to understand how the MHA, the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards all work together, and what rights and safeguards they have under the different frameworks. Professionals need to keep up-to-date with any legal changes that may affect these frameworks, and what these changes may mean for patients.
6.29 Within Dorset HealthCare all qualified staff receive training with regard to the Mental Health Act and Mental Capacity Act (Including Deprivation of Liberty), through a variety of platforms (face to face, e-learning etc). Training is monitored by the learning development team and reminders provided when renewal dates are approaching. Learning resources, amendments to legislation and case law updates are also available from the MHL office internet pages.
6.30 A new MHA / MCA practice educator began with the Trust at the start of April working 5 days a week. Current training presentations and materials are being reviewed and a proportion of the practice educators time being allocated to work through real time case studies and scenarios with staff. The MHL Office also provide a number of training presentations for community and inpatients staff, such as s132 rights and the overlap between MHA / MCA. All wards provide an admission booklet for patients which contains further information during their stay in hospital.
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6.31 Section 132 rights are monitored weekly, both via the MHA office and through local ward based audits, access to advocacy services is also checked through the audit process.
7. OBJECTIVES FOR THE COMMITTEE IN 2020/2021 THE COMMITTEE WILL CONTINUE TO OPERATE THROUGH THE PANDEMIC.
7.1 The Committee will continue to monitor the use of Mental Health Legislation (and any new additions to the law), training and any visits from CQC Mental Health Inspectors through the quarterly meetings.
7.2 Mental Health Legislation Manager and Deputy Chair of the MHA panel members will undertake appraisals of all Mental Health Act panel members when required.
7.3 The Committee will review any new publications regarding the use of Mental Health Legislation produced by the CQC.
7.4 The Committee will review updates on any forthcoming changes in Mental Health Legislation or relevant case law.
7.5 Mental Health Legislation Manager and Head of Quality Assurance and Compliance to continue with the review of work streams related to the use of the Mental Health Act, Mental Capacity Act and Deprivation of Liberty Safeguards.
Specific areas of work to be undertaken:
As Dorset’s statutory mental health services provider we need to think and reflect on the steady rise in detentions over this period (1200 in 2013 up to 1800 in 2019/20). Consideration needs to be given as to why and how this has happened and what does this trajectory say about our services and the use, purpose and change in use of the MHA? The Committee suggests that these statistics require further consideration and their impact fully understood by the Board.
The Committee will also look at CTO data in depth in their workplan for 2021. The Committee will also look at the work of the CMHTs and see if there is a relationship between the use of CTOs and the demand on CMHT capacity.
The MHLAC considers it is a priority to explore what is happening locally within our BAME community. Future reporting to the committee must include ethnicity data to properly understand the trends and effects of mental illness in this community.
The work of the Committee for 20/21 will focus on quality in all the areas that the MHA is used. Dorset Healthcare has improved its data collation and administration of the Act in the last 6 years and the committee will continue to scrutinise this work because it effects individuals’ liberty. However, as a well led organisation there is the opportunity to go further and look at and understand peoples’ experiences and the context in which the Act is being utilised now and in the future. We have seen in this report the upward trend of CTOs and detentions and the committee will spend time trying to understand this better and the journey of the individual through our MH provision so that we continue to follow our aspiration of “ Better Every Day”- for everyone.
8. MENTAL HEALTH ACT PANEL MEMBERS
8.1 Mental Health Act Panel Members (Panel Members) are trained lay people who are appointed by the Trust to review the cases of detained and CTO patients. Their role and powers derive from the Mental Health Act 1983 and are set out in the Mental Health Act
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Code of Practice. The Trust would like to thank the Panel Members for their commitment, care and professionalism when reviewing our patient’s detentions.
8.2 Mental Health Act Panel meetings are convened when: • Patients make an application to appeal against their section to the Hospital Managers • A Nearest Relative’s request for discharge from section is barred by the Responsible Clinician (RC) • A patient’s detention or Community Treatment Order is renewed • At the request of panel members
8.3 In 2019-20 there were 306 causes to convene a panel meeting with 197 of those cases having a review completed. The remaining cases were either discharged, transferred out or another section implemented. This represents a 51% increase in the number of panel meetings taking place in the previous year (130).
Period covered Total number of requests to Total number of cases convene a panel reviewed 2015-16 179 140 2016-17 258 190 2017-18 249 148 2018-19 233 130 2019-20 306 197
9. CONCLUSION
9.1 The Mental Health Legislation Assurance Committee has identified an improvement in the triangulation of available information relating to Mental Health Legislation. Triangulation of data and information collected from Core Services Reviews, Mental Health Legislation Audit, CQC Mental Health Act inspections, updates coming out of the Strategic MHA multi- agency group and reviews of untoward incidents have allowed themes to be clearly identified and shared as part of good practice to improve compliance.
9.2 Improved compliance in attempts to give patients their section 132 rights has been noted although CQC inspections has identified the need to ensure patients are regularly re- informed of their rights.
9.3 Work continues to ensure a timely response, fromprofessionals attending MHA assessments following detention under s136 of the Act. This piece of work is ongoing, although there has been progress made in terms of reviewing the process and ensuring an up to date pool of doctors have been collated and shared.
9.4 There are a number of factors affecting the timely scheduling of MHA panel hearings (Hospital Managers hearings). Despite the MHL Office now starting the process 8 weeks in advance of renewal dates a number of these have still fallen outside the required timescales. The committee will keep this area under review.
9.5 Nursing staff have been reminded of the requirement to document information within the RiO progress notes, particularly IMHA attendance. Work has been undertaken to give IMHA’s their own access to RiO, so that they can document within the system when they have attended and met with patients.
9.6 With regards to the implementation of My Wellbeing Plan, an experienced staff member, who has developed high quality plans, has been providing group and individual support across all of the wards to put these plans in place. This has seen a marked increase in the quality of the individual plans and inpatient involvement in their own care planning.
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10. APPLICABLE LEGISLATION
10.1 Mental Health Act 1983 Mental Health Act 2007 amendments Mental Capacity Act 2007 Deprivation of Liberty Safeguards
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APPENDIX A
GLOSSARY OF TERMS
NHS Digital 11.1 NHS Digital is the national provider of information, data and IT systems for commissioners, analysts and clinicians in health and social care. Its work includes: • publishing more than 260 statistical publications per year • providing a range of specialist data services • managing informatics projects and programmes, and developing and assuring national systems against appropriate contractual, clinical safety and information standards
Mental Health Act 11.2 The Mental Health Act (MHA) 1983 is a piece of legislation (in England and Wales) which tells people with mental health problems what their rights are regarding: • assessment and treatment in hospital • treatment in the community • pathways into hospital, which can be civil or criminal
Mental Health Act Code of Practice 11.3 The Code provides guidance to registered medical practitioners (“doctors”), approved clinicians, managers and staff of hospitals, and approved mental health professionals on how they should proceed when undertaking duties under the Act.
Mental Capacity Act 11.4 The Mental Capacity Act (MCA) is legislation designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over.
Deprivation of Liberty Safeguards 11.5 The Deprivation of Liberty Safeguards are an amendment to the Mental Capacity Act 2005. They apply in England and Wales only. It is legislation which allows the lawful deprivation of liberty of those who lack capacity to consent to admission, care and treatment and who are under continuous control and supervision.
Care Quality Commission 11.6 Body who monitor, inspect and regulate health and social care services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care.
Community Treatment Orders (CTO) 11.7 CTOs allow patients with a mental disorder to live in the community whilst still being subject to powers under the MHA. The patient must has been subject to a treatment section under sections 3, 37, 47 or 45a to be able to use a CTO.
Section 132 rights 11.8 Section 132 of the Mental Health Act (MHA) 1983 as amended by the MHA 2007 applies to all patients who are detained under the Act. It places a duty on the “Hospital Managers” to provide certain information to patients, regarding which section of the MHA for the time being authorises their detention or treatment and the effects of that section.
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Renewals of section 11.9 There are a number of sections under the Mental Health Act, which allows ongoing treatment of patients for their mental disorder. Most sections for treatment are for time- limited periods which can be renewed under sections 20 and 20A for a further time-limited period.
Independent Mental Health Advocates (IMHA) 11.10 An IMHA is someone who is specially trained to work within the framework of the Mental Health Act to meet the needs of patients. Any patient subject to a section which will last more than 72 hours is entitled to an IMHA. An IMHA helps patients understand their rights under the Mental Health Act 1983, parts of the Mental Health Act 1983 which apply to them, any conditions or restrictions which apply to them.
Section 136 11.11 The police can use section 136 of the Mental Health Act to take a person to a place of safety from a public place if they think the person has a mental disorder and are is in need of urgent care. A place of safety is usually a hospital.
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Agenda Item 14
Appointment of the Senior Independent Director
Part 1 Board Meeting 29 July 2020
Author Andy Willis, Chair
Purpose of Report To appoint Steve Peacock as Senior Independent Director.
Executive Summary
The Board is expected to appoint, in accordance with the Code of Governance for NHS Foundation Trusts, a Senior Independent Director. The appointment is made by the Board in consultation with the Council of Governors.
Monitor, when regulator of foundations trusts, set out requirements, expectations and guidance in respect of the role. In essence, the role of Senior Independent Director is to be a Board-level channel of communication when existing routes have failed to resolve and issue or cannot be used.
When undertaking the last round of Non-Executive Director recruitment, Steve Peacock was recruited with a view to him being appointed as Senior Independent Director in due course.
Consultation has taken place with the Council of Governors, which is supportive of Steve being appointed as Senior Independent Director.
Recommendation To appoint Steve Peacock as Senior Independent Director.
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