Ref: TS/PC Date: 29th May 2019
To the Members of the Board of Birmingham Community Healthcare NHS Foundation Trust
You are invited to attend a Public meeting of the Board of Birmingham Community Healthcare NHS Foundation Trust on 5th June 2019 at 10:00 in Rooms G05/06, Priestley Wharf.
The Non-Executive Directors will meet with the Chair at 09:15 in the Chair’s Office, Priestley Wharf.
The agenda is as set out below.
Yours sincerely
Mr J Gould Vice Chair
AGENDA
1. Freedom to Speak Up Guardian: Verbal Alison Last/ Noting 10.00-10.20 Staff Story Michelle Woodward
2. FORMALITIES to declare the Verbal Jerry Gould Noting 10.20-10.35 meeting open, quorate and called Vice Chair in accordance with Standing Orders. a) Apologies For Absence Verbal Jerry Gould Noting b) Conflicts of Interests Verbal Jerry Gould Noting c) Board of Directors’ Register of ENC 1 Jerry Gould Noting Interests d) Public Trust Board Minutes ENC 2 Jerry Gould Approval dated 1st May 2019 e) Matters Arising: Board Action ENC 3 Jerry Gould Approval Sheet
3. STANDING ITEMS a) Chairman’s Report ENC 4 Jerry Gould Noting 10.35-10.45 b) Chief Executive Officer’s Report ENC 5 Richard Kirby Noting 10.45-10.55
4. BEST CARE: HEALTHY COMMUNITIES a) Fit for 2022 Workforce Strategy ENC 6 David Holmes Approval 10.55-11.10 b) Risk Management Strategy ENC 7 Michelle Woodward Approval 11.10-11.25 Page 1 of 2
c) Board Assurance Framework ENC 8 Michelle Woodward Approval 11.25-11.40 2019/20 COMFORT BREAK 11.40-11.55
5. SAFE, HIGH QUALITY CARE a) Quality and Safety Committee ENC 9 David Sallah Noting 11.55-12.05 Escalation Report from meeting dated 30th May 2019
6. A GREAT PLACE TO WORK a) Workforce & Organisational ENC 10 Jacynth Ivey Noting 12.05-12.15 Development Committee Escalation Report from meeting dated 23rd May 2019
7. INTEGRATED CARE IN COMMUNITIES a) Primary Care Networks ENC 11 Micky Griffith Noting 12.15-12.25
8. MAKING GOOD USE OF RESOURCES a) Quality & Performance Report ENC 12 Ian Woodall Assurance 12.25-12.45 Marcia Perry Angie Wallace David Holmes b) Finance and Performance ENC 13 Jerry Gould Noting 12.45-12.55 Committee Escalation Report from meeting dated 28th May 2019
9. CORPORATE GOVERNANCE / REGULATORY COMPLIANCE None notified
10. ANY OTHER BUSINESS None notified
11. QUESTIONS FROM THE PUBLIC ON AGENDA ITEMS
12. DATE AND TIME OF NEXT MEETING The next public meeting of the Board of Birmingham Community Healthcare NHS Foundation Trust will take place at 10:00 on 3rd July 2019 in Rooms G05/06 Priestley Wharf.
13. MEMBERS OF THE PUBLIC AND PRESS The Board resolves that representatives of the press and other members of the public to be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted publicity on which would be prejudicial to the public interest - Section 1 (2) Public Bodies (Admissions to Meetings Act) 1960.
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Public Trust Board
Reference: Agenda Item no: 2c Enclosure no: 1 Date of Meeting: 5th June 2019 Document Title: Board of Directors’ Register of Interests Responsible Director: Michelle Woodward, Director of Corporate Governance Author: Michelle Woodward, Director of Corporate Governance
Executive In accordance with Corporate Governance good practice, the NHS Code of Summary / Accountability and Trust Standing Orders, it is a requirement for every Board Purpose of the Director to declare any interests that they may have which are relevant and Paper & Key material to the Trust Board. Interests that should be regarded as “relevant Points and material” are clearly outlined within the report.
The paper documents the current declarations of interest made by all Trust Board directors. Declarations of interest relating to new Trust Board Members are documented in blue text; removals from the register are represented in red text with strikethrough.
Action The Board (or Committee) is recommended to: required by the Committee 1. NOTE the Board of Directors’ Register of Interests
Prior None discussion
Safe, High A Great Integrated Care Making Good Corporate Quality Place to in Communities Use of Governance Implications: Care Work Resources Impact on: X Risks:
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Board of Directors Register of Interests
In accordance with good practice in corporate governance, the NHS Code of Accountability and the Trust’s Standing Orders, it is a requirement for every Board Director to declare any interests that they may have which are relevant and material to the Trust Board.
Interests that should be regarded as “relevant and material” are:
a) Directorships, including Non-Executive directorships held in private companies or PLCs (with the exception of those of dormant companies); b) Ownership or part ownership of private companies, businesses or consultancies, likely or possibly seeking to do business with the NHS; c) Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS; d) A position of trust in a charity or voluntary organisation in the field of health and social care; e) Any connection with a voluntary or other organisation contracting for NHS services; f) Any other commercial interest in the decision before the meeting.
Board members should also refer to the requirements of the Trust’s Standing Orders for further guidance in relation to declarations of interest. If members are in any doubt about the relevance of an interest they should discuss this with the Chair or the Head of Corporate Governance as soon as possible.
All Board members are reminded of their on-going duty to declare any other interests that may arise during the course of the year at the earliest opportunity.
Page 1 of 4 REGISTER OF DIRECTORS INTERESTS – June 2019
Appointment Voting Name Interest Date* Member Occasional course director for The Leadership Trust Mr Tom Storrow Trustee and Chair of Lench’s Trust (Charity) 01.11.11 Yes Chair Associate of Keele University School of Medicine in the Clinical Management and Leadership team. Course Director in NHS Management for SpRs Dr Barry Henley Chair of Trustees of Birmingham Jewish Community Care 01.06.19 Yes Chair Member of Aston University Business Advisory Council Governor, Sandwell Health Futures UTC Mr Richard Kirby 01.03.18 Director, West Midlands Quality Review Service Yes Chief Executive Officer Senior Steward (Trustee), Selly Oak Methodist Church Marcia Perry Director of Nursing and 01.04.19 None declared Yes Therapies Dr Doug Simkiss 06.02.19 None declared Yes Interim Medical Director Ian Woodall 01.04.19 None declared Yes Chief Finance Officer Chris Holt 03.06.19 To be confirmed following commencement of employment. Yes Chief Operating Officer Angie Wallace Interim Chief Operating 13.04.19 None declared Yes Officer Charitable Trustee Mr David Holmes Deputy National President of Healthcare People Management Association Director of Workforce and (HPMA) 01.04.16 No Organisational Vice President of West Midlands HPMA Development Governor, Birmingham Virtual Schools – Links with Children and Families services Suzanne Cleary 03.06.19 To be confirmed following commencement of employment. No
Page 2 of 4 Appointment Voting Name Interest Date* Member Director of Strategy and Partnerships Micky Griffith Interim Director of Strategy 01.04.19 None declared No and Partnerships Mrs Michelle Woodward Director of Michelle Elizabeth Consulting Ltd – a small healthcare company Director of Corporate 03.04.18 providing consultancy in the public and private sector – not associated with No Governance BCHC Mr Jeremy Gould 01.07.12 Non-Executive Director, Coventry and Warwickshire Hospitals NHS Trust Yes Non-Executive Director Founder/Joint Director of Tashie Consulting providing consultancy, and coaching to health and social care organisations – not associated with BCHC Consultant - Leadership Academy - Health Education England Professor David Sallah Emeritus Professor of Mental Health - Wolverhampton University 30.07.15 Yes Non-Executive Director Investor and shareholder, Off Grid Energy Limited, a medium, sized manufacturing company specialising in off grid hybrid power generation Wife, Non-Executive Director at The Royal Orthopaedic Hospital NHS Foundation Trust Non-Executive Director – Hadley Industries PLC (manufacturing) Non-Executive Director of Walsall Healthcare NHS Trust Mr Sukhbinder Heer Non-Executive Director of Black Country Partnership NHS Foundation Trust 01.10.15 Yes Non-Executive Director Partner Unicorn Ascension Fund (Venture Capital) Chairman – Powerfab Innovations Ltd (manufacturing) Partner – Qualitas LLP (Property Consultancy) Mrs Jenny Belza Director of Jenny Belza Consulting Limited – not associated with BCHC 01.06.18 Yes Non-Executive Director Member of the Royal College of Nursing Non-Executive Director of West Midlands Ambulance Service NHS University Mrs Jacynth Ivey Foundation Trust 11.03.19 Yes Non-Executive Director Associate Non-Executive Director of Health Education England Managing Director of Inspiring Hope Ltd – providing consultancy in the NHS
Page 3 of 4 Appointment Voting Name Interest Date* Member Chair of Bethel Health & Healing Network (Charitable Organisation commissioned by the NHS)
* Appointment date for the purpose of the register of interests relates to the establishment of Birmingham Community Healthcare NHS Trust unless appointed thereafter.
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DRAFT MINUTES OF A PUBLIC MEETING OF THE BOARD OF BIRMINGHAM COMMUNITY HEALTHCARE NHS FOUNDATION TRUST HELD AT 14:00 ON 1ST MAY 2019 AT TRUST HEADQUARTERS, ROOMS G05/06, PRIESTLEY WHARF
Present: Mr Tom Storrow TS Chair Professor David Sallah DSa Non-Executive Director Mr Richard Kirby RK Chief Executive Officer Mrs Jenny Belza JB Non-Executive Director Mr Sukhbinder Heer SH Non-Executive Director Mr Jerry Gould JG Non-Executive Director Mrs Jacynth Ivey JI Non-Executive Director Mrs Marcia Perry MPe Director of Nursing & Therapies Mr Ian Woodall IW Chief Finance Officer Dr Doug Simkiss DSi Medical Director Mr David Holmes DH Director of Workforce and Organisational Development Mr Micky Griffith MG Interim Director of Strategy Mrs Angie Wallace AW Interim Chief Operating Officer Mrs Michelle Woodward MW Director of Corporate Governance In attendance Mrs Patricia Cook PC Executive Assistant (Minutes) Mr Barry Henley BH Incoming Chair (Observer) Mr Peter Mayer PM Lead Public Governor (Observer) Mr Tim Murphy TM Public Governor (Observer) Mr Richard Shelton RS Head of Communications Ms Angela Aboagye AA Staff Side Representative Mrs Marie Tarplee MT Staff Member (observing) Mrs Sue Marsh SM Divisional Director, Children and Families Division Mrs Alison Last AL Associate Director of Patient Experience and Freedom to Speak Up Guardian Mrs JaH JaH Patient Story Mr JoH JoH Patient Story Mr Gareth Brock GH Consultant in Restorative Dentistry Ms Nicki Astle NA Dental Nurse
PATIENT EXPERIENCE STORY Deferred to 11.00 am.
19/001 FORMALITIES Action The Chair declared the meeting open and quorate and having been called in accordance with the Trust’s Standing Orders. He
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informed the meeting that the Patient Story would be later than indicated on the agenda and business would proceed until the presenters arrived.
19/002 Apologies For Absence No apologies for absence were received.
19/003 Conflicts of Interest There were no conflicts of interest declared in the business to be transacted.
19/004 Minutes of the Meeting held on the 28th March 2019 The Board considered the Minutes of the previous meeting, circulated in advance as Enclosure 2. Minute-takers, who had stood in at short notice, were thanked for providing support to the meeting. The following amendments were requested:
Second paragraph, page 6: JT update on Health Visiting caseload which should have stated ‘Universal Plus caseload of over 50’, not ‘caseload of over 50’.
Second paragraph, page 7: Annual Operating Plan: feedback from recent networks had identified the need for a number of amendments to the original policy, including late amendment of Medical and Dental Terms and conditions, linked to NHS Improvement guidance.
Second page 16: should have indicated that the strategy was ‘good’, not ‘god’.
It was also noted that there was inconsistent use of DSa and DSi.
With these amendments, the minutes of the meeting held on 28th March 2019 were held to be an accurate record.
Resolved: that the Minutes of the meeting held on the 28th March 2019 were approved as an accurate record, and were signed by the Chair on behalf of the Board.
19/005 Matters Arising: Board Action Sheet Matters Arising were noted within the Action Sheet previously circulated as Enclosure 3 and it was agreed that no changes were necessary.
Resolved: that the Action Sheet be received with approval given for the removal of completed actions.
STANDING ITEMS 19/006 Chairman’s Report TS welcomed Barry Henley (BH), the recently appointed incoming Chair, to the meeting as a public observer. He noted that the June Page 2 of 15
meeting would be chaired by JG as Deputy Chair to accommodate a prior commitment by BH.
TS noted key items in the report previously circulated as Enclosure 4, with particular reference to the induction day for Governors which will take place on 10th May. Both new and existing Governors had been invited to attend. Since this was TS’s final meeting as Chair, he wished to formally record his thanks to current and former Board colleagues for their support to himself and Governors, especially PM, Lead Governor, who was present as observer. He had considered it an honour to lead the organisation over the past seven years, including the opening of the new Birmingham Dental Hospital (BDH) and our developing role within the local Sustainability and Transformation Partnership (STP). The excellent work of BCHC staff had been celebrated at the recent VIP Awards event.
SH and DSa thanked TS for providing such effective leadership and management of challenges to Trust Board. RK wished also to express thanks on behalf of the Executive team and to wish him well in the future.
Resolved: that the Chairman’s Report be received and noted
19/007 Chief Executive Officer’s Report RK welcomed new Executive members to the Board and noted key points of the Chief Executive Officer’s update report, previously circulated as Enclosure 5. He was pleased to note progress on the Vision and Values work following last year’s staff consultation and engagement events. He stressed the importance of ensuring demonstrable progress during the next phase of implementation. The Digital, Estates and Workforce strategies were progressing as was the three year detailed financial plan. IW and MG were leading its development, and it was anticipated that it would be complete by the autumn.
RK thanked staff for their solid end of year performance, particularly pleasing to note at a time of increasing demand. The contract negotiations with Birmingham and Solihull Clinical Commissioning Group (BSOL CCG) were now completed following intensive work by IW and colleagues to progress. Operational changes were focused on supporting increased demand and improvements to childrens services. Although the agreed funding for adult health care was lower than requested, the outcome should result in stable services, and the proposed reduction of CCG financial support had been withdrawn. Allocation to individual services would continue over the coming weeks and RK would update in his next staff briefing.
A future Board Seminar would include discussion of the developing Primary Care Networks (PCNs) and RK noted the intention to invite
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GP colleagues. He commended MG and colleagues in developing engagement with local Networks. JG queried funding of Integrated Multi-disciplinary Teams (IMTs). IW noted past over-performance within these teams and noted that pressure remained high. Prioritisation of resources would be employed to support optimum use of funding. SH acknowledged progress on the Fit for 2022 programme, but queried Board awareness of the impact of withdrawal of some services. RK stressed the emphasis on whole economy awareness and the focus of PCNs on developing robust patient pathways. The importance of mental health services within care pathways was acknowledged by PCNs, but had not been priorities within delivery arrangements. DSi had met with the Director of the Birmingham and Solihull Mental Health NHS Foundation Trust and MP had also had discussions with their Director of Nursing. MG was working closely with Birmingham City Council and primary care partners on mental health issues. Closer working with BCC on District Nursing locality level arrangements was progressing. DSa felt that was a good beginning but stressed the need for awareness of clinical aspects and effective staff training on mental health care to ensure effective delivery of care.
IW and MG were leading on development of a detailed plan, including allocation of resources. RK proposed a future Board Seminar or Public Board discussion focused on the ‘bigger picture’ and the impact of actions, and noted that the improvement update was on the current agenda for discussion.
Other items of note included testing of the new STP models of intermediate care for Ladywood and Edgbaston. Following successful testing the model would now be extended across South Birmingham. JB queried testing of a care model for older people and service provision in the West Birmingham area. AW confirmed that the intermediate care model was still in the testing phase and would be evaluated in June/July. Consultation was under way in relation to future commissioning of care within the West Birmingham area, and RK noted the strong clinical view that delivery should be coterminous with the populations served. However, it was acknowledged that commissioning of West Birmingham focused services through BSOL CCG would impact on Sandwell and West Birmingham CCG. Although BCHC was not directly involved in the decision, he believed it reinforced the need for close working with Sandwell and West Birmingham Hospitals Trust in development of services at the new Metropolitan Hospital once it was finished.
DSa applauded the launch of the new NHS Confederation Black and Minority Ethnic Leaders network, but felt further development would be required for it to become an effective resource.
JG congratulated the Children’s and Families Division in winning the contract to deliver school nursing services in Birmingham.
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There was brief discussion of implementation and management of the new contract. RK agreed that the team had done a great job in winning the contract, and noted the impact on some teams in relation to services which would no longer be provided. Oversight of the new arrangements would be through the Finance and Performance and Quality and Safety Committees. MG noted that there were no partnership arrangements in the new contract, and stressed the need to ensure an integrated service for schools was developed.
Resolved: that the Chief Executive Officer’s Report be received and noted
BEST CARE: HEALTHY COMMUNITIES 19/008 Estates and Facilities Strategy: Fit for 2022 AW gave a brief history of development of the strategy previously circulated in abbreviated form as enclosure 6. The full document was available to view in the Reading Room area of Diligent. She outlined the eight key principles, shown on page two of the introduction, and key aspects of the Strategy. Changes emphasised included agile working, IT systems changes and development of local networks.
Prioritisation of linking to Integrated Care Hubs, integration of network teams and sharing of public estate, such as MH Trust and effective use of LIFT buildings would support a sustainable quality future Estates utilisation. The impact on colleagues of the Clean Air Zone soon to be imposed by BCC was under consideration. Use of West Heath Hospital was also being reviewed. It was also important to maximise use of facilities at Birmingham Dental Hospital.
JG noted consideration of the Strategy at Finance, Performance and Investment Committee (FPIC). He believed that further review of delivery metrics and wider analysis of property utilisation would be beneficial since the current strategy was based on only 26 locations.
SH noted that there had been no benchmark figures for income generation in the circulated document. He also suggested inclusion of costs to develop the re-envisioned service arrangements. He believed that agile working and infrastructure utilisation should be flexible enough to meet changing needs rapidly if necessary. MG acknowledged the challenge of managing 100+ properties and stressed there had been thorough consideration of new ways of working for effective management of Estate, ‘such as Hub and Spoke’ models for community based services. Once arrangements to optimum use of buildings had become operational, then metrics could be included in the Strategy. DSa did not believe that the strategy was fully developed yet, and queried presentation to Trust Board of an implementation plan. RK
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referred to previous discussion of team development and noted that the position would be clearer by the end of July.
DSa stressed the need to dovetail the Estates Strategy with the Information Technology Strategy for effective working. NB confirmed that aspect had been discussed at FPIC, where the need to ensure Estate was fit for the future was a key concern.
DSi conferment that development of neighbourhood teams included provision of childrens services. He stressed the importance of Estate in supporting the ‘Life Course’ approach to health service provision. MG confirmed through exploration of demographic needs and impact of estates use had been included in development of the Strategy.
RK summed up discussion, which he felt had been useful in reviewing intentions for the coming year, and noted that further development had been indicated. He also noted that future use of West Heath hospital was a significant focus for the team. He asked for endorsement of the eight key areas for future focus on development of estates use.
Resolved: that the Estates and Facilities Strategy: Fit for 2022 Report be approved
PATIENT EXPERIENCE STORY TS welcomed AL, JaH, JoH, GB and NA to the meeting and general introductions were made.
Al gave a brief background to JaH’s story which related to her very specialised dental treatment. Up to the time that AL was approached, the experience had been a negative one, but the situation had been improved to the point where the patient had now been discharged from the care of the restorative dentistry team. GB explained treatment aspects of restorative dentistry and the multi-disciplinary nature of the work carried out with colleagues, for example from UHB. He stressed the need to ensure that the correct treatment was carried out in the right place to maximise benefit to the patient.
JaH began her patient journey story by outlining her family circumstances and past experiences which had impacted on her view of dental health services, particularly in relation mental health awareness. She had been involved many years ago in a serious car accident which had caused musculoskeletal injuries, some needing extensive dental treatment. She also had experienced panic attacks which needed to be taken into account when attending for treatment.
A few years ago JaH’s own dental technician had been replaced with a new person whom she felt did not have the same in depth
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knowledge and experience in treating her particular dental problems. The felt that specialist treatment at the Birmingham Dental Hospital (BDH) was necessary but were unclear would be the most appropriate to service for referral. The panic attacks had continued and JaH was also upset that BDH had no record of her referral. When an appointment was made the treatment needed was clarified to her, and a tooth was successfully taken out by her own technician, who had been honest, supportive and gentle. Subsequent restorative work and fitting of dentures proved less satisfactory and JaH experienced a lot of discomfort and eating difficulties over a number of years. That affected her overall physical and mental health. However, when she approached AL, she was supported at further appointments and was assured that she would be able to progress through treatment, despite several unfortunate experiences. She was supported to request restorative treatment although the senior dentist at her own practice had left her extremely unhappy and upset. She felt he did not understand the knock on effects of the badly fitting dentures and the health impact of not being able to eat properly. Changed financial circumstances had also made the situation more difficult.
JaH was extremely grateful to AL for her support in arranging restorative treatments provided by GB and NA. They had been able over the past eighteen months to review and provide more successful partial dentures which had enabled her to return to a better diet. Although she would continue to have issues she was now able to manage them much better. She also stressed that the supportive attitude of the nursing staff and clinicians to herself and her husband had been vital in gaining her trust and supporting her improvement. Her anxiety issues had been taken into account when arranging appointments. She believed that earlier awareness of mental health issues by the dental clinicians previously treating her would have prevented a lot of her past distress. GB praised his team who had worked to treat JaH so successfully.
MPe thanked JaH for her powerful story which stressed the importance of the patient voice and awareness of impact on the whole body of clinical treatments. TS also contrasted JaH’s experience with that of his colleague who had also been treated at BDH, and queried whether GP and primary care awareness of access to advanced dental treatment was good enough. GB noted that a more proscriptive approach was indicated by NHS England, and also noted the complexity of referral to advanced treatments. He did not believe that psychological aspects of patient needs were prominent in the approach, and also felt that the website outlining dental treatments needed improvement. DSa also referred to earlier discussion of mental health and whole body care. GB believed that the new NHS England approach had been brought about to address previous inconsistencies in available treatments, but he believed there should be greater emphasis on psychological factors. JaH and her family did not feel that currently provision was
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not as good as in the past, and noted the links between physical and mental wellbeing. She stressed the importance of listening to patients and treating them with courtesy and dignity. She believed the problem was a national one ‘think global but act local’. She believed that GB and his team had given her exceptional care and consideration.
TS thanked JaH and the team for presenting the story, and noted the opportunity for Birmingham to influence more widely future good dental practice through the Dental School and BDH. AL, JaH, JoH, GB and NA left the meeting.
BEST CARE: HEALTHY COMMUNITIES 19/009 Fit for 2022 Improvement Programme (Quarter 4, 2018-2019) MG presented key points of the update previously circulated as enclosure 7, with improved visibility and a developing format including the three year operational plan. He noted good progress had been made to date on the ‘Making Good Use of Resource’ work strand. JG queried the delay in delivery of the technology improvements to support staff working in the community, which was reliant on an effective electronic network. He queried in the improvements could be brought forward, and also arrangements to ensure continued staff engagement in light of the delays. AW stressed that delay in delivery was due to third party suppliers and the situation was managed through the Digital Exemplary Group which would report to the Finance and Performance Committee.
RK suggested that additional consideration at Executive level was necessary to progress the situation and to evidence awareness of Executives/ arising issues. He noted that oversight of the workstream was led AW by AW. SH was pleased to note improvements to the report but felt that the potential impact of the IT implementation delay should be better reflected in the Corporate Risk Log, particularly in relation to financial, reputational and clinical aspects. MG agreed that would be useful to improve awareness.
JB noted the small number of remaining areas rated ‘amber’ and ‘red’ where the reason for slippage had not been indicated. However, DH noted the good progress made on the 60 recommendations and stressed the need to support areas of the greatest impact to optimise use of scarce resources. A number of equality and diversity improvements also needed to be put in place. There was discussion of thresholds used to achieve green or black status, and ensuring rigorous assessment. MG stressed the need for balanced reporting since objectives had different weighting. AW outlined the approach taken in light of earlier discussions, but believed that further refinement was possible. Comments would be taken into account in light of the present discussion.
TS stressed the organisational ambition to be as good as possible and the need to be honest and direct in its ability to deliver. The
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presentation and arising actions were duly noted.
Resolved: that the Fit for 2022 Improvement Programme (Quarter 4, 2018-2019) Report be received and noted for assurance
19/010 Fit for 2022 Well Led: Governance Structure MW referred to discussions and a number of board seminars prior to development of the document previously circulated as Enclosure 8. She noted two new sub committees had been developed to provide assurance to Trust Board; the Workforce and Organisational Development Committee and the Mental Health Legislation Committee. Two new executive groups had also been introduced; a Risk Management Executive and a Digital Transformation Executive. Naming conventions had been reviewed and resulted in change of the Quality Safety and Risk Committee to Quality and Safety Committee and the Finance, Performance and Investment Committee to the Finance and Performance Committee. The Board was asked to consider and approve the changes.
SH noted the changes but was not happy with the number of levels between the Board and the patient voice in the proposals. MW confirmed consultation with Clinical Leadership as part of the development of the document, and the prominence given to Divisional oversight. She noted that timing of meeting schedules had been adapted to provide a more effective reporting progression and earlier awareness of issues raised. Reporting documentation had been reviewed and improved, to include development of escalation reports to support the ‘Well Led’ improvement focus. However, SH praised the improvements but still believed that reporting should be streamlined further. IW noted that Divisions were empowered to take decisions by the new arrangements so not all concerns would need to pass through all tiers indicated in the structure.
RK believed the new proposal was a great improvement on the previous arrangements, and noted that other elements could be included at time of need. He noted leadership through Heads of Services, with some decisions being taken at Divisional management level although some decisions would still be taken at Executive and Board level.
SH requested addition of an accountability framework to evidence the decision making process. DSa agreed and noted the difference between meeting and management decisions. AW confirmed the organisational move towards delegated authority. She agreed that the decision making processes need further clarification. TS therefore proposed that the current Governance Structure document be accepted for regulatory purposes but further consideration of the management structure and scheme of
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delegation be carried out. He also proposed circulation of the Scheme Delegation of Authority. JB suggested that an update MW could be brought for review to Trust Board after six months of implementation, and DSi noted that over time it could be possible for a simpler structure be considered. It was agreed that this was a good course of action and the Governance Structure was agreed with the proviso that the comments made were taken into account.
JI suggested that meeting Terms of Reference would be a useful resource for new Board members. SH also indicated the use of Board seminar meetings as ‘sounding boards’, not as a decision making forum although it was noted that apologies had been received from SH at the last two board seminars. DH believed that a more explicit title for the structure would provide improved clarification, bit he was happy to endorse the document and felt it would be very useful across the organisation. Resolved: that the Fit for 2022 Well Led: Governance Structure be approved
19/011 SAFE, HIGH QUALITY CARE Children’s Improvement Group Progress Update AW and MPe outlined key points of the update previously circulated as Enclosure 9. Triangulation of issues was attained through consideration at the Quality and Safety Committee and within safer staffing reports.
The number of visits completed within the reporting period was rising. However, it was not expected that the impact of improved recruiting would be evidenced until September. The successful awarding of the Children in Care contract to BCHC was noted.
MPe stated that there had been a review of consultation on Governance, systems. Leadership and retention issues and Leads are looking to operational teams to embed the new culture and ways of working. SH considered that those actions could address retention issues and queried if they could be implemented more rapidly, perhaps through use of Bank or interim agency staffing. MPe shared the frustration and stressed the good work that had already been done, but noted that robust implementation would take time. One factor which had impacted was the reduction in University training places. She believed that if a more sophisticated approach adopted it could provide benefits. Actions included adjustments to staff hours, and DSi had also reviewed the potential for the Children in Care Team nursing staff to be redeployed to Partnership Plus working to reduce workload demand on Health Visitors. MPe confirmed that that was one possible solution being considered.
The response letter was sent to the CQC five weeks ago. They had requested and received additional information and their final response had now been received. The teams had worked to
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ensure that clinical prioritisation was evidenced. DSa noted the CQC’s focus on ensuring children were not at risk and felt that a more strategic approach should be adopted to workforce, clinical practice and training support. The uniquely youthful Birmingham demographic profile was acknowledged. MPe confirmed that peer discussions had already begun on promoting Birmingham and BCHC as a good place to work. JI applauded the focus on recruitment and was encouraged to hear about development of new roles, but queried retention actions. AW confirmed the details of the retention premium put in place to stabilise the workforce, which had proofed its effectiveness. There was also consideration of a similar scheme for newly qualified staff. DH confirmed that the Workforce Strategy had been developed to be in line with the NHS Improvement recruitment programme.
The impact of the BCC Clean Air Zone charge on staff working in the community was currently a focus, following anxiety about how it would be implemented. AW confirmed that she and IW were considering mitigating actions.
There was discussion of the role of the Council of Governors, as denoted on page 3, which AW reminded the meeting had related to concerns identified by the CQC visit report findings. She believed that the current arrangements demonstrated clear transparency and noted that the Childrens Improvement Group was time limited and would in time be no longer required.
RK noted that the structure had been developed and would be overseen by the Divisions delivering services. He confirmed that four of the five identified issues had been well addressed but the one in relation to workforce in the Health Visiting Teams had been a more difficult challenge. Administration support had been provided, but further actions would be necessary to ensure better workforce retention. Assessment of services to ensure fitness for purpose and supporting effective delivery was under way. He suggested that Trust Board was not responsible for design of Division structures unless a particular concern had been identified requiring such action. The presentation planned to be presented to Trust Board in June would evidence better awareness and the focus on provision of safe and stable services.
MW referred to page 9 ‘must do’ actions 11, 12 and 13 in relation to lone working policies, RTT et al and the need to provide clear evidence that identified issues had been addressed and assurance of implementation obtained. She did not feel that the report demonstrated assurance with respect to the aforementioned ‘must do’ actions. TS was pleased to note the report and the assurances given in relation to how issues had been addressed.
Resolved: that the Childrens Improvement Group Progress Update be received and noted
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19/012 Quality and Safety Committee Escalation Report dated 25th April 2019 and Minutes dated 20th March 2019 DSa wished to draw attention to three key escalation issues: Childrens services issues had already been discussed. Safer staffing report – the incoming Chair had observed the meeting and raised the fact that recent changes to the government focus on workforce were not reflected. Learning Disability and external partnership working. Information previously circulated in Enclosure 10, including the Memorandum of Understanding, were noted. The new group meeting would take place in July to discuss future arrangements.
SH noted that half of reported serious incidents related to pressure ulcers (PUs). MP stated that the increase had to be considered in light of the increasing frailty of the cohort of patients cared for and the number transferring from Acute care having existing PUs. DSa confirmed that it had been noted at the Quality and Safety Committee, and mitigating actions provided assurance.
DSi confirmed that he had met with Mental Health commissioners and discussed the setting up of a meeting to focus on the most recent governmental review of the Mental Health Act 1983.
AW noted that the wrong title had been used in the Escalation Report. JI also believed that the CQC definition of key lines of inquiry (KPIs) should be the focus of the report, which should evidence equitable outcomes.
Resolved: that the Quality and Safety Committee Escalation Report dated 25th April 2019 and Minutes dated 20th March 2019 be received and noted
19/013 A GREAT PLACE TO WORK There were no items for discussion at this meeting.
19/014 INTEGRATED CARE IN COMMUNITIES There were no items for discussion at this meeting.
MAKING GOOD USE OF RESOURCES 19/015 Quality and Performance Report
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The final report of 2018-19 had been circulated prior to the meeting as Enclosure 11. IW referred particularly to the information on page 3 outlining the organisation’s end of year financial position, which was £67,000 ahead of the control total. He noted that the month 12 update often details large technical adjustments. He noted that evaluation of estates had resulted in adjustment of their values. A surplus of £1.8 million was indicated. New auditors were in place and revised processes put into action. All recurrent savings programmes had been delivered and although the agency cap had been exceeded, it was considered to have been a successful year. IW thanked colleagues in ensuring delivery. SH had a technical query concerning impairment which would be more appropriate to address at the next Audit Committee. TS thanked IW and team for providing the finance update report.
MPe presented an update on quality issues, including A positive result for healthcare acquired infections, which was pleasing in light of issues with estate. There was current focus on falls prevention as there had been six reported incidents within the year. Significant improvement had been evidenced. Environmental cleanliness and infection prevention team work had been changed following a joint review with the Estates team.
TS thanked MPe for her report. AW provided an update on Estates issues, and noted that there had been significant improvements in respect of delayed transfer of care. These included two very long stay patients who had now relocated. She thanked MW and the legal team for their assistance in attaining these outcomes. TS was pleased to note progress and thanked AW for the update. DH noted key areas of the report in relation to workforce issues. The presented scorecards highlighted key areas of challenge. Two elements were still rated red but it was pleasing to note that all workforce indicators showed improvement. Sickness absences were still above target, but were improved on the position for the same period in 2017-18. It was disappointing that the target for completed Personal Development Reviews (PDRs) had not been achieved at year end, but all Divisions evidenced improvement. Corporate underperformance was being reviewed: DH acknowledged that there was still some way to go. TS had noted this aspect also but felt that encouraging improvements had been made.
Resolved: that the Quality and Performance Report be received and noted for assurance
19/016 Finance and Performance Committee Escalation Report dated
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23rd April 2019 and Minutes dated 26th March 2019be JB confirmed that she had chaired the April meeting in the absence of JG. It had been pleasing to note the very positive end of year position, and also the organisation’s success in recent contract negotiations. There were no questions from the Board and the presented update was received and noted.
Resolved: that the Finance and Performance Committee Quality and Safety Committee Escalation Report dated 23rd April 2019 and Minutes dated 26th March 2019 be received and noted
CORPORATE GOVERNANCE/REGULATORY COMPLIANCE 19/017 Audit Committee Escalation Report dated 16th April 2019 SH noted that the draft Internal Audit Plan reflected risks, but a review had been requested. The full plan would be reviewed prior to presentation to Board. SG noted the invitation to Governors to participate in the annual accounts ‘Page Turn’ and the request for formal approval of the meeting. He noted that Victor Cracroft would no longer be eligible to carry out the task, but PM had agreed to do so and would be accompanied by another of the Governors.
Resolved that the Audit Committee Escalation Report dated 16th April 2019 be received and noted
ANY OTHER BUSINESS 19/018 None notified.
19/019 QUESTIONS FROM THE PUBLIC ON AGENDA ITEMS PM welcomed his fellow Governor, Tim Murphy to his first Public Board Meeting, and gave a short joint response. HE wished to reiterate thanks to TS for his service to the organisation and felt that it had been more effective under his guidance. He also thanked MW and FW for their support to Governors. He believed that good communication was essential and noted that its lack could be a source of frustration for staff and patients. He also noted that there had been no specific discussion of research issues, in particular around governance structures.
TS thanked PM or the kind comments concerning his past service and his impending stepping down from the role of Chair.
SM had listened with interest to the discussion around governance, and the actions to support effective decision making. She believed that it was imperative to be aware of the right questions to ask at the correct forum, and also knowledge of clinical risks was vital in ensuring appropriate escalation of concerns.
The newly employed clinician, whose name had not been recorded, thanked the meeting for allowing her to observe, and stated that she had been assured by the breadth of discussion which had Page 14 of 15
taken place.
19/020 DATE AND TIME OF NEXT MEETING The next public meeting of the Board of Birmingham Community Healthcare NHS Foundation Trust will take place at 10.00 on the 5th June 2019 in Rooms G05/06 Priestley Wharf.
Signed by Chairman …………………………………………. Date …………
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ITEM 2e ENC 3 PUBLIC TRUST BOARD ACTION SHEET Presented June 2019
The Trust Board is asked to note the progress made with regards to matters arising and to approve the removal of completed items. Minute Agenda item Action Responsible Deadline Update Removal Ref Meeting Date: 24th May 2018 18/108 Quality Quality and Safety DSi Q4 Work in progress, although No (a) Governance & Improvement Plan to be 2018/19 some slippage had occurred Risk Committee presented to the Board and due to change of Medical Reorganisation would include the names of Director, and it was and Renaming sub-Committees. confirmed that the plan would be presented first to the Quality Safety and Risk Committee before coming to a future Trust Board Meeting Date: 29th November 2018 18/110 Chief Executive A new Director of Public MW August Date to be confirmed as part No Report Health for Birmingham, 2019 of the 2019-20 plan for Justin Varney, has now Board Seminar been appointed: he will be invited to attend a future Board Seminar 18/289 Board Assurance MW and SH to consider MW/SH May 2019 On the agenda for the June Yes Framework content of BAF and number 2019 Public Board Meeting of higher level risks reported to Board
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18/291 Learning From Discussion by DSi, DSa and DSi/DSa/MW June 2019 Update to be provided in No Deaths MW of processes to ensure advance of June 2019 Trust Framework awareness of learning Board. opportunities from death reviews Meeting Date: 28th March 2019 18/328 Questions from Governors to share any Governors July 2019 Action to be raised at the No the Public on feedback from the public next Council of Governors agenda items with respect to accessing Committee in June 2019. Children’s Centre Services with Fiona Waide, Governors and Members Manager. Meeting Date: 1st May 2019 Fit for 2022 Weighting of actions , Executives/AW July 2019 Not due. No 19/009 Improvement including review of impact programme of delivery delays in IT update improvements to be considered at Executive level before an update is presented to a future Board meeting Fit for 2022 Well To include information on MW November Not due. No 19/010 Led: Governance delegation of decision 2019 Structure making with the Governance Structure documentation and to provide an update report to Trust Board six months after implementation.
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Public Trust Board
Reference: Agenda Item no: 3a Enclosure no: 4 Date of Meeting: 5th June 2019 Document Title: Chair’s Report – June 2019 Responsible Director: Jerry Gould, Vice Chair Author: Jerry Gould, Vice Chair
Non-Confidential/ Non-confidential Confidential
Trust Issues and Updates Appointment of New Chair Our new Chair, Dr Barry Henley has started his induction programme. Barry officially commences his appointment with the Trust on 1st June 2019, however he has a pre- arranged holiday in early June. As such, Barry’s first Board Meeting will be on 5th July 2019.
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Public Trust Board
Reference: Agenda Item no: 3b Enclosure no: 5 Date of Meeting: 5th June 2019 Document Title: Chief Executive’s Report – May 2019 Responsible Director: Richard Kirby, Chief Executive Author: Richard Kirby, Chief Executive
Non-Confidential/ Non-confidential Confidential
Purpose of the This report provides an overview and update for the Trust Board on key Paper & Key issues facing the Trust as at May 2019. Points I am pleased formally to welcome Chris Holt and Suzanne Cleary to the Trust Board and would also like to thank Angie Wallace and Micky Griffith for their contribution to the Board in their interim roles.
We continue to develop the enabling strategies to support our “Best Care: Healthy Communities” vision. This Board meeting will consider our Workforce Strategy which sits alongside our wider drive to ensure we become a Great Place to Work.
I would like to thank everyone involved for an inspiring and engaging Leadership Conference on 22nd May. The two key messages were: the need for a change of gear for 2019/20 as we set out to deliver our vision and the importance of healthy, engaging and inclusive leadership to ensuring that we do so successfully.
We continue to be part of the work within the Birmingham & Solihull STP to develop plans for an Integrated Care System and within the Black Country & West Birmingham STP to explore a “care alliance” proposal for the Sandwell & West Birmingham locality.
Nationally, two recent reports and the BBC Panorama programme have exposed continued poor care for people with a learning disability. Our LD division is working with partners to review the care provided to Birmingham residents with a learning disability in institutional care.
Action The Board is recommended to: required by the Board NOTE the Chief Executive’s report for May 2019.
Prior None. discussion
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Safe, High A Great Integrated Making Good Corporate Quality Place to Care in Use of Governance Implications: Care Work Communities Resources Impact on: X X X X X Risk No new risks No new risks No new risks No new risks No new risks
Acronyms BCHC Birmingham Community Healthcare NHS Foundation Trust CCG Clinical Commissioning Group CQC Care Quality Commission EU European Union ICS Integrated Care System LiA Listening into Action NHSE / NHSI NHS England / NHS Improvement PCN Primary Care Network STP Sustainability & Transformation Partnership SWB Sandwell & West Birmingham UHB University Hospitals Birmingham NHS Foundation Trust
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CHIEF EXECUTIVE’S REPORT – MAY 2019
1. Introduction This report provides an overview for the Trust Board on key issues facing the Trust as at May 2019 and is organised into three sections: Trust Issues; Sustainability & Transformation Partnership (STP) / Regional Issues and National Issues.
2. Best Care: Healthy Communities Vision and Values As usual, right at the start of the report, I would like to include the summary of our vision and values as a reminder of what we have said matters most and how we want to work together.
Having spent much of 2018/19 engaging with colleagues across the Trust to develop the vision and values, our plan for 2019/20 sets out a clear change of gear as we take the steps to enable us to bring this vision to life and deliver improvements for colleagues, patients and service users.
We have continued to develop the enabling strategies that will support delivery. Having approved the Digital and Estates strategies at recent board meetings, our agenda for today includes our Workforce Strategy – setting out our approach to ensuring that we have the right numbers of staff with the right skills for the future. This strategy sits alongside our Great Place to Work ambition in the Fit for 2022 Improvement Programme.
We have also continued to develop our more detailed 3 year operational plan and Long Term Financial Model led by Ian Woodall and Micky Griffith. The process and timetable for this piece of work will be shared with our Management Board meeting in May for approval.
Finally, we have continued to work through Board workshops on the major risks to successful delivery of the Fit for 2022 programme and the mitigations we can put in place. The outcome Page 3 of 6 of this work is captured in the revised Board Assurance framework that we considered at our last board seminar.
3. Trust Issues
3.1 Executive Team Recruitment I am pleased formally to welcome Chris Holt as Chief Operating Officer and Suzanne Cleary as Director of Strategy & Partnerships to the Trust and to their first board meeting. I am very grateful to Angie Wallace and Micky Griffith for covering these posts on an interim basis so ably and trust the board as a whole will join me in thanking them for their contribution.
3.2 Annual Report, Quality Report and Annual Accounts Since our routine May board meeting, we have met to approve the Annual Report, Quality Report and Annual Accounts. I am very grateful to Ian Woodall, Marcia Perry, Michelle Woodward and their teams for their contribution to this and for producing a set of documents that provide a clear account of the progress that we have made in the last 12 months as well as an open assessment of their areas in which we are committed to improve further in the year ahead.
3.3 Leadership Conference 2019 We held on our 2019 Leadership Conference on 22nd May. I am very grateful to David Holmes, Becky Crowther and their teams for organising such an engaging and inspiring event for c. 150 of our senior clinical and operational leaders. Our 2018 conference focussed on the launch of our “Best Care: Healthy Communities” vision and values; this year we concentrated on the leadership behaviours that will support us to deliver successfully for patients, service users and colleagues. For me, there were two key themes from the conference: firstly that 2019/20 will see a change of gear as we begin to deliver the commitments we have made through our vision and secondly that healthy, engaging and inclusive will be key to our success.
3.4 Our Listening into Action Journey At the Leadership Conference, Sunny Kalsy launched our Listening into Action (LiA) Year 2 journey including the 2019 Pulse Check which will “go live” from 3rd June. Over 3 weeks we are seeking to reinforce our commitment to listening to our colleagues by generating an increased response to the Pulse Check from our – already high – 2018 levels. As last year, the ideas for improvement generated by our colleagues will then form the basis of a “simple changes” campaign through the summer.
4. City, Regional and STP Issues
4.1 Integrated Care System Development The Birmingham & Solihull Sustainability & Transformation Partnership (STP) has submitted an application to be part of the NHS England / NHS Improvement (NHSE/I), Integrated Care System (ICS) development programme. We are also holding an STP Board Away Day on 5th June to develop these plans further and for that reason I am afraid that I will send my apologies to the Trust Board meeting.
Within the Black Country & West Birmingham STP, we continue to be part of the discussions about a proposed “care alliance” for the Sandwell & West Birmingham locality to bring together commissioners and providers to deliver better results for patients and service users. We will share more information about this with the board as the discussions develop.
The Sandwell & West Birmingham (SWB) CCG consultation on their future configuration has now closed and the responses from stakeholders will inform the decision to be taken by the Page 4 of 6
SWB GPs. From BCHC’s perspective it remains important that the future arrangements for the CCG support a consistent and coherent service model across the whole of Birmingham.
4.2 Primary Care Networks The Primary Care Network (PCN) configuration for Birmingham & Solihull CCG and Sandwell & West Birmingham CCG has now been confirmed including the GPs who will lead the CCGs as clinical directors. Our initial assessment is that the majority of the PCNs will fit relatively with our neighbourhood team approach and we will now work through the detail of the next steps of reconfiguration with our Adult Communities division. As importantly, following our board seminar discussion led by Micky Griffith, we will develop our thinking on how BCHC can support the PCNs to succeed and in particular how we can support them in the seven national priorities for delivery by PCNs.
4.3 STP Digital Strategy Work continues to develop a coherent digital strategy for the Birmingham & Solihull STP that will support the delivery of improved, integrated care. As part of this work we are assessing whether there are areas in which we should strengthen collaboration on digital development with University Hospitals Birmingham NHS FT (UHB) in order to accelerate the changes we want to make at BCHC. Separately, as I write this report, UHB have also announced an intention to develop a strategic collaboration with Babylon / GP at Hand to reduce demand for A&E and we will work closely with partners to ensure that we are able to continue to support our existing long-term conditions specialist community services for people with diabetes, chronic kidney disease and respiratory conditions.
5. National Issues
5.1 National Mandate for NHS England / NHS Improvement Since our last board meeting the Department for Health & Social Care (DHSC) has published the annual mandate for NHSE combined with priorities for NHSI. The mandate seeks to reinforce the bringing together of NHSE and NHSI. It recognises that 2019/20 is a year of transition for the NHS and sets two priorities: ensuring the NHS is prepared for EU Exit and beginning to deliver the NHS Long Term Plan including through a series of locally-developed STP-level plans to be produced during the summer and autumn.
5.2 Services for People with a Learning Disability Two national reports (one from the Mortality Review for people with a Learning Disability and one from the Care Quality Commission (CQC)) and the shocking BBC Panorama programme have highlighted – again – the need to ensure that some of the most vulnerable people in our society are cared for with compassion, dignity and respect. In the light of the Panorama revelations in particular, our Learning Disabilities division and Marcia Perry are confirming that our services are doing all they can to ensure that Birmingham residents who are in institutional care are being well cared for and supported to live in the community. I am sure that Quality & Safety Committee will want to review the outputs of this work.
5.3 Interim NHS People Plan As I write we are awaiting the imminent publication of the Interim NHS People Plan to develop further the thinking set out in the NHS Long Term Plan about our workforce. The new NHS Chief People Officer, Prerrana Issar, has taken up post and is signalling a clear commitment to ensure that the NHS becomes a great place to work for all its staff. This part of the developing national agenda, clearly reinforces the importance of the work that we have already begun in BCHC to deliver on our commitment to make our own trust a Great Place to Work.
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6. Conclusion & Recommendations This report has presented an overview for the board of trust, STP / regional and national developments as at May 2019. The Board is recommended to:
1. NOTE the Chief Executive’s report for May 2019.
Richard Kirby Chief Executive 24th May 2019
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Public Trust Board
Reference: Agenda Item no: 4a Enclosure no: 6 Date of Meeting: 5th June 2019 Document Title: Fit for 2022 Workforce Strategy Responsible Director: David Holmes, Director of Workforce and OD Author: David Holmes, Director of Workforce and OD
Executive The Fit for 2022 Workforce Strategy sets out the current plans at Divisional Summary / and Trustwide level to meet service needs and changes for 2022. The Purpose of the document includes a series of workforce templates summarising at high level Paper & Key the current workforce profile, challenges and planned changes. Points The Workforce Strategy sits alongside the Great Place to Work strategic objective which focuses on health and wellbeing, engagement, leadership, training and development and equality and diversity.
The Great Place to Work workstream is concerned with the experience of our colleagues working in the organization, the hearts and minds and pulse of the organisation. Whereas the Workforce Strategy document describes the ‘shape and size’ of the desired workforce and how that might be achieved.
The planning element of the strategy shows a 2.7% increase in staffing, largely based upon commissioning outturn in 2019/20 and community services growth.
The conclusions within the document are summarised as:
Outside of year 1, the workforce plan shows little growth and makes few assumptions about significant service change and new models of care.
It is anticipated that during the course of the planning period the existing challenges around workforce supply will continue.
Workforce plans are high level and have been developed within senior teams and there is more work to do to embed workforce planning in the organisation.
Whilst there are various references to plans regarding the Nursing Associate role and Apprenticeships at Divisional level it is evident that there is no Trustwide strategy for the development of new clinical roles or Apprenticeship expansion.
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The document identifies 5 Strategic Objectives:
Workforce Planning: Workforce planning is embedded throughout the organisation in order that each service area is proactively forecasting the demand and supply for the workforce and putting plans in place to address any gaps.
Workforce Development: Workforce is developed to meet service and financial needs through introduction of new roles and workforce models, maximising capability and capacity of existing people.
Workforce Deployment: Capacity and capability of the workforce is maximised by effective and efficient workforce deployment systems.
Workforce Collaboration: BCHC is an active and lead partner in system wide workforce planning and development to support STP plans.
Workforce Attraction and Retention: BCHC is able to attract, recruit and retain workforce with right skills and the right numbers to meet service needs.
The specific high level actions are identified within the document. Clearly a more detailed implementation plan will need to be delivered.
The Workforce Strategy is written prior to the launch of the imminent National Workforce Implementation Plan and amendments may need to be reflected in the Trusts detailed actions.
It is intended that the workforce plans identified within the strategy provide a basis for the three year LTFM planning work to be undertaken and the resource requirements are built into these financial plans.
Action The Board is recommended to: required by the Committee APPROVE the Fit for 2022 Workforce Strategy
Prior Management Board: 28th May 2019 discussion Workforce and Organisational Development Committee: 23rd May 2019
Safe, A Great Integrated Care Making Good Corporate High Place to in Communities Use of Governance Quality Work Resources Implications: Care Impact on: X X X X Risks:
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Fit for 2022 Workforce Strategy
1. Introduction It is recognised that one of the most significant challenges to the delivery of the Trusts vision and strategic objectives is ensuring the supply of the right number of staff with the right skills in the right place at the right time. This objective is set within the context of high levels of vacancies, turnover and staff absence across the health and social care workforce.
Of the 2018/19 Board Assurance Framework risks 4 are those related to the current and future supply and engagement of the Trust workforce. At a more operational level, 26% of the Corporate Risk Register risks (+15) (as at April 2019) fall within the Great Place to Work strategic objective.
It is for this reason that under the Fit for 2022 Making Good use of Resources strategic objective there is a commitment to develop a high level workforce plan for 2022 identifying workforce demand based on service and activity forecasts. Such a plan will support the delivery of safe, high quality care.
To achieve this objective the Workforce Strategy describes the following, both at Divisional and Trustwide level:
Current workforce profile Current workforce challenges Future changes in service and associated workforce changes Future demand for the workforce expressed as a projected ‘shape and size’ Future anticipation of supply of workforce Identified ‘actions’ to respond to the workforce gap in demand and supply
2. Scope The workforce plan element of the strategy includes all staff groups within the Trust and covers the planning period from April 2019 to March 2022.
3. Great Place to Work Whilst this Workforce Strategy describes the ‘shape and size’ of the organisation for 2022, the ‘Great Place to Work’ programme focusses on how it would ‘feel’ to work in
1 | P a g e the organisation. It identifies the worksteams required to fulfil the ambition that the Trust will be experienced by all colleagues to be a Great Place to Work.
The high level deliverables are summarised as follows:
Support colleagues to be at work, make healthy choices, remain resilient in a demanding work environment through the implementation of our Health and Wellbeing Plan. Create a leadership style that is empowered, engaging and open delivered through leadership development across the organisation. Embed clinical leadership that delivers quality improvement through high performing teams. Create opportunities for colleagues to grow and develop their careers with us through the delivery of our Succession Planning and Talent Management Strategy. Ensure that the BCHC approach to improvement is based on the principle of colleague engagement, using the Listening into Action methodology. Embed an inclusive culture reflecting on our communities where colleagues feel that diversity is valued and there is equal opportunity to grow and progress. Develop a working environment that nurtures, educates and trains. All colleagues feel that they are listened to and can raise their concerns. Maximise the impact of our initiatives through partnership working across the STP.
4. NHS long Term Plan Chapter 4 of the NHS Long Term Plan “NHS Staff will get the backing they need” recognises the unsustainability of current job vacancy levels in health and social care and the subsequent strain placed on staff.
This section of the Long Term Plan articulates a vision for the workforce of more staff, who are better supported and developed, working in new roles which meet the needs of patients and highly quality services. To achieve the plan it is recognised that the NHS will need more staff, working in rewarding jobs and in a more supportive culture, with opportunities to develop. This supporting environment will be underpinned by compassionate and diverse leadership at all levels.
The plan includes a number of specific commitments to expand the national supply of nurses:
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Reduce Nursing vacancies to 5% by 2028
Increase Nursing Undergraduate places by 25%
Increase Nurse clinical placements by 5000 from 2019/20
Introduce 21,000 new Mental Health Nursing posts
Introduce 7500 new Nursing Associates started in 2019 - 50% increase from 2018
To deliver the plan targets a number of actions are identified:
To introduce a 5 year Job Guarantee within the region a Nursing Graduate qualifies
To widen access to the Nursing degree through ‘Earn and Learn’ programmes within Learning Disabilities and Mental Health
To expand Nursing Apprenticeship programmes
To review the use of the Apprenticeship Levy and promote Apprenticeships for all entry jobs
To enhance the opportunity for International recruitment
Another commitment within the plan is to grow the Medical workforce, which will be achieved by expanding the number of Medical school places and widening access through increase in part-time and accelerated degrees. The plan describes the commitment to achieve a better balance between generalist and specialist skills, to continue the GP expansion programme and to enable medical staff to switch specialities without restarting training.
The NHS Long Term Plan also recognises the need to improve the working lives of Doctors to improve recruitment and retention.
Key elements of the NHS plan resonate with the Trusts own Great Place to Work strategic objective, these are seen in the commitment to the following:
Maximising the opportunities for career and personal development Supporting staff Health and Wellbeing Tackle Bullying and Harassment Promoting a culture of Equality and Diversity Ensuring staff are engaged
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Providing opportunities to develop and grow through effective leadership and talent management Ensuring productive workforce deployment and efficiency
There is a commitment to increasing the workforce development investment following the Comprehensive Spending Review. A National Workforce Implementation Plan (WIP) is due to be published in 2019/20 to translate the vision, plan and objectives into action. NHS England / Improvement have appointed Prerana Issar as Chief People Officer to play a leading role in ensuring that the NHS in England has enough people with the right skills and experience to deliver the ambition of the long term plan. It is understood that the Workforce Implementation Plan will identify 5 key priority areas
1. Making the NHS the Best Place to Work 2. Leadership Culture 3. Addressing Urgent Shortages in Nursing 4. Building a 21st Century Workforce 5. A New Operating Model
5. Local Context This Workforce Strategy Plan does not attempt to duplicate the wealth of data and analysis to describe the national workforce challenges and trends. Levels of vacancies, retention and staff absence and the associated workforce supply gap are well articulated in previously published national documents for example ‘Facing the Facts, Shaping the Future’ (Draft Health and Core Workforce Strategy for 2027).
In response to the NHS education reforms and the changing role of HEE, under the BSol Local Workforce Action Board, a Provider-led Education Reform Group was established to increase recruitment and retention of undergraduate clinical programmes, improve education and placement quality and secure increased recruitment into the BSol health care workforce.
The Group focuses on the following actions:
Utilise workforce intelligence to understand workforce supply and to annually agree new student numbers
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Work with the BSol STP HRD group and Apprenticeship Federation to co- design branding materials to attract students onto non-medical programmes, recruit students on qualification and retain newly qualified staff
Inform the LWAB of any identified workforce supply risks and mitigations/ solutions implemented to address these, to include reduction in vacancies and improve student output. Respond to National/ STP workforce policy priorities to identify the future service need and new curricula developments required
Protect student placements from being destabilised by other national/ local workforce initiatives and work to increase capacity through reviewing and implementing best practice models of supervision
Understand student data, develop benchmarks and utilise quality indicators to improve student experience and increase placement capacity
Support for the building of workforce capability in primary and community care
Increase supervisory/ mentorship capability to support new roles, growing apprenticeships and additional pre-registration placements
Improve the quality of the learning environment across clinical placements in all settings in line with existing quality frameworks in particular the 2018 Nursing and Midwifery Education Standards
Improve student experience and respond to generational differences in career expectations
As part of the ERG work, a detailed workforce analysis was undertaken in 2018. The data collection was undertaken during 2018/19 and was supplied by all Birmingham and Solihull health providers and the Higher Education Institutes.
In this first exercise the workforce data did not include information from primary care, social care or private, independent and voluntary organisations.
A summary of the findings of the Birmingham and Solihull Education Reform Group Data Analysis Review are provided below.
Fall in applications to Nursing degrees (All HEI) Reduction in entrants to all health degrees except SLT and Physiotherapy Demographic changes in student numbers (reduction in students over 21, reduction in
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BME except in Nursing) Degree completion on time only 42% for Adult Nursing and overall 70% Insufficient placement capacity in Primary Care Insufficient placements in Learning Disabilities and Mental Health Between 70-80% of degree completers enter the Birmingham and Solihull workforce Majority of Adult Nursing leavers are within the 25-34 age group Majority of District Nursing / Health Visitors/ School Nursing are within the 55-64 age group
It is clear that many challenges exist locally in increasing the supply line for clinical staff. There is a need to work collaboratively with health and social care providers and Higher Education Institutions to significantly improve recruitment to clinical programmes, and to ensure that those educational programmes meet current and future service needs.
A key aspect of retention to programmes and the entry to the BSol workforce is the clinical placement experience and quality.
6. Workforce Plan Methodology As part of the Fit for 2022 Programme, service strategies were developed for each Clinical Division and it was anticipated that these would provide the basis for any subsequent workforce plans.
The objective within the Making Good use of Resources Workstream was therefore to develop a ‘Workforce Plan on a Page’ for each Clinical Division based on the individual service strategies. Those individual plans would be integrated into one Trustwide Plan on a Page.
These template plans were not designed to articulate the broader, cultural and people strategies included in the scope of the Great Place to Work objective but rather to describe the future size and shape of the workforce.
A workforce plan template was developed to capture the following at Divisional level:
Analysis of the current workforce profile identifying key characteristics and trends against a range of workforce
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indicators i.e. Turnover, Vacancies Age Profile Summary of current workforce challenges and risks Summary of planned workforce changes – these would be expressed as high level change percentages by staff groups Key high level actions to ensure that the workforce supply meets the workforce demand
7. Divisional Workforce Plan on a Page The individual workforce planning templates are provided in section 7 below for the following Clinical Divisions:
Adult and Specialist Rehabilitation Services Adult Community Services Children and Families Division Learning Disabilities Dental
At this stage it is assumed that there is no growth within the Corporate Division workforce and the only changes reflect the impact of cost improvement plans.
The individual workforce plans are collated into one Trustwide workforce plan template which is provided in section 8.
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Workforce Plan – Adults & Specialist Rehabilitation March 2019 AVERAGE FTE Staff in Post Staff Group 1,000.00 Row Labels FTE Headcount Future Workforce Demand (as at 2022)
990.00 Add Prof Scientific and Technic 29.09 34 % 980.00 Additional Clinical Services 293.69 329 Staff Group change Administrative and Clerical 155.35 178 970.00 Additional Clinical Services +10% Allied Health Professionals 259.41 300 Administrative and Clerical 0% 960.00 Estates and Ancillary 3.93 5 Allied Health Professionals +10% 950.00 Healthcare Scientists 4.99 6 Medical and Dental -50% 940.00 Medical and Dental 18.35 22 Nursing and Midwifery Registered -5% 930.00 Nursing and Midwifery Registered 223.36 243 920.00 Grand Total 988.17 1117
910.00
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Staff Movements (FTE) Staff Group by Band Main Changes Add Prof Scientific Medical & Dental 25.00 and Technic Further integration of the old UCS and Rehab services to form Bd 8b+ Additional Clinical the Adult and Specialist Rehabilitation Division Bd 8 Services 20.00 Administrative and Bd 7 Regional review of stroke services Clerical 15.00 Bd 6 Allied Health Bd 5 Professionals System review of the care of the Older Adult resulting in a new 10.00 Bd 4 Estates and Ancillary care model, including the transition to localities
Bd 3 Healthcare Scientists 5.00 Tendering of the primary care service within HMP Birmingham Bd 2 in 2022 Bd 1 Medical and Dental 0.00 local Nursing and Midwifery Registered
-5.00 0 50 100 150 200 250
2017 / 04 2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 -10.00 Starters FTE Leavers FTE -15.00
Age Distribution Main Challenges Vacancies (FTE) Data from when Rehab merged with Urgent Care 180.0 Lack of currently available details around new care models, thus 160.0 affecting the Divisions ability to plan the workforce to deliver 140.0 120.0 In-patient services have a large cohort of staff eligible to retire in 100.0 the next 5 years. The Nurse Associate role is new and not yet 80.0 embedded to aid the succession planning to some of the Band 5 60.0 nurse roles. This will increase over the next 2 years but the 40.0 numbers are currently low for NA’s. 20.0 0.0 On going challenges with a range of qualified staff, including some niche roles which are nationally difficult to recruit, 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65+
25.7 % of staff are above 55 years old Sustainability of current medical workforce model and its strategic fit with the new intermediate care model
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1150 Development of new roles (eg ANP, ACP) vs current delivery and investment costs for role development, and following 1100 development retention of the developed practitioner
1050 Identifying affordable posts to be converted for apprenticeships. Age Distribution by Staff Group New frameworks still being released e.g. OT, Physio (Jan 19) 1000
Add Prof Additional Rehabilitation Engineers still a national shortage. Scientific Clinical Admin and Medical and Nursing and Grand 950 Age and Technic Services Clerical AHPs Estates Dental Midwifery Total Lack of knowledge of the organisation and Divisions brand, role 900 10-20 20-30 0.0% 1.7% 1.2% 2.6% 0.7% 2.9% 9.1% and USP. 30-40 1.5% 1.5% 1.7% 3.6% 1.3% 5.5% 15.1% 850 40-50 3.4% 5.7% 1.4% 2.7% 1.2% 11.8% 26.2% 50-60 0.6% 14.9% 3.3% 4.0% 1.8% 14.9% 39.5% 60-70 0.0% 4.2% 3.8% 0.0% 0.0% 1.8% 9.7% 70+ 0.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% FTE in Post FTE Vacancy Total 5.8% 28.0% 11.4% 12.9% 5.0% 36.9% 100.0%
Leaving Reason BME Key Actions Redundanc Dismissal End of Death in y 7% Fixed Term On-going recruitment efforts Service 7% Contract 3% 4% Further support and development of the Nurse Associate role to reduce the impact of the reduction in Band 5 nursing posts.
Develop a plan to increase the apprenticeships offered across Retirement the Division. Voluntary 28% Resignation Development of non-medical practitioner roles within West Heath and the Intermediate Care Units 51%
Engagement with the STP and Urgent Care system in relation to the Older Adults development work
Development of the Divisional ‘brand’ and USP
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Adult Community Services Workforce Plan Average FTE Staff in Post Staff Group in Post Future Workforce Demand (as at 2022) Row Labels FTE Headcount % Change Increase in 1,000.00 Add Prof Scientific and Technic 0.48 1 Staff Group establishment 950.00 Additional Clinical Services 206.42 233 Administrative and Clerical 100.05 110 Add Prof Scientific and Technic 0% 900.00 Allied Health Professionals 51.21 59 Additional Clinical Services 14% 850.00 Medical and Dental 2.20 3 Administrative & Clerical 13% 800.00 Nursing and Midwifery Registered 486.21 553 Allied Health Professionals 26% Grand Total 846.56 959 750.00 Medical & Dental 0% Nursing and Midwifery Regsitered 22%
The forecast workforce changes shown in the table above relate
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 to the following: 14% clinical services – assuming a net increase in IMTs, The graph above shows the workforce numbers reduced between Rapid Response, Diabetes and Respiratory December 2017 and November 2018. 13% admin and clerical – assuming a net increase in IMTs, The main reasons for the movement are due to the following: Rapid Response, Diabetes and Respiratory o Complex Care service disinvestment - c(120) wte 26% AHPs – assuming a net increase in Therapy hub, o Lymphedema service development – recruitment to posts Respiratory and Diabetes services. o District Nursing recruitment drive following funding from 22% registered nursing – assuming a net increase in IMTs, commissioners for IMT’s. Rapid Response, ANPs, Nursing Associates, Respiratory and Diabetes services.
Staff Movements (FTE) Main Changes Age Distribution of Staff in Post by Headcount The forecast workforce anticipated for 2022 assumes the 20.00 following: 15.00 200 Move to locality model with integrated neighbourhood teams 180 10.00 Relocation of services to Specialist Hubs, as well as in 160 line with Locality and Neighbourhood model 5.00 140 Review of non-contractual services within the Division 0.00 Continuation with current & implementation of new 120 services transformation projects (e.g. Integration of IMTS -5.00
100 & CCMs, Therapy Hubs, Rapid Response & Continence)
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 -10.00 2017 / 04 80 Anticipated growth within Respiratory and Diabetes services -15.00 60 Increase in AHP’s expected due to Early Intervention Starters FTE Leavers FTE home based therapy 40 Increase in Nursing registered staff due to growth for 20 The graph above shows the trend of starters and leavers for the period of IMTs, ANPs and Rapid Response. January 2018 to December 2018. The main reasons are explained above 0 No identified growth in Medical & Dental, however <=20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 >=71 potential of sub-contracting from Acute for Specialist and relate to Complex Care, Lymphedema and District Nursing. Years Years In addition, during this period District Nursing also saw an increase in Services Medical staff (e.g. Diabetic Consultants) leavers due to early retirement, promotion and overperformance pressures Incorporates a level of turnover, which is assumed to within the service. The chart above shows that ACS has an ageing workforce reduce to recruitment plans and of the 947 workforce, 362 are over the age of 50. Following further clarification of service models/delivery a skill mix may be required to incorporate both registered & non-registered professionals Increase in nurse associate and apprenticeship roles
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Vacancies (FTE) BME 1200
1000
800
600
400
200
0
Vacancies shown in the graph above mainly relate to district nursing due to additional income receivedFTE in Post for overperformanceFTE Vacancy . There has
also been a small amount of vacancies that were held due to the transformation of services pending a skill-mix review.
Dismissal - Capability Key Actions Leaving Reason by FTE Engagement Employee Transfer Ensure staff engagement right from planning stages so service transformation is clinical led & inclusive of all staff Implement an approach to engagement and improvement based on the LIA methodology. End of Fixed Term Contract 2.39 1.40 Retention 2.00 Retirement - Ill Health 1.00 Divisional Retention assessment and action plan drawn up and implemented 2.80 3.44 4.00 Retirement Age Recruitment Voluntary Early Retirement - no Continuation with recruitment campaign & scoping other recruitment initiatives Actuarial Reduction Recruitment to the Nurse Associate role and embedding the role across the Teams 22.53 Voluntary Early Retirement - with Actuarial Reduction Education and Training Voluntary Resignation - Adult 25.26 Dependants Continuation with Big Top events to maximise mandatory training availability & attendance Voluntary Resignation - Health Develop a working environment that nurtures, educates and trains
Voluntary Resignation - Lack of Deployment 8.60 Opportunities Implementation of Community Nursing Pilot – introduction of 8am – 8pm working Voluntary Resignation - Other/Not Known New Models 1.00 14.57 Voluntary Resignation - Promotion Total Mobile – Implementation of total mobile and other technology to support community working 1.80 1.00 Voluntary Resignation - Relocation Implementation of the locality model with integrated neighbourhood teams Implement Early Intervention through home based Therapy Voluntary Resignation - Work Life Balance Leadership Create a leadership style that is empowered, engaging and open delivered through leadership development across the organisation Embed clinical leadership that delivers quality improvement through high performing teams
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Workforce Plan – Children’s & Families Service March 2019 AVERAGE FTE Staff in Post Staff Group 1,100.00 Future Workforce Demand (as at 2022) Row Labels FTE Headcount 1,050.00 Staff Group FTE +/- Add Prof Scientific and Technic 2.80 4 Additional Clinical Services 1 1,000.00 Additional Clinical Services 215.08 272 Administrative and Clerical 7 950.00 Administrative and Clerical 168.78 211 See appendices
900.00 Allied Health Professionals 92.06 113
Medical and Dental 36.58 42 850.00 Allied Health Professionals See appendices Nursing and Midwifery Registered 406.38 491 Medical and Dental 4.4 800.00 Grand Total 921.68 1133 Nursing and Midwifery Registered 55
New Roles 6
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04
Staff Movements (FTE) Staff Group by Service Main Changes (Narrative)
Student leavers comprise the majority of leavers in March 18 and March 820 Universal Response to RTT and waiting times has resulted in 19 Services 5 to 19 development of business cases across CDCs and (Childrens SN) increased staffing requirements 30.00 820 Universal Requiring increase in Medical, and therapy staffing New faster access roles for experienced dysphagia 20.00 Services 0 to 5 (Childrens HV) speech and language therapist 10.00 Need for Psychologists to reduce waits for ADOS and 0.00 820 Children's related assessments for school aged children -10.00 2017 2017 2017 2017 2017 2018 2018 2018 2018 2018 2018 2019 Specialist Services Rio data cleansing and management of long term waits / 04 / 06 / 08 / 10 / 12 / 02 / 04 / 06 / 08 / 10 / 12 / 02 -20.00 Starters increasing requirements for CHIS/CBS -30.00 Leavers 0.00 200.00 400.00 600.00 Need for Improved Clinic utilisation and improved booking Additional Clinical Services processes to increase efficiency and reduce waits in -40.00 Health Visiting and planned appointments/RTT requires -50.00 Administrative and Clerical increased capacity in CBS -60.00 Allied Health Professionals Governance of Paediatric Sexual Assault Service requiring -70.00 increased management oversight and forensic and FGM Medical and Dental experienced paediatricians -80.00 Nursing and Midwifery Registered Need for increased HCA roles aligned to apprenticeship schemes for PSAS support and within school health Vacancies (FTE) service for enuresis Age Distribution ASD/ADHD pathway requires increased therapy/psychology led posts Children in care caseloads and response to statutory assessment timeframes requires increased medical and nursing re design Increasing complexity of physio cases requiring new investment BCHC + ambition for extended offer Numbers of nursing staff particularly in Health Visiting reaching retirement age requires revised skill mix through use of band 5 staff nurses on a 2 year training programme which develops them as HVs decrease admin Band 2’s and decrease current overspend of Bank and Agency and recruit to medical secretarial roles to meet the challenge of letters backlog due to increased referrals and specific roles to support 12 | P a g e
1200 CIC/Adoption and SEND statutory requirements. 18.6% of staff are above 55 years old 1000
800
600
400
200
0
In post Vacancy
Leaving Reason Main Challenges (Narrative) Key Actions (Narrative) Dismissal - Inadequate rating by the CQC and outcome of local area Capability, 1, 1% SEND review has damaged the reputation of BCHC children’s Retention community services BCHC to participate in the NHSI retention scheme Reduced applicants for pre-registration degree programmes for including flexible working, more flexible retirement, Nursing and Allied Health CPD, mid-career flexibility and training for line Voluntary managers in fostering a positive culture Resignation - Employee Increased use of fixed term contracts due to protracted Other/Not Transfer, 16, commissioning decision making Culture Known, 22, 27% 20% Waiting List Initiatives and Locum staff needed to mitigate Respond to finding of the EDHR external review and capacity and demand gaps within funded commission work with colleagues to develop more inclusive ways End of Fixed Constrained and further reducing public health funding of working Term Contract, Health and Wellbeing Voluntary available to Local Authorities 14, 17% Resignation, Demographic changes ref recently published Joint Strategic Embed team-level implementation of the new Trust 10, 12% Needs Assessment with increasing child health population in Sickness Absence Policy from launch in 2019, in Birmingham, increasing demand on services order to reduce sickness absence levels within the Retirement division Age, 11, 14% Increasing use of lead provider model with multiple sub- Redundancy - contractors e.g. Birmingham Forward Steps; Paediatric Sexual Recruitment Voluntary Early Compulsory, 2, Assault Service; Child Health Information Service Aim to reduce the size of Health Visitors caseloads Retirement, 5, 3% with a more equitable spread of workload to support 6% Regulatory requirements re workforce e.g. nurse to child ratio retention of current workforce, with on-going for children in care and average caseloads per health visitor recruitment and retention campaigns System-wide approach to planning and delivery of integrated Defined career pathways through division structures maternity, children and adolescent services requires to support our own workforce longer term. infrastructure to drive change Enhanced focus on building relationships with local
Delivery of CRES/merging budgets/decreasing budgets in the Universities to assist the division harness its future BME context of a continuous cycle of service improvement workforce. Working within National Agency Staffing restrictions Map out recruitment plans due to 18.6% of the Relocation and redeployment of staff to align with service workforce can retire at 55 years old. changes and the Estates Strategy Education and Learning Availability of temporary staff with suitable qualifications on the Develop coaching and mentoring within the division to Trust bank, in part due to competition with other local NHS support succession planning Specialised training for community paediatric Trusts Need to respond to the introduction of apprenticeships and the registrars including training in sexual assault creation of a training budget from the levy. management and palliative care Workforce Development Increased use of 6 or 7 day working e.g. transition plans and access to Birmingham Forward Steps Develop new roles to meet the shortfall in recruitment 13 | P a g e
Reduction of available pool of suitably qualified band 6 Health of qualified pre-registrant Nurses and Allied Health Visitors professionals, providing a career pathway for the Recruiting suitable School Nurses with the required SCPHN future qualification Develop a strategy to utilise apprenticeships further Balance between centralised (e.g. Central Booking Service) across the division and place-based administrative support functions (within Mobilisation of commissioned pathways, e.g. Districts) inclusion, HV, ADHD, integrated with primary, acute, Promoting Children and Families service as the place to work mental health and social care Time to train staff with the necessary specialist nursing Increased skill mix with development of specialist qualification (Health Visiting and SCPHN) to meet the labour nurse roles market demands due to the age profile of this staff group. Nursing associates to be recruited into children’s Health Visitors and other practitioners have potential options to specialist services work in other areas of the country with lower child protection Workforce Planning cases and lower levels of caseloads Forward planning in paediatric eye service for specialist AHPs
Workforce Plan – Learning Disabilities March 2019 AVERAGE =FTE Staff in Post Staff Group Future Workforce Demand (as at 2022) 250.00 New roles Row Labels FTE Headcount apprenticeships? 240.00 Add Prof Scientific and Technic 13.65 16 Staff Group FTE Additional Clinical Services 62.91 68 Additional Clinical Services 230.00 Administrative and Clerical 29.71 33 Administrative and Clerical Allied Health Professionals 220.00 Allied Health Professionals 27.08 30 Medical and Dental Medical and Dental 12.73 14 Nursing and Midwifery Registered 210.00 Nursing and Midwifery Registered 87.42 93 240* Grand Total 233.49 254
200.00 Cannot estimate exact changes expect 190.00 small amount of growth re services staffing System leadership model will attract growth in admin, procurement, commissioning manger roles.
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Staff Movements (FTE) Staff Group by Band Main Changes CFT increase and focus over next 3 years re risk assessment and skilled team. IST increase and focus over next 3 years re discharge planning, avoidance of admission and PBS. Enhanced Community Models Specialist Residential and Day Services skills needed re PBS, CTRs, Health Facilitation, Epilepsy, Phlebotomy. Future TUPE of CHC assessors 4.5 wte Physician Associate roles to be introduced. Apprenticeship model for Nurses Rotational increase for all AHPs from acute services and internal. Potential location changes for staff as part of Locality (STP) redesign and agile working r e base preferences. 14 | P a g e
Have not applied 19/20 CRES to workforce plan. Add Prof Scientific 8.00 local New service redesign will be based on capacity and Technic and demand remodelling - not to be completely Bd 8b+ restrained by £ as demand will grow. Additional Clinical 6.00 Bd 8 Services
Bd 7 4.00 Administrative and Bd 6 Clerical
2.00 Bd 5 Allied Health Bd 4 Professionals 0.00 Bd 3 Estates and Ancillary Bd 2
-2.00
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Medical and Dental Bd 1 -4.00 local Nursing and 0 50 100 150 Midwifery Registered -6.00
Starters FTE Leavers FTE
Main Challenges
We have 30% of the workforce potentially at MHO status and retirement age in the next 2/3 years LD Nursing training was reduced leaving a national shortage Recruitment and retention of all posts Attracting AHPs – 3rd advert for key posts Psychologist posts becoming hard to recruit = 3rd advert for senior post
Vacancies (FTE) Age Distribution Key Actions 60.0 Change Management to start Phase 1 50.0 Divisional Management process by end March 19 40.0 Capacity and Demand – resourcing analyses to support redesign to 5 Localities and City wide service model 30.0 Explore rotational AHP model Increase Apprenticeships for all professions 20.0 Explore further Associate Physician roles Explore increase in Associate Nurse Therapist 10.0 roles Review safer staffing for community team 0.0 Introduce safer staffing review for AHPs 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65+ Increase student placements for service users with LD Increase preceptorship roles in Psychology 26 % of staff are above 55 years old Explore Associate Psychology role
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Explore IAPPT roles to support CBT needs of service 300 users
250
200
150
100
50
0
Jul-17 Jul-18
Jan-18 Jan-19
Jun-17 Jun-18
Oct-17 Oct-18
Apr-17 Apr-18
Sep-17 Feb-18 Sep-18 Feb-19
Dec-17 Dec-18
Aug-17 Aug-18
Nov-17 Nov-18
Mar-18 Mar-19
May-17 May-18
FTE in Post FTE Vacancy
Leaving Reason Age Distribution by Staff Group BME Add Prof Scientific Additional Nursing and Clinical Admin and Medical and Grand Age Technic Services Clerical AHPs and Dental Midwifery Total 10-20 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 20-30 0.0% 1.7% 1.2% 2.6% 0.7% 2.9% 9.1% 30-40 1.5% 1.5% 1.7% 3.6% 1.3% 5.5% 15.1% 40-50 3.4% 5.7% 1.4% 2.7% 1.2% 11.8% 26.2% 50-60 0.6% 14.9% 3.3% 4.0% 1.8% 14.9% 39.5% 60-70 0.0% 4.2% 3.8% 0.0% 0.0% 1.8% 9.7% 70-80 0.4% 0.0% 0.0% 0.0% 0.0% 0.0% 0.4% Total 5.8% 28.0% 11.4% 12.9% 5.0% 36.9% 100.0%
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Workforce Plan – Dental – March 2019 FTE Staff in Post Staff Group Main Changes Row Labels FTE Headcount 540.00 Add Prof Scientific and Technic 218.55 274 Potential future TUPE of School of Dental Hygiene Additional Clinical Services 66.87 70 520.00 New apprenticeship model for Trainee Administrative and Clerical 101.05 112 Dental Nurses 500.00 Allied Health Professionals 7.38 9 Review of working patterns e.g. three 480.00 Estates and Ancillary 12.47 13 session working Medical and Dental 115.74 151 Potential location changes for staff as 460.00 part of Community Dental Service review Nursing and Midwifery Registered 2.28 4
440.00 Grand Total 524.34 633
420.00
400.00
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Staff Movements (FTE) Staff Group by Band (FTE) Main Challenges
Add Prof Scientific and 60.00 Medical &… Recruitment and retention of specialist Technic Starters FTE Leavers FTE Bd 8b+ posts 50.00 Additional Clinical Recruitment and retention of Dental Bd 8 Services Nurses 40.00 Bd 7 Additional skills for Dental Nurses Administrative and Future of School of Dental Nursing Bd 6 Clerical 30.00 Reconfiguration of Dental Out of Hours Bd 5 Allied Health Service and associated resources 20.00 Bd 4 Professionals Tender for Out of Hours Dental Services NHS England Community Dental 10.00 Bd 3 Estates and Ancillary Service Review 0.00 Bd 2 Dependence on additional hours and Medical and Dental overtime Bd 1 -10.00
local
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Nursing and Midwifery -20.00 0 50 100 150 200 Registered
-30.00
Age Distribution (Headcount) Key Actions Vacancies (FTE) 120 Workforce Planning Development of specialty level workforce 100 plans for each staff group Continuing work to development staffing 80 capacity plans to meet current and future demand and planning 60 Service Change Consultation with Out of Hours Staff 40 Continuation of Community Dental Services Project 20 Deployment Development of plans to review and 0 consult on core working hours. 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60+
12.9 % of staff are above 55 years old
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600
500
400
300
200
100
0
Jul-17 Jul-18
Jan-18 Jan-19
Jun-17 Jun-18
Oct-17 Oct-18
Apr-17 Apr-18
Sep-17 Feb-18 Sep-18 Feb-19
Dec-17 Dec-18
Aug-17 Aug-18
Nov-17 Nov-18
Mar-18 Mar-19
May-17 May-18 FTE in Post FTE Vacancy
Leaving Reason Age Distribution by Staff Group
Add Prof Scientific Additional Admin Estates Medical Nursing and Clinical and and and and Grand Age Technic Services Clerical AHPs Ancillary Dental Midwifery Total 10-20 0.0% 3.7% 0.2% 0.0% 0.0% 0.0% 0.0% 3.9% 20-30 9.0% 5.3% 3.6% 0.0% 0.4% 6.4% 0.2% 24.9% 30-40 12.4% 3.4% 4.6% 0.2% 0.4% 8.3% 0.0% 29.2% 40-50 9.3% 0.3% 5.0% 0.3% 0.7% 3.6% 0.0% 19.2% 50-60 8.2% 0.5% 3.9% 0.9% 0.4% 3.8% 0.1% 17.8% 60-70 1.2% 0.0% 2.2% 0.1% 0.3% 0.6% 0.2% 4.7% 70-80 0.3% 0.0% 0.0% 0.0% 0.0% 0.1% 0.0% 0.4% Total 40.3% 13.1% 19.5% 1.6% 2.2% 22.8% 0.5% 100.0%
BME
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8. Trustwide Workforce Plan Workforce Plan – BCHC data as at 31-Mar-2019 AVERAGE FTE Staff in Post (Apr 17 – Mar 19) Staff Group Future Workforce Demand (as at 2022)
Row Labels FTE Headcount % 4,250.00 Row Labels FTE 2022 % Change notes Add Prof Scientific and Technic 279.89 349 Change 4,200.00 Additional Clinical Services 854.07 982 Add Prof Scientific and Technic 256.14 -9.27% -3- 4,150.00 Administrative and Clerical 899.82 1012 Additional Clinical Services 954.11 10.48% -1- Allied Health Professionals 442.14 516 4,100.00 Administrative and Clerical 858.17 -4.85% Estates and Ancillary 128.1 156 4,050.00 Allied Health Professionals 442.60 0.10% Healthcare Scientists 5.79 7 4,000.00 Estates and Ancillary 128.1 0% Medical and Dental 185.6 232 3,950.00 Nursing and Midwifery Registered 1256.05 1439 Healthcare Scientists 5.79 0% 3,900.00 Students 39.00 39 Medical and Dental 173.04 -7.26% -4- Grand Total 4090.47 4732 Nursing and Midwifery -2- 3,850.00 1,324.54 5.17% Registered
Students 39 0%
2017 / / 2017 05 / 2017 06 / 2017 07 / 2017 08 / 2017 09 / 2017 10 / 2017 11 / 2017 12 / 2018 01 / 2018 02 / 2018 03 / 2018 04 / 2018 05 / 2018 06 / 2018 07 / 2018 08 / 2018 09 / 2018 10 / 2018 11 / 2018 12 / 2019 01 / 2019 02 / 2019 03 2017 / / 2017 04 Grand Total 4,181.49 2.18% -1- Increases in Rehabilitation Assistants and Nursing Associates. Staff Movements (FTE) (Apr 17 – Mar 19) Staff Group (headcount) by Band -2- Net increase – especially IMT’s, Rapid Response, ANP’s
Add Prof Scientific -3- CRES not offset by any identified growth
and Technic -4- Reduction in medically ley wards & Care Centres 150.00 Medical & Dental Additional Clinical Services local 100.00 Administrative Bd 8b+ and Clerical Bd 8A 50.00 Allied Health Starters Bd 7 Professionals FTE Bd 6 Estates and 0.00 Ancillary Bd 5 Leavers Healthcare
FTE Bd 4 Scientists
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 -50.00 2017 / 04
Bd 3 Medical and Dental -100.00 Bd 2 Nursing and Bd 1 Midwifery -150.00 Registered Apprentice Students Mar 2018 leavers include the 58.2 FTE Staffordshire SN transfer. Sep 2018 hires include both Dental Nurse apprentices and Dental core trainees 0 500 1000
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Staff Group by Age Distribution
Vacancies (FTE) (Apr 17 – Mar 19)
5,000.00 4,500.00 4,000.00 3,500.00 3,000.00 2,500.00 2,000.00 Vacancy 1,500.00 FTE 1,000.00 500.00 0.00
Main Changes
2017 / 05 2017 / 06 2017 / 07 2017 / 08 2017 / 09 2017 / 10 2017 / 11 2017 / 12 2018 / 01 2018 / 02 2018 / 03 2018 / 04 2018 / 05 2018 / 06 2018 / 07 2018 / 08 2018 / 09 2018 / 10 2018 / 11 2018 / 12 2019 / 01 2019 / 02 2019 / 03 2017 / 04 Adults & Specialist Rehabilitation: Rehabilitation Assistant and Nurse Associates -1- 12.00% Adults Communities: Growth in IMT, ANP’s and rapid Response; - 2 -Relocation of services & implementation of locality model. 10.00% Children & Families: Growth in Therapies and Neuro Development. Dental: Review of three session working and service redesigns. 8.00% Learning Disabilities: Physician Assistant roles to be introduced; Intensive Support care. 6.00% % Vacancy
Main Challenges 4.00% - Recruitment remains a challenge – as is the case Nationally. We are competing with ‘acute’ providers. There are particular 2.00% 19.6 % of staff are above 55 years old challenges for: Staff Group by BME - Health Visitors 0.00% - District Nurses -New qualified nurses for InPatients Leaving Reason (Apr 2018- Mar 2019) - Allied Health Professionals - Sickness absence remains high compared to other Community 23.7% Retirement 21.3% Providers 11.2% End of Fixed Term Contract 8.6% - High activity and acuity increases workload pressures. 6.4% - Nearly 1/5th of the workforce is over 55 years old. Voluntary Resignation - Promotion 6.0% 5.4% - Contract change uncertainty: Prison, School Nursing, Dental End of Fixed Term Contract -… 3.6% 2.6% etc. Redundancy 1.9% Key Actions 1.7% Voluntary Resignation - Health 1.7% - Utilisation of new roles – reducing the dependence on difficult 1.5% Flexi Retirement 1.5% to recruit staff roles by the development of assistant, Nursing 1.1% Associate roles and also Advanced Clinical Practitioner. Voluntary Resignation - Lack of… 0.9% 0.7% - Capitalise on the opportunities for Apprentice roles. Voluntary Resignation - Adult… 0.2% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% - Explore efficiencies from Informatics, Digital developments and Estates strategies
- Recruitment & Retention initiatives
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8. Shape and Size Summary
The overall workforce plan is summarised in the key points below:
The Trustwide Workforce Plan is projecting a 2.7% increase in staffing over the 2019-22 period. Reductions in respect of CIP savings (primarily in Admin and Clerical, Additional Professional Scientific and Technical staff group) are off set by net projected growth in IMTs, Rapid Response and Therapies and Neuro Development within Children and Families Division. Any growth assumptions are based on commissioning outturn 2019-20 and thereafter the workforce plans generally ‘flatline’.
In respect to specific staff groups, the biggest projected increase is in Additional Clinical Services (13.1%) which is based on an increase in Rehabilitation Assistants and Nurse Associates. The Nursing workforce is planned to increase by 5% due to expansion, primarily in Adult Community Services but a 6.2% reduction is planned in the Medical workforce, based on a future shift to Nurse led services. It is worthy of note that there is no expansion in the Allied Health Professionals within the plans.
The year 1, 2019-20 workforce plan is based on detailed service, finance and activity plans informed by commissioning contracts. This plan reflects agreed cost improvement plans, contract growth and funded business developments.
Years II and III of the workforce plans are based on a generally ‘steady state’ – reflecting anticipated workforce CIP reductions and only minor growth. It should be noted that there was little evidence of service, activity or financial plans expressed numerically beyond year 1. It is therefore not surprising that there is no specific workforce growth assumption. Whilst the plan is not ambitious it is clear that it is affordable within the overall financial envelope
These plans make no assumption of significant service change i.e. Early Intervention, Neighbourhood Model the consequence of service tendering outcomes or of major service and bed configuration.
The Trust workforce plan anticipates that in the scope of the planning period there will be little positive change to the national workforce demand and supply gap and the Trust will have to employ a range of local initiatives and strategies to attract and retain the required staff.
“Challenges” - All Divisions articulate the challenge of the supply of staff meeting the demand, and the impact of vacancies, sickness and other forms of leave. Divisions also describe within the plans the challenge of meeting increasing patient activity, performance levels whilst maintaining requirements for Mandatory Training, Appraisal and development opportunities.
The impact of IT systems and an Ageing workforce are also noted.
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The challenge of recruiting to vacancies covers not only the high profile nationally recognised shortages in large Registered staff groups i.e. Nursing, but also a variety of specialist ‘niche’ roles which are nationally difficult to recruit to.
Sustainability of the current Medical workforce model in Adult Specialist Rehabilitation Division is noted.
“Changes” – The Divisional plans highlight a significant number of service transformation and service model changes which have a significant impact on the required shape and size of the workforce, but at the time of planning, no specific forecasts were made.
Significant examples of this would be the impact of a Neighbourhood Model or Primary Care Networks and Early Intervention Immediate Care Models.
Adult and Specialist Rehabilitation highlight the development of the BCHC Bed Model as part of the system wide review and the considerable impact this might have on the overall Divisional workforce.
Implications of the primary care service within the HMP Birmingham in the last year of the planning period would also have a considerable impact.
“Actions” – All Divisions set out the commitment to deliver the ‘Great Place to Work’ workstreams locally and recognise the importance of engagement of the local workforce, leadership and creating an environment where staff can grow and develop.
Every Division highlights the need to develop local plans for the Retention and Recruitment and reference is made to the Ageing workforce.
10. Conclusion Whilst the Strategic Workforce Plan provides some clarity on the future demand and supply for the workforce it is recognised that further work is required to develop and embed workforce planning. The following observations are made:
Immediate recruitment initiatives are required to meet short term workforce supply gaps and the opportunities for international recruitment and STP wide initiatives must be fully explored. The plans specified various initiatives to promote vacancies but there is a strong view that the Trust must do more as a corporate body to raise the brand and profile of BCHC as an employer both with potential applicants but also with other key stakeholders i.e.Higher Education Institutes.
The plan by definition focusses on the next 3 year planning period and makes little reference to longer term workforce planning demand, supply and solutions. Many sustainable workforce solutions have considerable long term lead in times.
The workforce plan and Divisional plans have been developed through engagement with Divisional Senior Teams and supported by local HR Business Partners but it is concluded that there is much more work to do to build workforce planning capacity and capability within the organisation. Given the key risks and challenges related to workforce it would be
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important to see workforce planning embedded within a long term and operational business planning cycle.
Whilst Divisional workforce plans make some reference to the development of new roles and consideration of skill mix there is little evidence of a consistent and corporately supported strategy and plan for workforce development. Work has commenced on developing the strategy for Allied Health Professionals recognising their vital role in supporting clinical services, however, this is not as yet evident in workforce plans.
There is recognition in the future planned workforce of an expansion of Nursing Associate and Apprentices but again no indication of a clear strategy
As already identified in the Making Good use of Resources workstream the planning process has identified a need for the Trust to build on the good work related to Safe Staffing and to expand this into all staff groups. It is recognised that this will require a commitment to roll out e-rostering to non-Nursing staff groups and implement e-job planning across Allied Health professionals.
11. Actions To deliver the ambition of having the right staff, with the right skills, in the right place at the right time. The plan identifies the following workstreams:
Workforce Planning
Workforce Development
Workforce Deployment
Workforce Collaboration
Workforce Attraction and Retention
The strategic aims and actions are as follows:
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Workforce Planning
Year 1: Year 2: •Develop a revised •Establish workforce workforce planning planning cycle framework and integrated into a template service and financial •Develop workforce plan planning skills •Develop specific Measure: Each development workforce plans in Objective: Workforce Division and service has programme relation to key planning is embedded an approved workforce •Revisit the Fit for 2022 programmes of work throughout the plan based on service Workforce Plan based i.e. Early Intervention, organisation in order and financial plans on the Trusts LTFM Primary Care Networks that each service area is developed through type plans and enabling strategies Year 3 proactively forecasting wider staff engagement •Establish workforce i.e. Digital Strategy the demand and supply setting out long term planning governance •Develop longer term for the workforce and workforce demand and arrangements through workforce plans putting plans in place to supply projections and Divisional structures beyond 2022 address any gaps. actions to address any through to the recognising the need gaps. Workforce and OD Sub to support integrated Trust Board working with primary Committee care, social care and the third sector •Develop specialist workforce planning lead capacity and capability
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Workforce Development
Year 1: Year 2: •Undertake an audit •Through large scale analysis of new clinical engagement identify roles and plans opportunities and currently in place potential for future •Undertake an audit new clinical role analysis of Apprentices development. Measure: There is a Objective: Workforce currently in place and •Develop a Trustwide clear, agreed and is developed to meet plans for further strategy and plan for owned strategy setting expansion new clinical role service and financial out the Trusts needs through •Continue work to development ambitions and plans in develop an Allied •Develop a introduction of new relation to the Year 3: roles and workforce Health Professionals commitment for all development of new strategy and plan entry posts to be on models, maximising roles, the use of capability and capacity •Develop a strategy in Apprenticeship and Apprentices and Allied agreed targets for of existing people. Health Professionals. relation to the Trusts approach to Widening Apprenticeship Participation Programmes •Develop a clear plan for advance practice for support service delivery and new models of care
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Workforce Deployment
Year 1: Year 2: Year 3: •Develop and roll out a •Develop effective •Develop workload plan for e-rostering rostering and Measure: Systems of allocation and across the clinical deployment across the workforce deployment effective e-rostering workforce clinical workforce skills and tools as part Objective: Capacity and e-job planning for through appropriate of the approach for and Capability of the the clinical workforce support, analysis and continuous workforce is maximised will be developed and monitoring improvement by effective and rolled out throughout efficient workforce the organisation •Explore options for •Develop workforce deployment systems. resulting in the extending flexible analysis and workforce reduction of Agency working and indicators to internally expenditure. deployment benchmark workforce efficiency
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Workforce Collaboration
Year 1: Year 2: Year 3: •Support work •Support work programmes to programmes to develop workforce collaborate on and supply across BSol streamline workforce health and care system systems and services including Recruitment (Temporary Staffing “getting people into Solution, Occupational the workforce” Health, Payroll). initiatives (careers interventions). •Support work to Measure: develop a systemwide Objective: BCHC is an Development and framework for active and lead partner delivery of a range of Apprentices and in systemwide systemwide led Widening Participation workforce planning and workforce programmes •Support work to development to to deliver people develop and maintain support STP plans. components of STP effective higher objectives and plans. education and training and to work with partners to improve student recruitment and retention by enhancing student clinical placements •Support integration with roles across primary care, mental health and third sector
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Workforce Attraction and Retention
Year 1: Year 2: •Deliver NHSI Retention •Develop a BCHC High Priority Actions in employer Branding addition to retention and sustained over and above Great campaign to support Place to Work effective recruitment. deliverables. •Develop a BCHC •Deliver NHSI Retention employer Branding High Priority Actions in and sustained addition to retention •Develop effective over and above Great relationships with key Place to Work stakeholders to Objective: BCHC is Measure: Vacancy deliverables promote BCHC as a able to attract, recruit rates will be reduced by •Develop a Temporary place to learn, work and retain workforce 5% by 2023 supported Staffing Plan to and grow. Such with right skills and the through clear and minimise Agency staff stakeholders will Year 3: right numbers to meet effective recruitment and maximise Bank as include Higher service needs. and retention an alternative solution Education Institutes. strategies. •Explore options for •Develop a clear International strategy and plans for Recruitment the development of BCHC as an Educational provider for undergraduate and post graduate education and explanding placement capacity. •Develop opportunity for rotational roles across pathways
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12. Resource Plan 2019 – 2021/22 It is intended that the Resource Plan arising from the Workforce Strategy will be integrated into the 3 year LTFM planning programme. Indicative costs are identified in the table below with potential sources of funding.
Resource Indicative Plan 2019 – 2021/22
Programme Activity Investment (£) Sources of funding Recurrent Non- Recurrent External workforce planning support to LTFM 60,000 Part cost pressure funding Programme and key Workforce Planning Skills development across Divisions 20,000 No identified funds
External workforce Workforce development support to 50,000 Part fund LWAB development monies Development Divisions and Trusts
Roll out e-Rostering and e- Workforce 2019/20 Cost pressure funding to Job planning AHP licenses 150,000 Deployment support
In house contribution - Workforce LWAB development monies – part Collaboration STP wide projects 50,000 funded
Workforce Attraction External Marketing / 100,000 No identified funds and Retention Branding Total 150,000 280,000
13. Recommendations The Trust is asked to approve the Fit for 2022 Workforce Strategy.
David Holmes Director of Workforce and Organisational Development June 2019
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Public Trust Board
Reference: Agenda Item no: 4b Enclosure no: 7 Date of Meeting: 5th June 2019 Document Title: Risk Management Strategy Responsible Director: Michelle Woodward, Director of Corporate Governance Author: Malcolm Parker, Head of Risk Management and Emergency Planning
Purpose of Executive level leadership of the Risk Management function and processes the Paper & within the Trust is the responsibility of the Chief Executive. Operational Key Points leadership of the risk management process is undertaken by the Director of Corporate Governance, who supports both a dedicated central Risk Management Team and delivery of the Risk Management Strategy and organisational objectives at a service level.
In April 2018, the Trust commissioned Deloitte LLP to undertake an independent Well Led CQC domain review within the Trust primarily focussing on Governance and assurance. During the period 15 May 2018 to 21 June 2018, the Care Quality Commission (CQC) undertook an inspection of the Trust. In the Final CQC report published on 15 October 2018, the CQC highlighted key areas of concern linked to the ‘Well Led’ domain and the Trust was rated as ‘Requires Improvement’. As a result of the recommendations a number of actions were initiated.
A comprehensive review of the Trust Risk Management Strategy has been undertaken which includes a review of the methodology, techniques, toolkits and training required to deliver the Strategy.
This Strategy sets out the approach that Birmingham Community Healthcare NHS Foundation Trust (BCHC) will take to ensure the effective management of strategic and operational risks (both clinical and non-clinical).
This document forms a core aspect of the Trust’s system of internal control and corporate governance arrangements and fulfils a specific legal requirement to ensure that risks are identified in a timely manner and are thereafter appropriately managed. This is in the context that the Trust recognises that delivering healthcare and the associated activities which support this (including employment of the organisation’s workforce, management of its premises and finances, provision of care services etc) will involve a degree of risk.
This Strategy aligns to the Care Quality Commission Domains and Key Lines of Enquiry; Caring, Responsive, Effective, Well-Led and Safe.
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Action The Board is recommended to: required by the Board APPROVE the Risk Management Strategy
Prior This Report is for Trust Board only discussion
Safe, High A Great Integrated Care Making Good Corporate Quality Place to in Communities Use of Governance Implications: Care Work Resources Impact on: X X X X X Risks:
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Equality Analysis Screening Form
Title of Proposal Risk Management strategy Person Completing this Malcolm Parker Role or title Head of Risk Management and Emergency proposal Planning Division Corporate Governance Service Area Risk Management Date Started December 2018 Date completed March 2019 Main purpose and aims of the proposal and how it fits in with the wider strategic aims and objectives of the organisation. The Risk Management Strategy sets out the Trust’s approach to the identification, assessment, treatment and tolerance of risk throughout the organisation. Who will benefit from the proposal? Patients,Staff and visitors
Impacts on different Personal Protected Characteristics – Helpful Questions: Does this proposal promote equality of opportunity? Promote good community relations? Eliminate discrimination? Promote positive attitudes towards disabled people? Eliminate harassment? Consider more favourable treatment of disabled people? Eliminate victimisation? Promote involvement and consultation? Protect and promote human rights?
Please click in the relevant impact box or leave blank if you feel there is no particular impact. Personal Protected No/Minimum Negative Positive Please list details or evidence of why there might be a Characteristic Impact Impact Impact positive, negative or no impact on protected characteristics.
Age X
Including children and people over 65 Is it easy for someone of any age to find out about your service or access your proposal? Are you able to justify the legal or lawful reasons when your service excludes certain age groups Disability X
Including those with physical or sensory impairments, those with learning disabilities and those with mental health issues Do you currently monitor who has a disability so that you know how well your service is being used by people with a disability? Are you making reasonable adjustment to meet the needs of the staff, service users, carers and families?
1 | P a g e Equality & Human Rights Analysis Tool & Guidance January 2018 Gender X
This can include male and female or someone who has completed the gender reassignment process from one sex to another Do you have flexible working arrangements for either sex? Is it easier for either men or women to access your proposal? Marriage or Civil X Partnerships
People who are in a Civil Partnerships must be treated equally to married couples on a wide range of legal matters Are the documents and information provided for your service reflecting the appropriate terminology for marriage and civil partnerships? Pregnancy or X Maternity
This includes women having a baby and women just after they have had a baby Does your service accommodate the needs of expectant and post natal mothers both as staff and service users? Can your service treat staff and patients with dignity and respect relation in to pregnancy and maternity? Race or Ethnicity X
Including Gypsy or Roma people, Irish people, those of mixed heritage, asylum seekers and refugees What training does staff have to respond to the cultural needs of different ethnic groups? What arrangements are in place to communicate with people who do not have English as a first language? Religion or Belief X
Including humanists and non-believers Is there easy access to a prayer or quiet room to your service delivery area? When organising events – Do you take necessary steps to make sure that spiritual requirements are met? Sexual Orientation X
Including gay men, lesbians and bisexual people Does your service use visual images that could be people from any background or are the images mainly heterosexual couples? Does staff in your workplace feel comfortable about being ‘out’ or would office culture make them feel this might not be a good idea? Transgender or X Gender Reassignment
This will include people who are in the process of or in a care pathway changing from one gender to another Have you considered the possible needs of transgender staff and service users in the development of your proposal or service? Human Rights X
2 | P a g e Equality & Human Rights Analysis Tool & Guidance January 2018 Affecting someone’s right to Life, Dignity and Respect? Caring for other people or protecting them from danger? The detention of an individual inadvertently or placing someone in a humiliating situation or position? If a negative or disproportionate impact has been identified in any of the key areas would this difference be illegal / unlawful? I.e. Would it be discriminatory under anti-discrimination legislation. (The Equality Act 2010, Human Rights Act 1998) Yes No What do you High Impact Medium Impact Low Impact No Impact consider the level of negative impact X to be? If the impact could be discriminatory in law, please contact the Equality and Diversity Lead immediately to determine the next course of action. If the negative impact is high a Full Equality Analysis will be required.
If you are unsure how to answer the above questions, or if you have assessed the impact as medium, please seek further guidance from the Equality and Diversity Lead before proceeding.
If the proposal does not have a negative impact or the impact is considered low, reasonable or justifiable, then please complete the rest of the form below with any required redial actions, and forward to the Equality and Diversity Lead. Action Planning: How could you minimise or remove any negative impact identified even if this is of low significance?
How will any impact or planned actions be monitored and reviewed?
How will you promote equal opportunity and advance equality by sharing good practice to have a positive impact other people as a result of their personal protected characteristic.
Please save and keep one copy and then send a copy with a copy of the proposal to the EDHR Team [email protected] The results will then be published on the Trust’s website. Please ensure that any resulting actions are incorporated into Divisional or Service planning and monitored on a regular basis.
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Risk Management Strategy
1. Introduction A comprehensive review of the Trust Risk Management Strategy has been undertaken following a review by Deloitte LLP into the Trust’s Well Led CQC domain. The review included the methodology, techniques, toolkits and training required to deliver the Strategy. The Trust Board is asked to approve the Risk Management Strategy.
2. Narrative In April 2018, the Trust commissioned Deloitte LLP to undertake an independent Well Led CQC domain review within the Trust primarily focussing on Governance and assurance. During the period 15 May 2018 to 21 June 2018, the Care Quality Commission (CQC) undertook an inspection of the Trust. In the Final CQC report published on 15 October 2018, the CQC highlighted key areas of concern linked to the ‘Well Led’ domain and the Trust was rated as ‘Requires Improvement’. The CQC highlighted the following key areas of concern linked to the ‘Well Led’ domain.
Ensure the effectiveness of governance arrangements and that the Board is consistently informed and sighted of risks The Board Assurance Framework (BAF) was not dynamic. Whilst the framework clearly set six strategic objectives (purpose, people, price, promotion, place and partnership) and seven aligned quality priorities, the Board did not assess and review progress and priorities regularly. There was a governance structure in place. However, this did not always provide accurate or reliable assurance to the board. Information did not flow effectively between the tiers of the governance structure Leaders were therefore not always aware of the risks across the organisation.
In addition to the initial work requested to be undertaken by Deloitte in April 2018, a result of initial feedback from the CQC, the Trust further commissioned Deloitte to undertake further support to strengthen and develop risk management arrangements. This review recommended the following actions:
The Trust should revisit and revise the format and content of the BAF to bring it into line with good practice. The Trust should adopt an approach to the BAF which allocates certain BAF risks to committees to seek assurance, in order to support the Board’s work-load in this area The Board, rather than Quality, Safety and Risk Committee (QSRC) – (now Quality and Safety Committee), should routinely receive a condensed paper on high level risks setting out where these sit and what the key changes to the Corporate Risk Register (CRR) - high level risks rated 15+. The Risk Management (now Risk Management Executive) exhibits many aspects of good practice, however we recommend that this be elevated to an executive level committee chaired by the CEO The Trust should review its risk management policy and strategy, both in relation to the training for senior staff in risk management and more specifically how the Trust identified and manages service level risks
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As a result of the recommendations a number of actions were initiated.
Introduction of a Corporate Risk Register (CRR) to replace the ‘High Level Risk Register’ and refresh of the complete CRR New model of phrasing risk introducing the X, Y, Z - Problem, Reason, Outcome structure Introduction of a Risk Management Board (Now Risk Management Executive) Chaired by the Chief Finance Officer to replace the Risk Management Committee Refresh of the BAF following ratification of new Fit for 2022 Strategy, including a revision of a new style BAF report The Trust adopted an approach to the BAF which allocates certain BAF risks to committees to seek assurance, in order to support the Board’s workload in this area Training/awareness workshops/seminars across all levels of the Trust Development of a new risk management strategy aligned to the Trusts new Strategic objectives
During Quarter 3, 2018/19, the Trust Strategic Objectives, together with draft risks for the 2019/2020 Board Assurance Framework were developed.
Specialist risk management training has been delivered across the organisation in a range of settings and using a variety of methodologies, albeit with clear focus upon self- service training which will enable colleagues to access the information and support that they need, where and when is most convenient and appropriate to them.
In January 2019, the Trust Board seminar agreed the risk appetite descriptors and rating for each of the Trust Strategic Objectives.
This Strategy sets out the approach that Birmingham Community Healthcare NHS Foundation Trust (BCHC) will take to ensure the effective management of strategic and operational risks (both clinical and non-clinical).
This document forms a core aspect of the Trust’s system of internal control and corporate governance arrangements and fulfills a specific legal requirement to ensure that risks are identified in a timely manner and are thereafter appropriately managed. This is in the context that the Trust recognises that delivering healthcare and the associated activities which support this (including employment of the organisation’s workforce, management of its premises and finances, provision of care services etc) will involve a degree risk.
This Strategy aligns to the Care Quality Commission Domains and Key Lines of Enquiry; Safe, Effective, Caring, Responsive and Well-Led.
3. Recommendation The Board is recommended to:
APPROVE the Risk Management Strategy
Appendices Appendix 1 - Draft Risk Management Strategy
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RISK MANAGEMENT STRATEGY
BCHC To be inserted by Document Library Services post Reference ratification Number
If this is a paper copy of the document, please ensure that it is the most recent version. The most recent version is available on the Intranet/internet
Title: Risk Management Strategy Version number: 3 BCHC Policy Reference To be inserted by Library Services post ratification Number Author/Document Lead Malcolm Parker, Head of Risk Management and Emergency Planning Name of Executive Director Michelle Woodward, Director of Corporate Governance Lead: Name of Approving Risk Management Executive – 8 May 2019 Committee/Group & Date: Quality and Safety Committee – 30 May 2019 Trust Management Board – 28 May 2019 Name of Ratifying Committee Trust Board – 5th June 2019 & Date: Review Date: Date Issued: Date that the document was placed on intranet and circulated to staff (to be added by Library). Date & Outcome of March 2019 – No impact assessment for E&HRA Target Audience All Staff
Subject category: Clinical Managerial (non -clinical) Emergency Planning Employment Estates Finance Infection Control Information Technology Medicines Management Risk Management Safeguarding Caring, Responsive, Effective, Well Led and Safe Summary The Risk Management Strategy sets out the Trust’s approach to the identification, assessment, treatment and tolerance of risk throughout the organisation.
Commencement of Consultation Date: Consultation History: The following Committees, groups or individuals have been consulted in the development of this version of this policy:
Name: Date: Quality & Safety Committee May 2019 Management Board May 2019 Risk Management Operational Development Group April 2019 Health and Safety Committee April 2019 Clinical Safety Committee May 2019 Divisional Quality, Governance and Risk Committees (or equivalent) April 2019 Divisional Management Boards April 2019
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Version History
Version Date Change Lead Reason for Change No. Implemented 1. Head of Risk Management April 2011 New 1.1 Head of Risk Management May 2011 Minor changes 1.2 Head of Risk Management June 2011 Minor changes 2 Head of Risk Management November 2012 Full review
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Contents
Section Title Page Number Executive Summary 5 1 Introduction 11 2 Purpose 13 3 Risk Appetite 15 4 Risk Management at an Operational level 16 5 Strategy Objectives 17 6 Roles and Responsibilities 18 7 Risk Management Process 24 8 Risk Training 26 9 Organisational Learning 26 10 Financial Implications 26 11 Circulation of the Strategy 26 12 Implementation of the Strategy 26 13 Duty of Candour 26 14 References 27 Appendices A Strategic Goals and Objectives 28 B Definitions of Terms 29 C Governance roles and Responsibilities 31 D Key Responsibilities for Trust Managers and Specialist Leads 34 E Risk Scoring Matrix 36 F Risk Register Process 40 G CQC Domains and Key Lines of Enquiry 41
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Executive Summary
Birmingham Community Healthcare NHS Foundation Trust Board is committed to supporting a robust and effective risk management system and ensuring that the risk management process underpins all key strategies and activities that lead to the achievement of its strategic objectives. By doing so it will safeguard against harm to patients, staff and visitors, financial loss, failure to meet objectives, and damage to reputation. The risk management strategy as outlined in this document aims to ensure the optimisation of risks to achieving the Trust’s objectives at all levels of the organisation.
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It is however, recognised that in an organisation such as ours there is always likely to be a level of risk exposure. Therefore, risk management should be an integral part of everyday business providing assurance to the Board that appropriate processes are in place to manage corporate and operational risks effectively. Risk Management is the responsibility of all staff and managers at all levels are expected to take an active lead to ensure that risk management is a fundamental part of their operational area. May 2019 Page 6
The Trust encourages an open culture that requires all Trust employees, contractors and third parties working within the Trust to operate within the systems and structures outlined in this strategy. Managers at all levels are expected to make risk management a fundamental part of their approach to clinical and corporate governance. We are committed to continuously improving and developing our risk management arrangements. This strategy specifies the actions that we will take, in the form of five specific objectives that will ensure we achieve this and will continue to do so over the life of this strategy, in alignment with the key improvement objectives and milestones it establishes. This Strategy sets out the approach that Birmingham Community Healthcare NHS Foundation Trust (BCHC) will take to ensure the effective management of strategic and operational risks (both clinical and non-clinical). This document forms a core aspect of the Trust’s system of internal control and corporate governance arrangements and fulfils a specific legal requirement to ensure that risks are identified in a timely manner and are thereafter appropriately managed. This is in the context that the Trust recognises that delivering healthcare and the associated activities which support this (including employment of the organisation’s workforce, management of its premises and finances, provision of care services etc) will involve a degree risk. The diagram below summarises the roles of groups at each level of governance within the Trust responsible for receiving, reviewing and managing risk registers. All Trust colleagues have a clear responsibility for identifying risks relevant to their service, team and/or working environment. These risks may be apparent as a result of colleagues’ observations, or they may require the triangulation of information from a range of sources.
A range of tools and resources will be maintained to support colleagues in the identification and escalation of risks, including:
a portfolio of fully documented risk management, protocols, procedures and guidance documents that will be readily available via the Trust intranet; an electronically maintained set of risk registers, that together, identify the extent of significant operational risks faced by the Trust and that are defined by service, directorate or project; and standardised risk assessment forms.
The Trust undertakes a proactive approach to the identification of risks. This is primarily through the risk assessment process. The risk assessment process will assess the potential to cause any of the following: injury, damage to the environment or property, complaint, litigation, loss of reputation and financial loss.
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Corporate Directorates and Divisions must undertake continuous risk surveillance identification, which is necessary to identify new risks, re-evaluate existing risks, and escalate risks that cannot be managed locally, identify mitigating actions and remove risks that are controlled or no longer relevant.
All staff are accountable for identifying and managing risk. Where a risk can be immediately mitigated (e.g. removing a cable from the floor), this should be done without delay. Where the risk cannot be immediately mitigated, staff should conduct a risk assessment in accordance with the guidance detailed within this Risk Management Strategy and then it must be added to the Datix Risk Register. If the staff member feels they are not able to adequately assess the risk themselves, they should report this to their line manager.
Staff who identify a potential risk should report it using the link located on the front page of the Trust Intranet. The details will then be reviewed by the reporter’s line manager and then tabled for discussion at the appropriate operational meeting and the risk agreed or rejected as outlined below. If the risk is rejected, the rationale for this will be fed back to the risk reporter. If the risk is agreed a dynamic process for the escalation of risks from service to Board level is to be applied as detailed below.
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The Trust recognises that there is scope to further develop its risk management arrangements towards best practice and to ensure that, as with all aspects of governance, our systems and processes are subject to a continuous cycle of improvement. To this end we have identified the following key objectives to further strengthen our risk management arrangements. These are supported by a more detailed articulation of deliverables and delivery milestones in Appendix A of this Strategy.
Objective 1: Embed the management of risk role of Sub-Committees of the Board regarding assurance and oversight.
Objective 2: Embed the newly formed Risk Management Executive (RME).
Objective 3: Introduce consistent divisional arrangements for risk management processes in line with this strategy.
Objective 4: Introduce consistent use of the actions module in Datix.
Objective 5: Establish directorate and service level risk registers across the Trust.
This Strategy aligns to the Care Quality Commission Domains and Key Lines of Enquiry; Caring, Responsive, Effective, Well-Led and Safe.
The ‘Well – Led’ Domain explicitly states leadership, management and governance of the organisation assures the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture. Furthermore, this Strategy also directly aligns with the following Key Lines of Enquiry; Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there clear and effective processes for managing risks, issues and performance? Is appropriate and accurate information being effectively processed, challenged and acted on? Are there robust systems and processes for learning, continuous improvement and innovation? Further details of the CQC Domains and Key Lines of Enquiry can be found at Appendix G.
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1. Introduction As the Trust’s vision is “Best Care: Healthy Communities”, i.e. BCHC, exists to provide the Best Care possible to support the people who use its services, many of whom are amongst the most vulnerable in our society, to live healthy in Healthy Communities. This vision is directly linked to the Birmingham & Solihull STP vision: “Live Healthy: Live Happy”.
This Strategy aims to support our vision by providing a framework of risk management that underpin our Organisational Values, namely; Caring, Open, Respectful, Responsible and Inclusive:
A definition of terms can be found in Appendix B
The key benefits of maintaining robust risk management processes are that:
the Trust will be better placed to fulfil its ambitions, as articulated within its Vision and Values and Strategic Objectives, thereby ensure its long-term sustainability; the Board and Sub-Committees will have full understanding and assurance of the key strategic and high level operational risks that may affect the Trust’s optimum functioning; all relevant stakeholders including the public and all professional partners will have evidence that the Trust is aware of its environment, pressures and threats and is taking all appropriate remedial actions in line with its legal and ethical responsibilities, so as to ensure continuous quality improvement; there will be a measurable reduction in detrimental impact upon the quality of health care services provided, thereby improving service user safety and experience; and decisions of the Trust will be taken with full consideration and awareness of the risk environment.
This Strategy will be reviewed three years after ratification or following any significant change in the management arrangements or committee structure within the Trust. It will also be reviewed following any recommendations from external assessment bodies. The Trust has a system for consistently reviewing policies and procedures and this Strategy will be treated as a policy for this purpose.
2. Purpose The purpose and scope of the Trust’s Risk Management Strategy is to detail the framework within which the Trust leads, directs and controls the risks to its key functions, including protecting patients and staff as well as ensuring compliance with Health and Safety legislation, Foundation Trust Terms of Authorisation and good governance requirements. May 2019 Page 11
The Trust’s Risk Management Strategy includes the processes for identifying and managing strategic risks (those risks to the delivery of the Trust’s stated strategic objectives) and in totality the strategy exists to support the successful delivery of these objectives. The Trust’s Strategic Objectives are detailed in Figure 1 below.
Figure 1
This strategy does not cover individual risk assessments such as Lone Working arrangements, Display Screen Equipment etc. Further guidance in relation to these can be found in the Risk Assessment procedure or in the individual Policies. This type of risk assessment will include, but are not limited to: Work based risk assessments. Task based risk assessments. All risk assessments will be fully documented and sent to the Risk Management Team for assurance/audit purposes. If the risk assessment results in a risk being placed onto Datix, the Risk Assessment(s) should be attached to the risk on Datix.
Failure to manage risks effectively can lead to harm/loss or damage in terms of both personal injury but also in terms of loss or damage to the Trust’s reputation; financial loss; potential for complaints; litigation and adverse or unwanted publicity.
The Strategy aims to promote an integrated and consistent approach across all parts of the organisation to managing risk. The strategy applies to all Trust staff, contractors and other third parties, including honorary contract holders, working in all areas of the Trust.
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3. Risk Appetite The Trust will periodically review its appetite for and attitude to risk, updating this where appropriate. The risk appetite of the Trust is the level of exposure to risk it will accept in relation to each of its Strategic Objectives in order to deliver its strategy over a given timeframe. In practice, the Trust’s risk appetite will address:
The nature of the risks to be assumed The amount of risk to be taken on The desired balance of risk versus reward
Risks throughout the organisation will be managed wherever possible within the Trust’s risk appetite, and where not possible, action taken to reduce the risk and / or the impact of it occurring. The Trust’s risk appetite will be communicated to relevant staff involved in the management of risk.
The Board recognises that risk is inherent in the provision of healthcare and its services, and therefore a defined approach is necessary to identify risk context, ensuring that the Trust understands and is aware of the risks that it is prepared to accept in the pursuit of the delivery of the Trust’s aims and objectives.
In January 2019, the Trust Board seminar agreed a risk scoring matrix comprising risk appetite descriptors and rating for each of the Trust Strategic Objectives as detailed in Table 1 along with a risk appetite for each Strategic Objective as detailed in Table 2
Table 1: Risk Scoring Matrix
Appetite Descriptor Rating Strategic Objective Eager to be innovative and to choose options based on those that offer the highest probability of productive OPEN outcomes. Prepared to accept high and 15-25 even extreme rated risks in pursuit of our objectives in this areas to realise the potential rewards Willing to consider all potential delivery A Great Place to Work – options and choose based on delivery of 8 (L2xC4) an acceptable level of reward and value for money. Prepared to accept that risks Making Good Use of MODERATE 8-12 are likely to occur in the pursuit of our Resources – 8 (L2xC4) objectives in this area and that we will need to tolerate risks up to a rating of Integrated Care in the ‘high’ to realise potential rewards Community - 8 (L2xC4) Preference for safe delivery options that have a low degree of inherent risk and may have more limited potential for reward. Willing to expend some time and CAUTIOUS resource to mitigate risks, but accepting 4-6 that some risks in this area will not, or cannot, be mitigated below a moderate level.
AVERSE Preference for ultra-safe delivery options 1-3 Safe, High Quality Care –
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that have a low degree of inherent risk 3 (L1xC3) and only limited reward potential. Prepared to expend significant time and resource to mitigate risks in this area to a minimal level. No appetite, not prepared to tolerate risk AVOID 0 above a negligible level
To ensure that the Trust takes and accepts risks in a controlled manner, thus reducing its exposure to unacceptable risk, the Board has considered and agreed a risk appetite statement for each of the Trust’s Strategic Objectives which are aligned to a risk scoring matrix.
Table 2: Agreed Risk Appetite Levels
Risk appetite Strategic objective Risk appetite statement rating Safe, high quality care Preference for ultra-safe delivery options that Working with the people have a low degree of inherent risk and only we care for, their families 3 limited reward potential. Prepared to expend and our partners to deliver Averse significant time and resource to mitigate risks in the best possible outcomes this area to a minimal level. and experience. Willing to consider all potential delivery options A great place to work and choose based on delivery an acceptable Creating a great place to level of reward (and VfM). Prepared to accept 8 work and learn, enabling that risks are likely to occur in the pursuit of our Moderate our colleagues to be the objectives in this area and that we will need to best that they can be. tolerate risks up to a rating of ‘high’ to realise potential rewards. Willing to consider all potential delivery options Integrated care in and choose based on delivery an acceptable communities level of reward (and VfM). Prepared to accept Working with our partners 8 that risks are likely to occur in the pursuit of our to support people to live Moderate objectives in this area and that we will need to healthy in their tolerate risks up to a rating of ‘high’ to realise communities. potential rewards. Willing to consider all potential delivery options Making good use of and choose based on delivery an acceptable resources level of reward (and VfM). Prepared to accept Getting the best from our 8 that risks are likely to occur in the pursuit of our people, technology, Moderate objectives in this area and that we will need to information, estates and tolerate risks up to a rating of ‘high’ to realise money. potential rewards.
The Trust’s risk appetite statement will be applied through the Board Assurance Framework which will present the strategic risk score against the established risk appetite level for each risk considered by the Board and committees and through a May 2019 Page 14
heat map which sets out the Corporate Risk Register risks relating to each strategic objective in the context of the established risk appetite, for consideration at the Risk Management Board.
From time-to-time Board Assurance Framework risk ratings may fall outside the Board- agreed risk Appetite. In such instances, as part of the dynamic nature of risk appetite, there may be a need to re-evaluate the risk Appetite the Trust Board is willing to accept for each Strategic objective as well as put in place mitigations to reduce risks to the agreed level.
4. Risk Management at an Operational Level Whilst this document is focused on risk management at a strategic level, it is important to recognise that failure to manage Operational Risks will ultimately have an impact on Strategic Risks.
Strategic Risks relate to the delivery of the organisation’s strategic objectives and should not change significantly over time. They have the highest potential for external impact – for example, does the organisation meet the publics’ expectations of access to treatment times.
Operational risks relate to the organisation’s on-going day to day business delivery – for example, patient safety; staff safety; security; information; finances and litigation. Whilst they may have some external impact, operational risks mostly affect internal functioning and services. It helps if the organisation defines the level of risk that is to be managed at each level of the organisation; in that way risks are managed by the correct level of seniority and each organisational layer has oversight of the risks managed in the layer below.
It is important to bear in mind that significant operational risks, which are not effectively managed, can have an impact on the delivery of the organisation’s strategic objectives.
The Audit Committee focusses upon establishing and ensuring the effectiveness of over-arching systems of integrated governance, risk management and internal control and to provide assurance to the Board thereon. It is responsible for ensuring a robust internal audit programme and for reviewing results of audits undertaken which measures effectiveness of governance and risk management systems. The specific Risk Type Management Assurance Board Assurance 2- 5 Year Forward view Exec Lead manages risks and Trust Board receives Framework. (Any rating – risk to delivery of provides assurance to Sub- assurance from but ordinarily 15+). Trust Strategic Committees of the Trust Board – Chairs of Sub- STRATEGIC Objectives QSC, Workforce and OD, FPC Committees
Corporate Risk Register 0-1 year high level risks Divisional Governance/DMB or Sub-Committees of (15+). OPERATIONAL to delivery of equivalent. Some of these risks the Trust Board – Operational Objectives may be managed at Exec level if they QSC, Workforce and are sufficiently significant. OD, FPC Operational Risk Register Generally 0-1 year (but Divisional Governance/DMB or Risk Management (<15). OPERATIONAL may be longer) medium equivalent Operational and low level risks to Development Group delivery of Operational Objectives May 2019 Page 15
functions of the Committee are:
5. Risk Management Strategy Objectives The Trust recognises that there is scope to further develop its risk management arrangements towards best practice and to ensure that, as with all aspects of governance, our systems and processes are subject to a continuous cycle of improvement. To this end we have identified the following key objectives to further strengthen our risk management arrangements. These are supported by a more detailed articulation of deliverables and delivery milestones in Appendix A of this Strategy.
Objective 1: Embed the management of risk role of Sub-Committees of the Board regarding assurance and oversight. To ensure that QSC, FPC and W&OD are effective in providing oversight of the relevant Corporate Risk Register and Board Assurance Framework risks. To ensure that the sub-committees hold divisions and directorates to account for the appropriate and timely management of risks and for providing assurance to Trust Board of the governance arrangements in place.
Objective 2: Embed the newly formed Risk Management Executive (RME). To ensure that the RME is effective in providing oversight of the Corporate Risk Register and Board Assurance Framework and in holding divisions and directorates to account for the appropriate and timely management of risks.
Objective 3: Introduce consistent divisional arrangements for risk management processes in line with this strategy. To ensure that the risk reporting of the divisions is standardised throughout the risk management process; identification, description, assessment, evaluation and in reporting to the RME. This will provide improved assurance to the Board that all significant risks are identified throughout the organisation and facilitate enhanced oversight via the newly developed reporting template.
Objective 4: Introduce consistent use of the actions module in Datix. Use of the actions module will improve the response to identified risks by detailing the action required, any resources necessary to manage the risk and details on how the actions will be monitored. Progress can be inputted and monitored against action taken to date creating a ‘live’ forum’ on progress which may be accessed by all stakeholders in the risk.
Objective 5: Establish directorate and service level risk registers across the Trust. This will facilitate the improved identification of risk at directorate and service level, standardising what is already in place at other levels of the organisation. Use of risk registers and the process of adding risks to a register at all tiers of the organisation will improve the scrutiny and challenge in relation to risk and assist in developing maturity within the risk culture of the organisation.
6. Roles and Responsibilities The diagram below (Fig 2) summarises the roles of groups at each level of governance within the Trust responsible for receiving, reviewing and managing risk registers. A detailed narrative role description for each governance group can be found at Appendix C.
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6.1 Chief Executive The Chief Executive is the Trust’s Accountable Officer, and as such, has overall responsibility for ensuring that the organisation delivers the highest quality services: this includes responsibility for the effective management of risks that may otherwise impact upon service quality. The Chief Executive is responsible for signing the Annual Governance Statement. The Chief Executive is a member of the Trust Quality and Safety Committee.
6.2 Roles of Executive Directors Executive Directors have responsibility for the management of strategic and operational risks within individual portfolios. This includes responsibility for, evaluating these risks, and ensuring that adequate responses, actions and/or mitigations are in place and monitored.
These responsibilities include the maintenance of a risk register and the promotion of risk management training to staff within their directorates. Executive Directors have responsibility for monitoring their own systems to ensure they are robust, for accountability, critical challenge, and oversight of risk. The Chief Finance Officer has responsibility as Chair of the Risk Management Executive.
6.3 Director of Corporate Governance The Director of Corporate Governance has Executive Lead responsibility for the implementation of this Strategy; providing performance management monitoring and assuring the Board that robust risk management systems are embedded throughout the organisation. The Director of Corporate Governance attends the Trust Board, Quality and Safety Committee, Audit Committee and the Risk Management Executive.
6.4 Head of Risk Management and Emergency Planning The Head of Risk Management and Emergency Planning is responsible for the development of a robust Risk Management Strategy, risk management processes, the maintenance of the risk register and for maintaining associated policies. The Head of Risk Management and Emergency Planning will be responsible for developing an Annual Risk Report, which will be agreed, reviewed and monitored by the Trust Board, and which will serve to provide robust assurance that all internal control systems are performing with optimum efficiency.
Key responsibilities for other Trust Managers and Specialist Leads are set out in Appendix D.
6.5 Divisional Leadership Teams It is the responsibility of the divisional leadership teams to ensue effective risk management in their divisions.
7. Risk Management Process The Trust’s risk management process ensures that risks are identified, assessed, controlled, and when necessary, escalated. These main stages are carried out through:
1. Clarifying objectives 2. Identifying risks to the objectives 3. Assessing and recording risks 4. Completion of the risk register and identifying actions
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5. Escalation and de-escalation of risks
7.1 Clarifying objectives Clarifying objectives is a critical stage of the risk management process. To understand whether something constitutes a risk, it must first be understood what the objectives/outcomes are that you want to achieve.
7.2 Identification of risks to objectives All Trust colleagues have a clear responsibility for identifying risks relevant to their service, team and/or working environment. These risks may be apparent as a result of colleagues’ observations, or they may require the triangulation of information from a range of sources including:
Business planning, Clinical Audit, External Audit, Operational Performance, Incidents, Internal Audit, Legislation, Horizon scanning, Financial planning, Regulatory standards, Risk assessments
A range of tools and resources will be maintained to support colleagues in the identification and escalation of risks, including:
a portfolio of fully documented risk management, protocols, procedures and guidance documents that will be readily available via the Trust intranet; an electronically maintained set of risk registers, that together, identify the extent of significant operational risks faced by the Trust and that are defined by service, directorate or project; and standardised risk assessment forms.
The Trust undertakes a proactive approach to the identification of risks. This is primarily through the risk assessment process. The risk assessment process will assess the potential to cause any of the following: injury, damage to the environment or property, complaint, litigation, loss of reputation and financial loss.
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Figure 2
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Corporate Directorates and Divisions must undertake continuous risk surveillance identification, which is necessary to identify new risks, re-evaluate existing risks, and escalate risks that cannot be managed locally, identify mitigating actions and remove risks that are controlled or no longer relevant.
All staff are accountable for identifying and managing risk. Where a risk can be immediately mitigated (e.g. removing a cable from the floor), this should be done without delay. Where the risk cannot be immediately mitigated, staff should conduct a risk assessment in accordance with the guidance detailed within this Risk Management Strategy and then it must be added to the Datix Risk Register. If the staff member feels they are not able to adequately assess the risk themselves, they should report this to their line manager.
Staff who identify a potential risk should report it using the link located on the front page of the Trust Intranet. The details will then be reviewed by the reporter’s line manager and then tabled for discussion at the appropriate operational meeting and the risk agreed or rejected as outlined in Fig 3 below. If the risk is rejected, the rationale for this will be fed back to the risk reporter. If the risk is agreed a dynamic process for the escalation of risks from service to Board level is to be applied as per Fig 3 below.
7.3 Assessing and recording risks The Trust will apply a consistent Trust-wide methodology to the assessment of all associated and significant categories of risk including strategic, operational, reputational and financial risks to reduce them to an acceptable level. Risk assessments will identify the significant risks arising out of the activities undertaken within the organisation and assess their potential to cause harm, loss or damage to the Trust, its clients, staff and reputation
Risks will be assessed and scored based on the impact of the risk and the potential likelihood of it to occur. The impact is based on a number of factors, for example: the financial implications, the number of service users or staff potentially affected, the ability of the Trust to achieve its objectives or the effect on Trust’s reputation. The likelihood is based on the probability of the risk emerging, and the timeframes and / or frequency in which the risk might occur, e.g. weekly, monthly, etc. The risk scoring matrix and criteria for use in assessing risks can be found at Appendix D of this strategy.
The risk assessment process and approach will be consistent across the Trust for clinical and non-clinical issues. 7.4 Describing a Risk Once a risk has been identified and assessed then a unique identifier will be allocated to distinguish the risk from the other risks on the register. Each risk needs to be described so that others understand what the risk is. The Trust uses the ISO method of risk description which captures the event, cause and consequence. For example:
Event Cause Consequence Loss of and/or leakage It systems governance and Regulatory sanction, reputational of patient data security failure damage and loss of public confidence The loss of or leakage of patient data due to failures in IT systems, governance and security may result in regulatory sanctions and a loss of public confidence.
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Having described the risk, then:
Assign an owner to the risk. This is the individual who is accountable and has overall responsibility for the risk. The risk owner must know, or be informed that they are the owner and accept this. List the key controls (actions) being taken to reduce the likelihood of the risk happening, or reduce the impact If it is a severe risk (rated above 12 or red or orange on the risk scoring matrix) then consider what the contingency action plan is, i.e. what will you do should the risk happen Rate the likelihood of the risk materialising Rate the impact of the risk happening. Identify mitigating actions to reduce the impact and/or likelihood of the risk, including identification of the action owner and completion deadline.
7.5 Completion of the risk register and action plan An integral part of the risk management strategy includes the completion of the Trust wide risk register. The purpose of a risk register is as follows:
To provide the Trust with a risk profile to enable oversight and benchmarking of risk across divisions and directorates To inform the decision-making process within the Trust so that all key decisions will result in a reduction in the Trust’s highest priority risks. To allow business plans and proposals etc to be evaluated on the basis of their effectiveness in reducing risks. To ensure that there is a consistency in the way in which risks are treated, regardless of the type of risk or the source of the information about a particular risk. The risk register process (attached at Appendix E) is an essential tool in aiding the Trust to identify and manage its ‘risk portfolio’. Risk Registers will include clinical, non- clinical, strategic, financial and business risks etc.
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Figure 3
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The ‘4 Ts’ provide a simple list of options available to anyone considering how to manage risk:
Tolerate – the likelihood and consequence of a particular risk happening is accepted. However, the risk must be mitigated, i.e. action should be taken to reduce the likelihood or consequence of the risk (this is the most common action) Transfer – shifting the responsibility or burden for loss to another party, e.g. the risk is insured against or subcontracted to another party. Terminate – an informed decision not to become involved in a risk situation, e.g. terminate the activity Take the opportunity - actively taking advantage, regarding the uncertainty as an opportunity to benefit. In most cases the chosen option will also involve taking action to mitigate the risk.
The selection of the most suitable action will include a measure of the potential impact of the risk weighed against the cost or effort necessary to enact it. Where substantive reductions in risk can be achieved with relatively low expenditure or activity, such actions should always be implemented, albeit with the approval of the risk lead. Further options for improvement may be deemed to be uneconomic or inappropriate, and therefore judgement must be exercised by the relevant risk lead or owner as to whether or not they are justifiable;
Responsibility to review the on-going management and mitigation of operational risks will be conducted within appropriate forums at both local and Trust-wide level, dependent upon the nature and severity of the risk. Risk policies will serve to regulate where and how these risks are received, and the respective responsibilities of each of the governing forums, so as to ensure a clear governance process that ultimately provides assurance up to the Trust Board.
In particular, each of the nominated forums will be responsible for undertaking a process of “check and challenge” that will ensure rigorous scrutiny of all presented risks, and enable the forum to make recommendations to adjust risk ratings accordingly. The Process Flowchart for reporting and managing risks on Datix is attached at Appendix F.
There will be a formal annual review of the effectiveness of the structure and processes for managing operational risks across the organisation. This will include a routine proactive internal audit cycle.
7.6 Closing a risk Once a risk has been terminated, or mitigated to the agreed target score, there are three options for management as set out in the decision tree below. The risk may be closed and a new risk raised which more appropriately describes the concern, the frequency of review could be reduced to annual (‘inactive’) or the risk can be closed.
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Target risk rating reached
Classify as Close the risk and ‘inactive’ and Close the risk open a new risk schedule for
annual review
8. Risk Training The Trust will deliver Trust-wide training so that strategic and operational risk management is clearly understood and enacted
8.1 Training for Board Members All Board members receive risk management training as part of their induction programme to the organisation and receive annual Board development and risk awareness training in accordance with the training requirements outlined in the Training Needs Analysis (TNA) below.
8.2 Staff Training The majority of risk management training is provided to staff in order that they are able to undertake their specific role and responsibilities e.g. Incident Management within Datix, Medical Devices.
However, other risk management related training forms part of staff Mandatory Training e.g. Health and Safety, Fire Safety, Manual Handling.
The Trust will ensure that the range of training programmes effectively raises the profile and understanding of risk identification, assessment and management, and clearly demonstrates to all colleagues across the Trust, how their routine and consistent application of risk management processes will serve as a key enabler to ensuring continuous improvement in the quality of the Trust’s delivered care.
Specialist risk management training will be delivered across the organisation in a range of settings and using a variety of methodologies, albeit with clear focus upon self- service training which will enable colleagues to access the information and support that they need, where and when is most convenient and appropriate to them.
More specifically, an overview of risk management systems and processes will be included within the induction programme that is mandatory for all new Trust colleagues.
Prior to any member of staff being responsible for the management of risk on Datix, they must undertake the ‘Management of Risk’ training, which can be accessed via the Trust Intranet. Furthermore, in order to augment the Trust’s risk management training May 2019 Page 24
programmes and to provide additional or supplemental advice and support on all issues related to risk, detailed guidance materials and resources will be maintained on the Trust intranet.
The Trust will ensure that its risk management training is appropriate to fulfil the personal development needs of all colleagues. This is equally applicable whether the training is being provided to frontline colleagues within operational teams who need to understand how to identify, report and escalate operational risks within their services, or whether the training is more specialist and therefore targeted at meeting the needs of those Trust colleagues with specific role-based responsibility for risk management, such as Information Governance and Medicines Management.
8.3 Risk Management Training – Training Needs Analysis Staff Groups Training need Frequency Format Executives and Board Risk Annually Workshop session Non-Executive Awareness training as part of Board Directors of the Development Board Programme Trust Management Refresher and Annually As part of a Board update session scheduled meeting Trust Senior Risk Management On arrival in Trust E-Learning Managers (Band 8a for Senior staff and above or equivalent) Senior Risk Risk Management Before managing a Face to face Managers – ALL Training risk on Datix. session (Power Risk Owners Annual Update Point presentation) All new staff Risk Awareness Once only as part of Face to face training and Corporate Induction session (Power understanding of Point presentation) role of risk management in the Trust Existing Staff Ad Hoc bespoke As required Variable by need training Risk Assessment training Staff involved in risk Individually Dependent on As required management e.g addressed individual needs Governance Leads according to individual needs
9. Organisational Learning
The Trust will ensure that learning from risks is communicated and integrated so as to inform future service delivery arrangements.
The Trust is committed to learning from its risk experiences, including learning from how risks occurred, how they were identified, mitigated or otherwise managed, and how they were finally resolved or accepted within the Trust’s agreed risk appetite.
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By sharing such critical learning across teams and directorates, the Trust will seek to encourage closer working relationships within and across services, and will also strengthen its operational service delivery. Learning will be shared through Divisional newsletters and the monthly Corporate Risk Management Team Newsletter - ‘Compass’.
Through its routine communications and engagement processes, the Trust will seek to ensure that all changes to practice that result from learning from risks are effectively communicated to the Trust’s professional partners and other stakeholders in order to evidence the organisation's integrity and commitment to continuous quality improvement. This action is also in line with the Trust’s commitment to be an excellent partner within the wider community.
An Organisational Learning Framework is being developed in the Trust and will be introduced by the end of Quarter 3, 2019/20.
10. Financial Implications This strategy has no direct financial implications, however, managing individual risks may require funds and this will be addressed through the usual business processes by the responsible manager
11. Circulation of the Strategy This Strategy will be circulated to all Divisional Directors and Associate Directors, Executive and Non-Executive Directors and Divisional lead persons with specific management responsibility for risk management and Divisional Management teams, with clear instructions for cascading to staff. The Strategy will also be available through the Intranet on the Risk Management Home Page.
Through its inclusion in Trust Board papers, the Risk Management Strategy and the Risk Management Annual Report will be available to the public and widely circulated.
12. Implementation of the Strategy Following ratification, the strategy’s author/lead will ensure that the document is forwarded to the Quality and Standards Assurance Team who will make final checks, amend the footer and forward to the Library for uploading to the intranet. Once uploaded to the intranet the Library will inform the Communication Team to ensure notification appears in the next Staff E-Newsletter
13. Duty of Candour The Trust recognises it has a duty of candour under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20. Under this duty it has a responsibility to be open and transparent with patients, families and carers in relation to their care and treatment and has specific requirements when things go wrong. This will include informing people about any clinical incident, providing reasonable support, providing truthful information and an apology when things go wrong. If an incident occurs which involve a breach of the requirements of this policy, staff and managers should consider following the guidance set out in the Being Open incorporating Duty of Candour Policy available on the trust intranet site.
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14. References
A Promise to Learn - a Commitment to Act (National Advisory Group on the Safety of Patients in England, Berwick 2013)
A Risk Matrix for Risk Managers (National Patient Safety Agency, 2008)
Code of Governance for NHS Foundation Trusts (Monitor, 2014)
Hard Truths: The Journey to Putting Patients First (Department of Health, 2013)
Orange Book: Management of Risk - Principles and Concepts (HM Treasury, 2013)
Review into the Quality and Safety of Care at 14 NHS Hospital Trusts in England (Department of Health, 2013)
Risk Assessment Programme Overview (National Patient Safety Agency, 2006)
Risk Management Standards 2013-14 (NHS Litigation Authority, 2013)
The Healthcare Risk Assessment Made Easy (National Patient Safety Agency, 2007)
The Management of Health and Safety at Work Regulations 1999
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Appendix A Strategic Goals and Objectives
Objective Description Timescale Embed the To ensure that QSC, FPC and W&OD are effective in Q2 2019/20 management of risk providing oversight of the relevant Corporate Risk role of Sub- Register and Board Assurance Framework risks. To Committees of the ensure that the sub-committees hold Executive Board regarding Directors to account for the appropriate and timely assurance and management of risks for services within their portfolio oversight. and for providing assurance to Trust Board of the governance arrangements in place. Embed the newly To ensure that the RME is effective in providing Q2 2019/20 formed Risk oversight of the Corporate Risk Register and Board Management Assurance Framework and in holding divisions and Executive (RME). directorates to account for the appropriate and timely management of risks. Introduce consistent To ensure that the risk reporting of the divisions is Q2 2019/20 divisional standardised throughout the risk management arrangements for risk process; identification, description, assessment, management evaluation and in reporting to the RME. This will processes in line with provide improved assurance to the Board that all this strategy. significant risks are identified throughout the organisation and facilitate enhanced oversight via the newly developed reporting template. Introduce consistent Use of the actions module will improve the response Q2 2019/20 use of the actions to identified risks by detailing the action required, any module in Datix. resources necessary to manage the risk and details on how the actions will be monitored. Progress can be input and monitored against action taken to date creating a ‘live’ forum’ on progress which may be accessed by all stakeholders in the risk. Establish directorate This will facilitate the improved identification of risk at Q4 2019/20 and service level risk directorate and service level, standardising what is registers across the already in place at other levels of the organisation. Trust. Use of risk registers and the process of adding risks to a register at all tiers of the organisation will improve the scrutiny and challenge in relation to risk and assist in developing maturity within the risk culture of the organisation
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Appendix B Definitions of Terms
The terms in use in this document are defined as follows:
Actions- Actions relate to the proposed strategy or course to be taken in order to mitigate a risk.
Assurance- Confidence based on sufficient evidence that internal controls are in place, operating effectively and objectives are being achieved.
Board Assurance Framework (BAF)- sets out the strategic objectives, identifies risks in relation to each strategic objective along with the controls in place and assurances available on their operation.
Consequence – the result of a threat or an opportunity
Control – actions taken to reduce likelihood and or consequence of a risk
Escalation – the act of advancing an issue to the next appropriate management level for resolution, action or attention.
Internal control – a method of restraint or check used to ensure that systems and processes operate as intended and in doing so mitigate risks to the organisation; the result of robust planning and good direction by management. If a control is not working effectively then it is not a control.
Inherent risk – the level of risk before any control activities are applied
Controls are the measures put in place as preventative measures to lessen or reduce the likelihood or consequence of the risk happening and the severity if it does. Key Controls must describe the practical steps that need to be taken to manage and control the risk.
Likelihood – the chance or possibility of something happening
Mitigations - the action of reducing the severity or seriousness of risk
Operational risks - those risks, both clinical and non-clinical, that are associated with the day-to-day workings of the Trust.
Residual risk – the risk ‘left over’ after controls, actions or contingency plans have been put in place.
Risk - is the combination of the probability of an event and its consequences. Described as Event, Cause, Consequences (ISO guide 73)
Risk Appetite – the level of risk considered the Trust is prepared to accept, tolerate or be exposed to at any point in time.
Risk Capacity – Maximum level of risk to which the organisation should be exposed having regard to the financial and other resources available. Page 29
Risk Management - is all the processes involved in identifying, assessing and judging risks, assigning ownership, taking actions to mitigate and anticipate them, and monitoring and reviewing progress.
Risk maturity- the overall quality of the risk management framework
Risk owner – the individual who is responsible for the management and control of all aspects of individual risks. This is not necessarily the same as the action owner as actions may be delegated.
Risk profile – the overall exposure of the organisation to risks or a given level within the organisation
Risk rating – the total risk score worked out by identifying the consequence and likelihood scores and cross-referencing the scores on the risk matrix.
Risk register – the tool for recording identified risks and monitoring actions and plans against them
Strategic Risk - those risks that, if realised, could fundamentally affect the way in which the Trust exists or operates and/or which may have a detrimental effect on the organisation’s achievement of its key strategic objectives. The realisation of strategic risks may lead to material failure, loss or lost opportunity.
Target Risk rating - is the score (based on a 5x5 risk matrix) that the risk is required to be reduced to in order to be aligned to the risk appetite and tolerances of the organisation.
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Appendix C Governance Roles and Responsibilities Trust Board
All Trust Board members are responsible for promoting and supporting a proactive approach to risk management within the organisation. The Trust Board has overall responsibility for the management of risk across the organisation. Its specific duties include:
setting the risk appetite for the organisation; ensuring an effective system of internal control including risk management; receiving the corporate risks and Board Assurance Framework quarterly, and advising on mitigations and actions after consideration of sources of assurance. receiving assurance reports from all Board Sub-Committees with regard to risks, internal control and assurance. identifying the principle strategic risks facing the Trust. revisiting the BAF to evaluate whether it continues to be representative of the principle strategic risks facing the organisation on an annual basis
The Board will have up to date access to information on the Trust Risk Register through reporting arrangements from the sub committees described below. Information on significant risks, the magnitude of those risks, options for risk prevention or control and progress made in achieving control will be agreed and approved at the Risk Management committee.
The Board, advised by the Risk Management Board, will verify that the Annual Governance Statement signed by the Chief Executive gives an accurate summary of the overall effectiveness of risk management within the Trust.
Assurance Sub-Committees of the Board
Each of the sub-committees of the Board has delegated responsibility for ensuring that effective risk management and assurance processes exist throughout the Trust on behalf of the Board in their relative spheres of accountability. The Committees will do this quarterly through receipt and review of those BAF risks delegated to them by the Board and Corporate Risk Register risks relevant to their sphere of accountability. Each Board sub-committee will provide a quarterly report to the Board, through the BAF and through the committee chair’s report relating to achievements and areas of concern. The sub-committees are; Quality and Safety Committee, Finance and Performance Committee and Workforce and Organisational Development Committee.
Audit Committee
The purpose of the Committee is to focus upon establishing and ensuring the effectiveness of over-arching systems of integrated governance, risk management and internal control and to provide assurance to the Board thereon. It is responsible for ensuring a robust internal audit programme and for reviewing results of audits Page 31 undertaken which measures effectiveness of governance and risk management systems. The specific functions of the Committee are:
The Committee will:
Report formally to the Board at the Board meeting that follows an Audit Committee meeting. Review the establishment and maintenance of the Trust risk management system and monitor the effectiveness of this system by ensuring that all risk and control disclosure statements indicate the degree of achievement against corporate objectives. Agree the Trust annual internal audit plan taking into account the Assurance Framework and the requirement to complete an Annual Governance Statement. Review the Assurance Framework quarterly.
Risk Management Executive
The Risk Management Executive is an Executive chaired forum that includes representation and membership from across the wider Executive Team and from Divisional leadership. Its role is to
Provide oversight of the corporate risk register (those risks scoring 15 and above) Hold the divisions and corporate directorates to account for appropriately describing and managing risks scoring 15 and above; and To hold the divisions and corporate directorates to account for timely and effective management and review of risk.
The Risk Management Executive will receive the Corporate Risk Register, a Risk Movement Log and a Risk Dashboard at every meeting along with undertaking a rolling programme of divisional deep dives.
There are a number of committees which provide assurance to the Risk Management Executive and the Trust Board Assurance Committees. These are the Trust Health and Safety Committee, the Trust Medical Devices Management Committee and the Risk Management Operational Development Group. The Risk Register relating to each area of the committee are standing agenda items reviewed at every meeting. The Chair of each committee is responsible for analysing trends/hotspots related to risks. Assurance is obtained from local governance groups that they are effectively managing and investigating risks.
Divisional Management Boards
Each Divisional Management Board will be responsible for regularly receiving and scrutinising the Divisional Risk Register (all risks scoring 12 and above) on a monthly basis. They will also be responsible for the approval for addition to the risk register, any risks identified within the division scored at 8 or above.
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Divisional Quality, Governance and Risk Committees
Each Divisional Quality, Governance Risk Committee will be responsible for ensuring that they and their division fulfil their responsibility for risk management by identifying, reporting, monitoring and managing risk in line with this and other associated policies, including the policy for managing incidents. They are also responsible for ensuring that appropriate and effective governance processes are in place to pro-actively identify, assess and manage risk within their designated area and scope of responsibility.
Divisional Quality Governance and Risk Committees will routinely receive the divisional risk register in full, and will be responsible for approving for addition to the risk register, any divisional risks identified scoring 1 to 6.
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Appendix D Key responsibilities for Trust Managers and Specialist Leads Managers (in General) Responsibility for operational risk management is cascaded down through the line management structure from the Executive Directors, through Divisional and Clinical Directors, Heads of Service, Matrons, Team Leaders/Departmental Managers and all other managers and supervisors to all employees of the Trust in job descriptions and Personal Development Plans. Specific responsibilities of line managers include ensuring that: • this strategy is communicated to all staff and implemented across the Trust. • risk management training needs are evaluated and that staff receive appropriate training to meet their responsibilities. • a sound risk management culture is encouraged throughout the organisation. • all staff are involved in the risk management process and consulted on risk assessments and risk control measures. • all significant risks are identified assessed and evaluated and where necessary controlled. Risk assessments will be carried out at the most appropriate level. Specialist Leads The Head of Patient Safety is responsible for providing specialist clinical risk management advice and providing guidance to managers in assessing clinical risks. He / she is responsible for ensuring that risks identified through clinical incidents and claims lead to risk assessment reviews and where necessary additional risk reduction or control. The Health and Safety Manager is responsible for providing specialist non-clinical risk management advice and providing guidance to managers in assessing non-clinical risks. He / she is responsible for ensuring that risks identified through non-clinical incidents and claims lead to risk assessment reviews and where necessary additional risk reduction or control measures. The Head of Patient Safety and Health and Safety Manager are jointly responsible for providing support, advice and guidance to directors and managers on the risk identification and assessment process. The Local Security Management Specialist (LSMS) is responsible for providing specialist security and personal safety advice and providing guidance to managers in assessing security and safety risks. He / she is responsible for ensuring that risks identified through security incidents and claims lead to risk assessment reviews and where necessary additional risk reduction or control measures. The Manual Handling Advisor is responsible for providing specialist manual handling advice and providing guidance to managers in assessing manual handling risks. He / she is responsible for ensuring that risks identified through manual handling incidents and claims lead to risk assessment reviews and where necessary additional risk reduction or control measures.
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Directorate / Divisional Risk and Governance Managers are responsible for supporting delivery of the Risk Management Strategy and action plan within local and corporate services. He / she is responsible for maintaining effective two way communication, supporting the provision of information and training, supporting the risk assessment process and escalating risk issues through local management and corporate management processes. The Responsibilities of all Employees All employees have a responsibility to comply with all policies, procedures, protocols, systems or rules put in place to eliminate, control or reduce risks. All employees must participate in fostering an effective risk management culture within the Trust by reporting all incidents or near misses in line with this policy and reporting any inadequately controlled risks to their managers. Additionally all staff must ensure that they: • Attend mandatory and other relevant training events • Notify managers of any risks identified
Add the identified risk to Datix and take immediate action where possible to mitigate the risk • Comply with incident management and reporting policies and procedures • Participate in risk assessment programmes relevant to the post / speciality.
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Appendix E Risk Scoring Matrix
Risk Evaluation Matrix
Determining Consequence Scores Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column.
Consequence 1 2 3 4 5 Score Descriptor Not Significant Minor Moderate Major Catastrophic Financial Small loss, risk of claim Loss of 0.1 – 0.25 % of Loss of 0.25 – 0.5% of Under delivery of key Non delivery of key objective. remote. Insignificant budget. budget. objectives. >1% adverse impact on cost increases or Claim less than £10,000. Claim(s) between £10,000 - 0.5 – 1.0% adverse impact financial position. schedule slippage <5% over project budget. £100,000. on financial position. Loss of contract. Claim(s) Minor schedule slippage 5-10% over project budget. Claim(s) between £100,000 - >£1Million. >25% over project Moderate schedule £1Million. budget. slippage. 10-20% over project budget. Significant schedule slippage. Major schedule slippage. Workforce Short-term low staffing Low staffing or skill mix Late delivery of key Uncertain delivery of key Non delivery of key poor skill mix that that reduces the service objective/service due to lack objectives/service due to objectives/service due to lack temporarily reduces quality for over 1 day. of staff or key personnel. lack of staff required or skill of staff or non-availability of service quality <1 day, Short term need to Unsafe staffing levels or mix. key professional personnel. but does not impact cancel staff training competence >1 day. Low Unsafe staffing level or Ongoing unsafe staffing safety. which can be rectified in staff morale. competence <5 days. Loss levels or competence (open a month. Poor staff attendance at of key staff. ended). mandatory training. Very low staff morale. No Loss of several key staff. No staff attending mandatory staff attending mandatory training/key training > 1 training on ongoing basis month. (open ended) Quality and Safety Peripheral element of Overall treatment or Treatments or service has Non-Compliance with Totally unacceptable level or treatment of service service sub-optimal. significantly reduced national standards with quality of treatment/service. sub-optional. Formal complaints. effectiveness. significant risks to patients Event leading to death or Minimal injury/harm Minor injury or harm Moderate injury requiring if unresolved. Major injury multiple permanent injuries, requiring no or minimal requiring minor professional intervention. leading to long term several patients impacted. treatment/intervention. intervention. <14 days off work or incapacity >14 days off work Gross failure of patient safety
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No time off work and no <3 days extended stay or extended length of stay. or extended stay. if findings not acted upon. extended length of stay. off work. Minor Formal complaint (Stage 2). Multiple Inquest/Ombudsman Inquiry. Informal complaint or implications for patient Local resolution (with complaints/independent Gross failure to meet national inquiry. safety if unresolved. potential to go to review. standards. Prosecution. Single failure to meet independent review). Enforcement action/Warning internal standards. Repeated failure to meet notice. internal standards with patient safety implications. Partnerships and Rumours. Rumours, both internal Local media coverage. National media coverage, National media coverage with Reputation Limited potential for and external. Reduction in public with <3 days service well >3 days service well below stakeholder concern. Minor challenges related confidence. below reasonable reasonable stakeholder Partnerships unlikely to to working with Elements of stakeholder stakeholder expectation. expectations. be compromised. stakeholders and expectations not met. Significant elements of Loss of stakeholder partners, but limited Some challenges likely to stakeholder expectations confidence at Board level. potential for impact in arise in relationships at a are not met. Relationships and relationships at a senior senior level. Significant challenges likely partnerships likely to be level. in maintaining relationships dissolved or broken as a with key partners. result.
Likelihood Score (L) What is the likelihood of the consequence occurring?
The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency.
Likelihood 1 2 3 4 5 score Descriptor Rare Unlikely Possible Likely Almost certain Frequency This will probably Do not expect it to Might happen or recur Will probably happen / recur Will undoubtedly happen / How often never happen / recur happen / recur but it is occasionally but it is not a persisting recur, possibly frequently might it / does possible it may do so issue it happen
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Risk rating = Consequence x Likelihood (C x L)
Consequence
Not Significant Minor Moderate Major Catastrophic L Almost Certain 5 10 15 20 25 I K Likely E 4 8 12 16 20 L Possible I 3 6 9 12 15 H O Unlikely 2 4 6 8 10 O D Rare 1 2 3 4 5
For grading risk, the scores obtained from the risk matrix are assigned grades as follows
Risk entered on local service risk register 1 - 3 Low risk Incident advised to Divisional lead for / further investigation potential root cause analysis Risk entered on risk register Moderate 4 - 6 Risk notified to Director for acceptance / treatment / referral to Trust risk Board May be referred to local Manager responsible for the service area for further investigation / potential root cause analysis
8 - 12 High risk Risk entered on risk register Risk accepted / controlled at service / department level or referred to Director May be referred for inclusion on to Assurance Framework
Extreme If significant or service quality impact risk assessment / action plan 15 - 25 risk required / RCA to be undertaken
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Instructions for use 1 Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk. 2 Use table 1 to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated. 3 Use table 2 to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score. 4 Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score) 5 Identify the level at which the risk will be managed in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the organisation’s risk management system. Include the risk in the organisation risk register at the appropriate level.
Use of the Matrix
Use of the matrix enables a list of prioritised risks to be developed with an indication of the action that may be required. The matrix highlights the most significant risk issues to be considered by the Risk Management Committee and subsequently the Board. Risks scoring high or extreme should be deemed as unacceptable in the first instance and options for action considered. This level of risk will be considered as ‘significant’ and will be communicated to the Board in all circumstances. The Divisional Management team, Risk Management Committees, local directorate groups or Board, as applicable, will then identify and agree whether these risks can be controlled to an acceptable level.
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Appendix F
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Appendix G CQC Domains and Key Lines of Enquiry (KLOE’s)
Safe By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.
How do systems, processes and practices keep people safe and safeguarded from abuse? How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe? Do staff have all the information they need to deliver safe care and treatment to people How does the provider ensure the proper and safe use of medicines, where the service is responsible? What is the track record on safety? Are lessons learned and improvements made when things go wrong?
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.
Are people’s needs assessed and care and treatment delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes? How are people's care and treatment outcomes monitored and how do they compare with other similar services? How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment? How well do staff, teams and services work together within and across organisations to deliver effective care and treatment? How are people supported to live healthier lives and, where the service is responsible, how does it improve the health of its population? Is consent to care and treatment always sought in line with legislation and guidance?
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Caring By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect.
How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed? How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support as far as possible? Applies How are people's privacy and dignity respected and promoted?
Responsive By responsive, we mean that services meet people’s needs.
How do people receive personalised care that is responsive to their needs? Do services take account of the particular needs and choices of different people? Can people access care and treatment in a timely way? How are people’s concerns and complaints listened and responded to and used to improve the quality of care?
Well-Led By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality and person-centred care, supports learning and innovation, and promotes an open and fair culture.
Is there the leadership capacity and capability to deliver high-quality, sustainable care? Is there a clear vision and credible strategy to deliver high-quality sustainable care to people, and robust plans to deliver? Is there a culture of high-quality, sustainable care? Are there clear responsibilities, roles and systems of accountability to support good governance and management? Are there clear and effective processes for managing risks, issues and performance? Is appropriate and accurate information being effectively processed, challenged and acted on? Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services? Are there robust systems and processes for learning, continuous improvement and innovation? Page 42
Board Assurance Framework & Strategic Risks
1. Introduction Strategic risks relate to the delivery of the organisation’s strategic objectives and therefore should not change significantly over time. However, in line with the requirements of the UK Corporate Governance Code, the Board should review strategic risks periodically and particularly in light of significant changes within the organisation, such as the introduction of a new strategy.
The purpose of this report is to share the new style BAF and assurance index with the Board for approval. Each strategic risk has been reviewed and signed off by their respective executive leads and the proposal is for each assurance sub- committee of the board to scrutinise, challenge and assure themselves of each relevant strategic risk during committees in June 2019 prior to assurance reporting by Chairs and Executive leads to Trust Board in July 2019.
2. New Strategic Risks The new strategic risks developed by the Trust Board collectively are detailed as follows against each of our new strategic objectives:
Safe, High Quality Care BAF19/1: Failure to implement and embed an effective Trust wide improvement methodology programme due to lack of engagement and empowerment with all colleagues and a systematic approach to improve culture modelled by our leaders may result in the quality of our services not improving to support delivery of our 2022 strategic plan.
BAF19/2: If we do not deliver safe high quality care we will not meet stakeholder including regulators' requirements. This could lead to poor clinical care, potential loss of reputation and income
BAF19/3: A failure to deliver the improvements required by CQC and OFSTED in Children's services could result in poor outcomes for children and young people
Great Place to Work BAF19/4: Failure to promote and embed an inclusive culture and comply with EDHR recommendations due to a lack of sustained investment in and focussed leadership on the EDHR agenda may result in missed opportunities to utilise the talents of our diverse workforce in leadership positions, low morale in the workforce and reputational damage.
BAF19/5: If we do not improve staff health and wellbeing due to a failure of leadership at all levels to fully recognise and respond to the impact that mental and physical wellbeing can have on staff and a lack of investment, may result in
higher sickness absence, poor staff morale and higher turnover which will have an adverse effect on the delivery of our strategic objective.
BAF19/6: If we do not embed our vision and values in behaviours and leadership style we will not deliver our objective of Making a Great Place to Work, nor delivering a high quality service.
BAF19/7: If we are unable to transform our digital capability due to the cost and difficulty of effectively implementing change, we risk impacting on patient care and foregoing efficiency opportunities
Good Use of Resources BAF19/8: If we are unable to maintain sustainable contractual margins, develop and deliver efficiency gains due to market pressure and a lack of opportunity and/or capability, we risk damaging our financial sustainability.
BAF19/9: If we are not able to mitigate emerging risks relating to EU exit due to lack of visibility of the true risk and /or availability of mitigations, we risk impacting on accessibility of services and quality of patient care.
BAF19/10: If we are unable to ensure an estate that complements our clinical and enabling strategies due to technical and commercial constraints, we risk impacting on delivery of our strategic work programme.
BAF19/11: If we do not recruit and retain staff and develop a workforce with the right skills to deliver our strategy due to inadequate workforce planning and an ineffective recruitment and retention strategy we may fail to attract and retain the most capable and ambitious staff and deliver our Fit for 2022 Strategy
BAF19/12: If Commissioners reduce funding for services or fail to increase funding to meet increasing demands, we may be unable to provide a safe, high quality service and/or to meet service demands
BAF19/13: If we fail to implement a clear strategic direction for research and innovation due to lack of commitment and/or resources, we will lose and/or fail to attract research activity and income and the ability to contribute to evidence based care
BAF19/14: Reduced funding for the services we provide may result in a failure to provide a safe, high quality service, and a failure to meet service demand.
BAF19/15: If we are unable to provide equity of access and/or quality across the entire geography and population we serve or fail to successfully implement our
2
locality model due to recruit challenges in some areas, this may result in inequality of provision
Integrated Care in Communities BAF19/16: If we fail to engage with the new primary care network model we will lose the contracts that make up the core of our community services and will as a result be unable to implement and successfully deliver on our strategy related to integrated community services.
BAF19/17: If we do not change and redesign our services quickly enough to demonstrate the effectiveness of our model to partners and stakeholders we will be unable to retain key contracts which will result in us being unable to deliver our older people model.
BAF19/18: If we don’t have sufficient Commissioning Expertise in Learning Disability Services, we may be unable to demonstrate our system leadership model and consequently may be unable to realise the benefits of being a commissioner of other LD services’
BAF19/19: Failure to develop a strong partnership with BSMHT will reduce the chances to bring together mental and physical community health services affecting our ability to provide the best care to our patients and service users.
3. Top 6 Strategic Risks The organisation’s top strategic risks are as follows:
1. BAF19/13: If we do not recruit and retain staff and develop a workforce with the right skills to deliver our strategy due to inadequate workforce planning and an ineffective recruitment and retention strategy we may fail to attract and retain the most capable and ambitious staff and deliver our Fit for 2022 Strategy (20)
2. BAF19/3: A failure to deliver the improvements required by CQC and OFSTED in Children's services could result in poor outcomes for children and young people (16)
3. BAF19/4: Failure to promote and embed an inclusive culture and comply with EDHR recommendations due to a lack of sustained investment in and focussed leadership on the EDHR agenda may result in missed opportunities to utilise the talents of our diverse workforce in leadership positions, low morale in the workforce and reputational damage (16)
4. BAF19/8: If we are unable to transform our digital capability due to the cost and difficulty of effectively implementing change, we risk impacting on patient care and foregoing efficiency opportunities (15) 3
5. BAF19/18: If we fail to engage with the new primary care network model we will lose the contracts that make up the core of our community services and will as a result be unable to implement and successfully deliver on our strategy related to integrated community services (15)
6. BAF19/9: If we are unable to maintain sustainable contractual margins, develop and deliver efficiency gains due to market pressure and a lack of opportunity and/or capability, we risk damaging our financial sustainability (15)
4. Next Steps We have aligned each of our four strategic objectives to a sub-committee of the Board. The Quality and Safety Committee will oversee Safe, High Quality Care. The Workforce and Organisational Development Committee will oversee Great Place to Work. The Finance and Performance Committee will oversee Integrated Care in Communities and Good Use of Resources.
The committees will oversee delivery of the respective Fit for 2022 Improvement Programme underpinning each strategic objective and will commit to RAG (red, amber, green) rated reporting progress formally to the Board on a quarterly basis. The committees will also ensure full consideration of the risks relating to the delivery of their strategic objectives and will commit to RAG rated assurance reporting formally to the Board on a quarterly basis.
5. Recommendation The Trust Board is recommended to:
1. APPROVE the new strategic risks and the next steps;
2. REQUEST the Board sub-committees to review their strategic risks and report back to the Board at its July 2019 meeting.
Appendix 1 Board Assurance Framework 2019/20
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Trust Public Board
Reference: Agenda Item no: 4c Enclosure no: 8 Date of Meeting: 5th June 2019 Document Title: Board Assurance Framework 2019/20 Responsible Director: Michelle Woodward, Director of Corporate Governance Author: Malcolm Parker, Head of Risk Management and Emergency Planning
Purpose of Further to the approval of our new strategy in October 2018, executive and the Paper & non-executive directors participated in an online exercise which informed the Key Points Strategic Risk Workshop held at the Trust Board Away Day in December 2018. At the workshop, the Board collectively considered the significant risks to the Trust’s successful delivery of its strategic objectives. In January 2019, a Board Seminar was held to consider the risk appetite with respect to each strategic objective. Additional Board Seminars were held in April and May 2019 to finalise the strategic risks, and agree the organisations top 6 strategic risks which are:
BAF19/13: If we do not recruit and retain staff and develop a workforce with the right skills to deliver our strategy due to inadequate workforce planning and an ineffective recruitment and retention strategy we may fail to attract and retain the most capable and ambitious staff and deliver our Fit for 2022 Strategy (20)
BAF19/3: A failure to deliver the improvements required by CQC and OFSTED in Children’s services could result in poor outcomes for children and young people (16)
BAF19/4: Failure to promote and embed an inclusive culture and comply with EDHR recommendations due to a lack of sustained investment in and focussed leadership on the EDHR agenda may result in missed opportunities to utilise the talents of our diverse workforce in leadership positions, low morale in the workforce and reputational damage (16)
BAF19/8: If we are unable to transform our digital capability due to the cost and difficulty of effectively implementing change, we risk impacting on patient care and foregoing efficiency opportunities (15)
BAF19/18: If we fail to engage with the new primary care network model we will lose the contracts that make up the core of our community services and will as a result be unable to implement and successfully deliver on our strategy related to integrated community services (15)
BAF19/9: If we are unable to maintain sustainable contractual margins, develop and deliver efficiency gains due to market pressure and a lack of opportunity and/or capability, we risk damaging our financial sustainability (15)
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The purpose of this report is to share the final draft of our new style BAF and assurance index with the Board for approval.
Each strategic risk has been reviewed and signed off by their respective executive leads and the proposal is for each assurance sub-committee of the board to scrutinise, challenge and assure themselves of each relevant strategic risk during committees in June 2019 prior to assurance reporting by Chairs and Executive Leads to Trust Board in July 2019.
Action The Trust Board is recommended to: required by the Board 1. APPROVE the new strategic risks and the next steps;
2. REQUEST the Board sub-committees to review their strategic risks and report back to the Board at its July 2019 meeting.
Prior This report is for the Public Trust Board only. discussion
Safe, High A Great Integrated Care Making Good Corporate Quality Place to in Communities Use of Governance Implications: Care Work Resources Impact on X X X X X Risks: X X X X X
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BOARD ASSURANCE FRAMEWORK OVERVIEW QUARTER 1 Quarterly Assurance Strategic Executive Assuring Strategic Risk Rating Reason for Current Assurance Rating Current Risk Score vs Appetite Change Objective Lead Committee Q1 Q2 Q3 Q4 BAF19/1: Failure to implement This will be completed in Q1 via the Trust Board Sub- and embed an effective Trust wide Committees improvement methodology programme due to lack of engagement and empowerment with all colleagues and a Dr Doug [X VALUE] Safe high quality systematic approach to improve Quality & Safety Simkiss/ care Committee culture modelled by our leaders Marcia Perry may result in the quality of our services not improving to support delivery of our 2022 strategic plan.
0 5 10 15 20 25 BAF19/2: If we do not deliver safe This will be completed in Q1 via the Trust Board Sub- high quality care we will not meet Committees stakeholder including regulators' Dr Doug [X VALUE] Safe high quality Quality & Safety requirements. This could lead to Simkiss/ care Committee poor clinical care, potential loss Marcia Perry of reputation and income
0 5 10 15 20 25 BAF19/3: A failure to deliver the This will be completed in Q1 via the Trust Board Sub- improvements required by CQC Committees Dr Doug [X VALUE] Safe high quality and OFSTED in Children's Quality & Safety Simkiss/ care services could result in poor Committee outcomes for children and young Marcia Perry people 0 5 10 15 20 25 BAF19/4:Failure to promote and This will be completed in Q1 via the Trust Board Sub- embed an inclusive culture and Committees comply with EDHR recommendations due to a lack of sustained investment in and focussed leadership on the EDHR Workforce & [X VALUE] A great place to agenda may result in missed David Organisational work opportunities to utilise the talents Holmes Development of our diverse workforce in Committee leadership positions, low morale in the workforce and reputational damage. 0 5 10 15 20 25 BOARD ASSURANCE FRAMEWORK OVERVIEW QUARTER 1 Quarterly Assurance Strategic Executive Assuring Strategic Risk Rating Reason for Current Assurance Rating Current Risk Score vs Appetite Change Objective Lead Committee Q1 Q2 Q3 Q4 BAF19/5:If we do not improve This will be completed in Q1 via the Trust Board Sub- staff health and wellbeing due to Committees a failure of leadership at all levels to fully recognise and respond to the impact that mental and physical wellbeing can have on Workforce & [X VALUE] A great place to staff and a lack of investment, David Organisational work may result in higher sickness Holmes Development absence, poor staff morale and Committee higher turnover which will have an adverse effect on the delivery of our strategic objective. 0 5 10 15 20 25 BAF19/6:If we do not embed our This will be completed in Q1 via the Trust Board Sub- [X VALUE] vision and values in behaviours Committees and leadership style we will not Workforce & [X VALUE] A great place to David Organisational deliver our objective of Making a 0 5 10 15 20 25 work Great Place to Work, nor Holmes Development delivering a high quality service. Committee 0 5 10 15 20 25 BAF19/7: If we are unable to This will be completed in Q1 via the Trust Board Sub- transform our digital capability Committees due to the cost and difficulty of Finance & [X VALUE] A great place to effectively implementing change, Ian Woodall Performance work we risk impacting on patient care Committee and foregoing efficiency opportunities 0 5 10 15 20 25 BAF19/8 :If we are unable to This will be completed in Q1 via the Trust Board Sub- maintain sustainable contractual Committees margins, develop and deliver Finance & [X VALUE] Making Good Use efficiency gains due to market Ian Woodall Performance of Resources pressure and a lack of opportunity and/or capability, we Committee risk damaging our financial
sustainability. 0 5 10 15 20 25 BAF19/9: If we are not able to This will be completed in Q1 via the Trust Board Sub- mitigate emerging risks relating to Committees EU exit due to lack of visibility of Finance & [X VALUE] Making Good Use the true risk and /or availability of Ian Woodall Performance of Resources mitigations, we risk impacting on accessibility of services and Committee quality of patient care.
0 5 10 15 20 25 BOARD ASSURANCE FRAMEWORK OVERVIEW QUARTER 1 Quarterly Assurance Strategic Executive Assuring Strategic Risk Rating Reason for Current Assurance Rating Current Risk Score vs Appetite Change Objective Lead Committee Q1 Q2 Q3 Q4 BAF19/10:If we are unable to This will be completed in Q1 via the Trust Board Sub- ensure an estate that Committees complements our clinical and Finance & [X VALUE] Making Good Use enabling strategies due to Ian Woodall Performance of Resources technical and commercial Committee constraints, we risk impacting on delivery of our strategic work programme. 0 5 10 15 20 25 BAF19/11: If we do not recruit This will be completed in Q1 via the Trust Board Sub- and retain staff and develop a Committees workforce with the right skills to deliver our strategy due to inadequate workforce planning Workforce and [X VALUE] Making Good Use and an ineffective recruitment and David Organisational of Resources retention strategy we may fail to Holmes Development attract and retain the most Committee capable and ambitious staff and deliver our Fit for 2022 Strategy 0 5 10 15 20 25 BAF19/12: If Commissioners This will be completed in Q1 via the Trust Board Sub- reduce funding for services or fail Committees to increase funding to meet Finance & [X VALUE] Making Good Use increasing demands, we may be Angie Performance of Resources unable to provide a safe, high Wallace quality service and/or to meet Committee service demands 0 5 10 15 20 25 BAF19/13: If we fail to implement This will be completed in Q1 via the Trust Board Sub- a clear strategic direction for Committees research and innovation due to lack of commitment and/or resources, we will lose and/or fail Finance & Making Good Use to attract research activity and Ian Woodall Performance of Resources income and the ability to Committee contribute to evidence based care BOARD ASSURANCE FRAMEWORK OVERVIEW QUARTER 1 Quarterly Assurance Strategic Executive Assuring Strategic Risk Rating Reason for Current Assurance Rating Current Risk Score vs Appetite Change Objective Lead Committee Q1 Q2 Q3 Q4 BAF19/14: If we fail to engage This will be completed in Q1 via the Trust Board Sub- with and build strong Committees partnerships externally or to foster relationships and failure to align our priorities to those of our partners and the wider system [X VALUE] Finance & Making Good Use due to a lack of leadership Angie Performance of Resources capability, may result in us being Wallace unable to secure contracts, Committee sustain our services over the longer term and ultimately deliver integrated services for our community
BAF19/15: If we are unable to This will be completed in Q1 via the Trust Board Sub- Committees provide equity of access and/or [X VALUE] quality across the entire geography and population we serve or fail to successfully Finance & Making Good Use Angie implement our locality model due Performance 0 5 10 15 20 25 of Resources Wallace to recruit challenges in some Committee areas, this may result in inequality of provision
0 5 10 15 20 25 BAF19/16: If we fail to engage This will be completed in Q1 via the Trust Board Sub- with the new primary care Committees network model we will lose the contracts that make up the core of our community services and Finance & [X VALUE] Integrated care in Angie will as a result be unable to Performance communities Wallace implement and successfully Committee deliver on our strategy related to integrated community services.
0 5 10 15 20 25 BAF19/17: If we do not change This will be completed in Q1 via the Trust Board Sub- and redesign our services quickly Committees enough to demonstrate the effectiveness of our model to Finance & [X VALUE] Integrated care in Angie partners and stakeholders we will Performance communities Wallace be unable to retain key contracts Committee which will result in us being unable to deliver our older people model. 0 5 10 15 20 25 BOARD ASSURANCE FRAMEWORK OVERVIEW QUARTER 1 Quarterly Assurance Strategic Executive Assuring Strategic Risk Rating Reason for Current Assurance Rating Current Risk Score vs Appetite Change Objective Lead Committee Q1 Q2 Q3 Q4 BAF19/18: If we don’t have This will be completed in Q1 via the Trust Board Sub- sufficient Commissioning Committees Expertise in Learning Disability Services, we may be unable to Finance & [X VALUE] Integrated care in demonstrate our system Angie Performance communities leadership model and Wallace consequently may be unable to Committee realise the benefits of being a commissioner of other LD
services 0 5 10 15 20 25 BAF19/19: Failure to develop a This will be completed in Q1 via the Trust Board Sub- strong partnership with BSMHT Committees will reduce the chances to bring together mental and physical Finance & [X VALUE] Integrated care in Angie community health services Performance communities Wallace affecting our ability to provide the Committee best care to our patients and service users. 0 5 10 15 20 25 Risk Appetite Strategic Safe High Quality Care Objective AVERSE
Initial Strategic Risk Risk 8 Committee QSC Score BAF19/1: Failure to implement and embed an effective Trust wide improvement Current Dr Doug methodology programme due to lack of engagement and empowerment with all Executive Risk 8 Simkiss/ colleagues and a systematic approach to improve culture modelled by our leaders may lead result in the quality of our services not improving to support delivery of our 2022 strategic Score Marcia Perry plan.Assurance Q1 Q2 Q3 Q4 rating (quarterly)
Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group Failure to deliver a number of quality improvement programmes, including actions stipulated by CQC and Ofsted, due to senior management team capacity resource constraints and business as usual requirements, would mean that safe, effective, 2319 responsive and well-led Claire Paintain QSC 16 16 16 16 services are not delivered, evidenced and embedded, resulting in children and families not receiving high quality care, and children and young people with special educational needs and disabilities not having their needs identified, met and their outcomes improved Failure to develop and embed a Safety Culture and a patient focussed Quality Improvement Programme 2270 due to a lack of resource and Julie Jones QSC 15 capacity will result in increased patient harm, Serious Incidents and Never Events. 2275 Failure to develop and embed a Safety Culture and a patient focussed Quality Improvement Programme due to a lack of resource, Tina Gorman QSC 16 20 16 capacity and expertise could result in increased patient harm, Serious Incidents and Never Events. Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Learning Into action (LiA), Safety Huddles, Learning from These programmes are supported by the Patient Excellence and Patient Safety Ambassadors. Safety team and Organisational Development and promote clinical teams to review the quality of their care, identify solutions and implement them. Action plans have been developed Jan-19 following the crowdfixing events. Listening into Action/ Safety Ambassador events.
The Trust has had a number of events to engage with staff Taking themes from the staff feedback a number throughout 2019 and asking them to identify areas of improvement, of crowdfixing events have taken place with a and through LiA look to make changes. specific focus on staff wellbeing, mandatory Jan-19 training, and IT. Clinical audit of service standards, and for risk management and Quarterly review of clinical audit programme. the development and maintenance of risk registers. Jan-19 Development of visions, values and strategic objectives which see Trust systems and processes to monitor the quality improvement as an essential part of the growth of the trust quality of services, through divisional structures and staff, supported by a Fit for 2022 work programme. (QGRC), through corporate monitoring of performance (Workforce and OD, and FPC) and Jan-19 through corporate monitoring of quality via Clinical Safety Executive (CSC), and its sub- committees, and Quality and Safety Committee.
Internal review including Patient Safety Visits (execs and Quarterly quality reports to Clinical Effectiveness governors) and Internal Quality Reviews (Quality and Standards Committee (CEE) , Infection Control Committee Assurance (QASA) Team) (IPCC) and CSC from each of the divisions Jan-19
LiA (Listening into Action) programme in place. Eleven teams currently going through improvement journeys and are sharing their Jan-19 experience through Pass it on events
Crowd Fixing events, Team Talk, Pulse checks and Friend and A number of Crowd fixing 'quick wins' in place, family Tests taking place to better engage and empower staff. feedback is that staff feel more engaged. Jan-19
Communication and Engagement Strategy in place. Jan-19 Roadshows, schedule of visits to all teams by Exec Directors in Visibility to and accessibility of senior leadership place. team. Feedback from participating teams Jan-19 positive Quality impact assessments on Cost Releasing Efficiency Quality impact assessments on Cost Releasing Schemes (CRES) Efficiency Schemes (CRES) reported to Jan-19 Gateway and to CSC on a monthly basis. Contract meetings with commissioners
Significant gaps in control / assurance Actions Deadline
The main areas of weakness which result in ineffective or absent Target date Ref Actions required to mitigate the weakness controls / assurance for completion The Trust is reviewing the Clinical Quality Governance Framework Key objective for FF2022 Safe High Quality Care and implement a quality and safety approach applicable Objective. - SHQC 1.1 throughout all levels of the organisation to create and sustain a Sep-19 strong quality safety culture Develop a co-designed model for the BCHC improvement Key objective for FF2022 Safe High Quality Care approach, building on existing programmes including LIA, Safety Objective - SHQC 2.1 Huddles, Learning from Excellence (LfE) and Patient Safety Dec-19 Ambassadors, and adopting new tools. Evaluate the impact of the quality and safety aspects of the BCHC Key objective for FF2022 Safe High Quality Care improvement approach through a series of metrics reported to Objective - SHQC 2.3 Mar-20 CSE.
Insufficient capacity to deliver improvement methodology To be agreed
Lack of understanding, embedding and engagement Aug-19 Lack of alignment to all colleagues roles - written into role profile, Review as part of implementation phase work plans, supervision, appraisal. Aug-19 Risk Appetite Strategic Safe High Quality Care Objective AVERSE
Initial Strategic Risk Risk 12 Committee QSC Score BAF19/2: If we do not deliver safe high quality care we will not meet Current Dr Doug stakeholder including regulators' requirements. This could lead to poor Executive Risk 12 Simkiss/ clinical care, potential loss of reputation and income lead Score Marcia Perry Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There is a risk of maintaining standards of safe, high quality and continuity of patient care across the Inpatient services within the division due to the continued high number of registered nurse vacancies despite the ongoing monthly recruitment days. The wards are maintaining safer staffing numbers of registered nurses each shift by relying heavily on block booked bank and agency staff. However, the wards are currently undergoing a large number Amanda 1957 QSC 16 of nurses (Band 5 & 6) leaving for Hoult other posts or to work full time for agencies. The feedback from patient experience is that patients and families benefit from continuity of care and this is more difficult when using high levels of temporary staffing. There is also a risk to maintaining safe, high quality standards of effective nursing care when using high levels of temporary staffing.
Insufficient temporary staffing due to the specialism of community nurses and levels of staff required Victoria 2278 to meet appropriate staffing levels, QSC 15 15 15 could potentially impact on the Clarke ability to deliver our core services and financial balance Failure to deliver a number of quality improvement programmes, including actions stipulated by CQC and Ofsted, due to senior management team capacity resource constraints and business as usual requirements, would mean that safe, effective, responsive and Claire 2319 well-led services are not delivered, QSC 16 16 16 16 Paintain evidenced and embedded, resulting in children and families not receiving high quality care, and children and young people with special educational needs and disabilities not having their needs identified, met and their outcomes improved BCHC as the main contract lead are unable to deliver on their contractual obligations in full of the PSAS due to the fact that the Ida Road SARC building has a number of estates related issues that make David 2419 the building unfit for purpose. This QSC 16 Coles may result in NHSE raising quality and performance issues with BCHC and poses a risk to the forensic integrity of the service which may impact on organisational reputation.
The CCN service has not routinely been completing and reviewing clinical assessments, care plans and some prescription charts for over 12 months, due to the fact that Hannah 2404 robust systems and processes for QSC 15 formal review dates has not been in Lewis place. This may result in clinical interventions and individualised care not being carried out safely and effectively. Inability to view assessments, treatment/care plans and updates due to an incomplete roll out of a single EPR, results in children having records in multiple formats, Claire 2132 held by a range of BCHC QSC 15 15 15 professionals, caring for the same Paintain child, resulting in incomplete information sharing, which may impact on effective care planning and delivery. Failure to develop and embed a Safety Culture and a patient focussed Quality Improvement Programme due to a lack of Kevin 2275 16 16 16 resource, capacity and expertise will Faibrother result in increased patient harm, Serious Incidents and Never Events.
Key controls in place Assurance that controls are effective Date The Trust has a variety of mechanisms to Assurance data shared and discussed at a variety monitor and assure regarding maintaining of Divisional and Trust Committees including CSC, patient safety and high quality care. QSC and Trust Board. Any concerns are Jan-19 escalated and improvement action plans implemented and monitored From a contracting perspective, a number of Assurance provided at a variety of Commissioner mechanisms are in place to monitor KPIs meetings including Contract Review Meetings and Clinical Quality Review meetings. Jan-19
Clinical policies, procedures and Standard Subject to review and updating. Operating procedures in place Approval/comment via a number of appropriate Jan-19 Committees Patient Experience undertake a variety of The Trust regularly receives high satisfaction patient satisfaction audits and other responses which are discussed at Divisional and Jan-19 mechanisms Trust Committees.
Significant gaps in control / assurance Actions Deadline
The main areas of weakness which result in Target date for Ref Actions required to mitigate the weakness ineffective or absent controls / assurance completion
There are still challenges linked to recruitment Recruitment Summit in LiA approach scheduled across the Trust, with specific work on-going for for March 2019. District Nursing teams and Health Visiting. 31-Mar-19
There are a number of out of date policies in the Policy review and action plan to complete in place Trust - a process of escalation and management is in place, but there are limited Jun-19 resources to ensure full compliance.
Recent CQC inspection has rated the Trust as Detailed action plan in place and 'Must do' actions 'Requiring Improvement' with a small number of complete, however, 'Should do' actions continue 31-Mar-19 Services rated as inadequate. with a completion date of 31 Mar 2019. Risk Appetite Strategic Safe High Quality Care Objective AVERSE
Initial Strategic Risk Risk 15 Committee QSC Score BAF19/3: A failure to deliver the improvements required by CQC and OFSTED in Current Dr Doug Executive Children's services could result in poor outcomes for children and young people Risk 16 Simkiss/ lead Score Marcia Perry Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Ref Description Lead Q1 Q2 Q3 Q4 Failure to deliver a number of quality improvement programmes, including actions stipulated by CQC and Ofsted, due to senior management team capacity resource constraints and business as usual requirements, would mean that safe, effective, 2319 responsive and well-led services are not delivered, Elizabeth Webster 16 16 16 16 evidenced and embedded, resulting in children and families not receiving high quality care, and children and young people with special educational needs and disabilities not having their needs identified, met and their outcomes improved Key controls in place Assurance that controls are effective Date Sources of assurance that Date of Ref The main controls/systems in place to manage principle risks demonstrate the controls are assurance effective Action plans for CQC Must Do and Should Do actions, SEND Statement of Oversight provided at weekly call Action and specific BCHC actions within system-wide plan with DON and COO and monthly children's improvement group chaired by CEO. All 'Must Do' actions due completion December Jan-19 18 are complete and all remaining 'Should Do' actions are on target for completion by 31 March 2019
Additional staffing and infrastructure requirements in place. All 'Must Do' actions due completion December 18 are complete and all remaining 'Should Do' actions are on target for completion by 31 March 2019. Jan-19 Planning for next CQC visit includes data collection/evidence to show a limited impact on patient care and service delivery. Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent controls / Actions required to mitigate the Target date Ref assurance weakness for completion Influence rather than control over other partners in the SEND system across BCHC engaged in all city wide Birmingham for delivery of joint actions meetings to drive improvements Sep-19 forward Whilst patient safety is being maintained, there is potential that the Trust fails to Adult Community Services demonstrate to CQC that actions have been completed. division model of separate Risk management meeting is being adopted in Jan 2019, to better Mar-19 assure the Division and trust that all key aspects of the Well Led review are introduced BAU - other Trust meetings not fully supported such as Contracting meetings. Closer working with Support services such as IPC,E&F IT etc. as enablers is progressing. Mar-19 Risk Appetite Strategic A Great Place to Work Objective MODERATE
Initial Workforce and Strategic Risk Risk 16 Committee OD Score BAF19/4:Failure to promote and embed an inclusive culture and comply with EDHR Current recommendations due to a lack of sustained investment in and focussed leadership on the Executive Risk 16 David Holmes EDHR agenda may result in missed opportunities to utilise the talents of our diverse Lead workforce in leadership positions, low morale in the workforce and reputational damage. Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the controls Date of Ref The main controls/systems in place to manage principle risks are effective assurance Internal assessment linked to EDS 2 undertaken. Variable assurance linked to aspects of EDS2 Jan-19 submission in the past as a result of inadequate data, however, elements linked to race are assured
EDHR policy in place. Policy used to promote culture and data acquired as Jan-19 part of previous Staff Surveys The Trust Values have been redefined, re-launched and led by Jan-19 staff champions. The Equality recommendations have been included in the ‘Fit for 2022’ Improvement plan SMART objectives
Each Division is completing their own version of the ‘Fit for 2022’ Jan-19 Improvement plan which will include SMART equality objectives.
A commitment to the elimination of discrimination and the Jan-19 promotion of equality has been made as our response to the WRES, Big Conversations and the 2018 Staff Survey results action plan. EDHR communication and engagement campaign linked to Culture Calendar in place. Jan-19 recommendations of the EDHR review. Following the Annual Leadership Event on 8 November 2018, work Following the series of Big Conversation events Jan-19 has commenced on the design of the senior leadership programme each of the senior leaders have been requested to and a generic inclusive leadership programme for all colleagues in sign up to deliver at least one ‘quick win’. order to embed a leadership style brings our values to life. This has been identified as a priority for action. Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion The senior leadership programme and a generic inclusive Wide consultation and engagement of all staff in the 31-Mar-20 leadership programme for all colleagues. development and delivery of the programme. Significant backlog in approved EHRAs linked to Policies, CRES Review underway of committee structures and and Service change. Quality Review and CQC has increased need governance arrangements. EHRA process in place, To be agreed for EHRA submission, but Committees will not progress Policies but not yet embedded from Board to Ward without a EHRA being completed. Review of current EDHR policy statement underway to include a An approved refreshed policy statement by March much more positive statement of intent. 2019. 31-Mar-19 From the Business Plans, EDHR needs to be translated into This work will progress once Improvement Plans personal objectives for all corporate, divisional and operational have been finalised and agreed. Directors, their direct reports, their senior management teams and direct reports, coming all the way down the organisation. Then, the To be agreed team and personal objectives need to be incorporated into SMART objectives and linked to their personal and functional performance.
Whilst a number of Equality networks exist, there is a need for A plan is in place to have all Equality Networks further networks to be established including Women's and Neuro- established by March 2019 To be agreed Diversity Internal assessment linked to EDS 2 undertaken. Previous submissions have not been as robust as they should be and there are some actions which need to be addressed. External verification of To be agreed assessment to be undertaken Feb 2019. The key reason for a reduction in assurance is due to the quantity, quality and robustness of data. Accessible Information Policy not in place. Risk (IT) that BCHC will Risk to be opened and managed to reduce impact not implement and embedded across the Trust - linked to To be agreed Servelec, Rio and other systems. Visibility of the information dashboard does not include all Dashboards are being created to rectify this issue. equalities and the nine protected characteristics data for all teams To be agreed for the demographic of the population they serve. Risk Appetite Strategic A Great Place to Work Objective MODERATE
Initial Workforce Strategic Risk Risk 12 Committee and OD Score BAF19/5:If we do not improve staff health and wellbeing due to a failure of leadership at all levels to fully recognise and respond to the impact that mental and physical wellbeing Current Executive David can have on staff and a lack of investment, may result in higher sickness absence, poor Risk 12 lead Holmes staff morale and higher turnover which will have an adverse effect on the delivery of our Score strategic objective. Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group Inability to recruit significant HV staff due to national shortages will result in reduced service delivery, reduced quality and impact on staff health and well 2058 Cheryl Newton 15 being. This is impacting on the ability to reduce caseload sizes to a 350 target in line with funding and commissioned service.
Failure to effectively support staff resulting in high levels of sickness absence may continue to rise which result Workforce 2219 Victoria Clarke 16 16 16 16 in a failure meet contractual and OD, QSC obligations and is therefore a financial and reputational risk to the Trust. Due to sustained clinical staff shortages, increasing clinical acuity and over performance in district nursing, there is an increased workload pressure on clinical staff which may result in a reduction in morale Workforce 2286 and health and wellbeing in Rupinder Chal 15 15 15 these teams. This may further and OD, QSC impact on increasing sickness levels leading to further capacity/demand issues across the city wide service
Due to the over performance of the IMT contract, there is a risk of this impacting on the Workforce 1971 quality of care being provided Liza Walsh and OD, 20 20 20 16 to patients and the wellbeing QSC, FPC of staff. Loss of flexibility to recruit additional staff to address waiting times due to recent changes to the OT contract, from cost per case to block, on top of a background of insufficient capacity to meet Workforce 2220 Sarah Acton 15 15 15 15 demand, will result in and OD, QSC children's needs not being met, an impact on patient experience, staff health and wellbeing and may have a reputational impact on the Trust. Failure to have a fully staffed and long-term senior management team as a result of long term secondments, vacancies and recruitment will result in a potential Workforce 2279 impact on performance Zelda Peters 16 16 16 and OD targets, long-term sustainability and delivery of key Divisional initiatives, which will impact of staff wellbeing, care delivery and performance. Failure to meet best practice guidance from the Information Commissioners code of practice and to progress funding to replace the CCTV system currently installed at Moseley Hall Hospital which is of poor 2260 quality and will not Simon Bates FPC 16 16 16 16 appropriately support and safeguard staff following incidents of assault/theft will result in a potential reputational risk to the Trust and impact on staff morale/health and well-being
Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance EAP (Employee Assistance Programme) System has been Expectation that the Trust will see sickness implemented from Dec 2018 to support colleagues wellbeing absence and stress related conditions improve. 31-Aug-19
A Health and Wellbeing Mastermind group has been created who National Staff Survey and Pulse Check have taken 5 priority actions identified by colleagues at a LiA Aug-19 Crowdfixing event Trust Sickness Absence Policy in place. Expectation that the Trust will see sickness absence and stress related conditions improve Sep-19 and the processes will take less time and be more supportive to staff . A monthly HWB themed approach is being launched to support Uptake in events and internet hits / downloads. May-19 colleagues by events, leaflets and self help.
Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or absent Actions required to mitigate the weakness for controls / assurance completion Trust Sickness Absence Policy is being reviewed to drive Policy review to be completed and revised Policy May-19 wellbeing and 'staying at work' issued. EAP is a new system. Unclear of its effectiveness and impact on To review data and usage. Review effectiveness sickness / wellbeing at this point of sickness levels and wellbeing issues raised. May-19 Need to enhance skills of managers and leadership development As part of a new leadership programme in relation to staff health and wellbeing. managers will access sickness absence training and have availability of other wellbeing training ( Jul-19 mental health, mindfulness etc.). Supporting infrastructure for Organisational development capacity Proposal submitted regarding restructuring and and capability aligning resource to support management Jun-19 Risk Appetite Strategic A Great Place to Work Objective MODERATE
Initial Workforce Strategic Risk Risk 12 Committee and OD Score BAF19/6:If we do not embed our vision and values in behaviours and leadership style Current Executive David we will not deliver our objective of Making a Great Place to Work, nor delivering a high Risk 8 lead Holmes quality service. Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Vision and Values based recruitment process in place. Used in all areas and monitored through HR. Jan-19 Vision and Values road shows in place since Dec 18. Impact being monitored but unclear yet due to Jan-19 programme only recently being commenced. Refresh of Induction pack for new starters linked to Vision and Appraisal yet to take place Jan-19 values Vision and values are incorporated into the corporate induction Better understanding for new starters of the Trust Jan-19 and shared by Executive Leads Vision and Values. Leaders Code and Staff Charter in place Well established and used within trust, information Jan-19 shared with all staff. Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or Ref Actions required to mitigate the weakness for absent controls / assurance completion Investment required in a Workforce and OD/Leadership Investment to be agreed as part of the Cost Jul-19 Programme pressure submission. Leaders Code and Staff Charter need refresh linked to Vision Action Plan for refresh to be delivered Jun-19 and values Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 15 Committee FPC Score BAF19/7: If we are unable to transform our digital capability due to the cost and difficulty of Current effectively implementing change, we risk impacting on patient care and foregoing efficiency Executive Risk 15 Ian Woodall opportunities lead Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group Failure to update technology to support clinicians within a community environment due to a delay in the implementation of total mobile is impacting on the ability of our clinicians to be Workforce 2277 Victoria Clarke 15 15 15 as efficient and effective as and OD, FPC they could be. This results in unnecessary delays in updating patient records which includes, assessments, activity, follow up appointments etc. Inability to view assessments, treatment/care plans and updates due to an incomplete roll out of a single EPR, results in children having records in multiple formats, held by a range of 2132 BCHC professionals, caring Stephen Rawlings FPC, QSC 12 15 15 15 for the same child, resulting in incomplete information sharing, which may impact on effective care planning and delivery.
Failure to implement a Trust wide Electronic Prescribing System across appropriate areas of the Trust due to 2272 Melanie Dowden FPC, QSC 15 15 15 financial constraints will result in a detrimental impact on reducing harms in care.
Failure to implement a Trust wide Patient Administration System due to financial 2273 constraints will result in a Colin Graham FPC, QSC 15 15 15 detrimental impact in ensuring effective harm free care. Failure to have effective Information Security systems/cyber security counter measures in place due to a lack of resource or 1861 financial investment will result Duncan Robinson FPC 16 16 16 in a potential loss of data or service, which could lead to an impact to patient care and reputational damage to the Trust. Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Receipt, review and approval of Capital Bids and Cost Pressures in As a result of some elements being agreed, support of Digital improvements funding has enabled a number of initiatives to 28/03/2019 progress EPR Business Case High Level Implementation Plans in place and 31/03/2019 monitored for assurance Total Mobile pilots underway Pilot being rolled out across ACS and also a small 20/01/2019 element of HV Service LiA Pulse Check and IT Crowdfixing Event 10-Week "IT Quick Wins" Delivery Plan 15/03/2019 Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or absent Ref Actions required to mitigate the weakness for controls / assurance completion Production of a new Digital Strategy 2019-2022, underpinned by Strategy being developed relevant business cases (Infrastructure, EPR, Telecoms etc.) 26-Mar-19 Total Mobile Pilot and Main Deployment Plans in support of Pilots to be completed and assessed to ensure enhanced mobile/agile working system is fit for purpose. Sep-19 Capital Bids and Cost Pressures in support of Digital improvements Decisions regarding various funding not yet 31-Jan-19 have been made agreed Cessation of Estates & IT Steering Group in favour of just an Proposed incorporation of IT oversight within the Estates Steering Group existing Information Board 31/03/2019 Proposed CCIO roles not yet recruited to Job Descriptions being banded by HR 08/02/2019 Adverts ready for publishing Clinical Digital Innovation Forum not yet in place Proposed Clinical Digital Innovation Group to be convened and operational - will incorporate CCIOs 31/01/2019 when recruited to Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/8 :If we are unable to maintain sustainable contractual margins, develop and Current Executive deliver efficiency gains due to market pressure and a lack of opportunity and/or Risk 15 Ian Woodall lead capability, we risk damaging our financial sustainability. Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group If we do not have access to high quality information due to poor quality data input or inaccurate data input processing, there is a risk that poor clinical and 2304 Ashley Murtagh FPC business decisions are made 15 15 as by relevant Trust managers / leaders, which will have a financial and reputational impact on the Trust Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Robust financial management arrangements indicating potential This will reduce the original CRES requirements financial flexibility of control total and inflated funding allocated Jan-19
Gateway process in place to identify opportunities for efficiencies The first stage of the gateway process has taken place and the second stage should be complete by the end of March as of time of writing 58% of 31/01/2019 the 19/20 CRES target has been identified.
Trust reviews NHS benchmarking, Carter opportunities and Appropriate benchmarking was an enabler in model hospital data to support the identification of opportunities. ensuring 100% of 18/19 CRES is on track to be 31/01/2019 delivered Actively engaged in the STP and work streams where possible BCHC active member in the Early Intervention opportunities have been identified. work stream which is looking to deliver qualitative 31/01/2019 and quantitative benefits Service Line Reporting produced on a monthly basis to show FPC review of SLR on monthly basis and all margin on all service lines along with risks to income. Divisions present their SLR highlights on cyclical basis. This identifies risks and opportunities and 18-Jan-19 provides assurance to mitigate risks
Periodic re-basing of contracts where possible to reduce outlier MLA contract fully re-based in 2017/18; re-basing areas of margin. of NHS England contract on-going. 18/01/2019
Multi-year contracts where possible to reduce short term Signed multi-year contracts for non-NHS exposure to changes. contracts. 18/01/2019 Annual financial planning round considers likely areas of Annual financial plan to Board, which highlights disinvestment and builds in mitigating actions or financial and provides funding for risk areas such as 18/01/2019 contingency. BSHAS. Soft intelligence from commissioner discussions to understand Monthly contract briefing document. Actions 18/01/2019 and mitigate emerging risks taken as necessary and managed through Tenders for new business or renewal of existing business all MinutesManagement of FPC, Board. Board showing challenge and reviewed by Exec Team/FPC/Board. scrutiny. 18/01/2019 Service Transformation Team in place to support Divisions in Formal management arrangements CRES development 31/01/2019 Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date Ref Actions required to mitigate the weakness controls / assurance for completion BCHC does not have a single approach to productivity BCHC Single Improvement Steering group has improvement that supports the identification and delivery of been established and it has been identified as To be agreed opportunities and efficiencies part of the Fit for 2022 delivery objectives that a The first stage of the gateway process has identified that 42% of Furthersingle improvement Gateway processes approach to isidentify introduced. areas of the 19/20 CRES target has not been identified. CRES to reduce shortfall To be agreed
Number of CRES programmes being developed but not yet Programmes to be finalised and agreed to meet approved 42%. To be agreed
Limited understanding of competitors' costs and margins given Remain transparent with Commissioners commercial sensitivities. identifying that BCHC offers value and to 'sell' the To be agreed BCHC positions best as possible. Inability to influence procurement arrangements within the Local Consultation exercises with LAs to highlight the Authorities collective value of NHS providers To be agreed Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/9: If we are not able to mitigate emerging risks relating to EU exit due to lack Current Executive of visibility of the true risk and /or availability of mitigations, we risk impacting on Risk 8 Ian Woodall lead accessibility of services and quality of patient care. Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseei Ref Description Lead Q1 Q2 Q3 Q4 ng group
There are no applicable corporate risk register risks related to this strategic risk
Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Key potential impacts identified linked to key or significant Initial risk assessment identified costs suppliers based on financial value. associated with suppliers, which excluded a 07-Jan-19 number of suppliers who provide services as opposed to products RA now in place for DHSC areas and BCHC areas. Submission to DHSC completed and discussions at ETM. No immediate concerns 10-Jan-19 highlighted regarding process Trust working group established to meet fortnightly. Meeting provides updates on progress, any identified gaps and actions for assurance 23-Jan-19 Of the 116 Companies it has been assessed that a total of 39 Companies identified as low risk have been potentially pose a risk of disruption to continuity of supplier as agreed by Divisions/services as being equipment/components are believed to be manufactured within the primarily 'services' or entirely UK based 25-Jan-19 EU. product supply chain
Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or absent Ref Actions required to mitigate the weakness for controls / assurance completion Financial impact uncertain as self assessment took place without Further engagement with key BCHC services contacting suppliers at the direction of DHSC. to identify stock holdings, potential time to impact and impact on patient care/service 30-Jun-19 delivery Service delivery impact uncertain. Specific work streams linked to high risk Governmental actions are out of BCHC control areas undertaken in January 2019 30-Jun-19 System wide assurance via CCG led teleconferences have CCG to engage with external partners and identified that assurance linked to Primary Care, OOH, and private provide feedback 30-Jun-19 providers has not been undertaken Unclear how local coordination through CCGs will take place. Trust working group established to meet Limited assurance regarding DHSC actions/mitigations - inc 6 fortnightly. 30-Jun-19 week supply post EU exit date Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 9 Committee FPC Score BAF19/10:If we are unable to ensure an estate that complements our clinical and Current Executive enabling strategies due to technical and commercial constraints, we risk impacting on Risk 9 Ian Woodall Lead delivery of our strategic work programme. Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group BCHC as the main contract lead are unable to deliver on their contractual obligations in full of the PSAS due to the fact that the Ida Road SARC building has a number of estates related issues that make the building unfit for 2419 David Coles QSC 16 purpose. This may result in NHSE raising quality and performance issues with BCHC and poses a risk to the forensic integrity of the service which may impact on organisational reputation.
Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Comply with and report on HTM and statutory/regulatory BCHC has Authorising Engineer requirements (external/independent) and internal trained authorised personnel to ensure process and Jan-19 practices are carried out in accordance with HTM and statutory/regulatory requirements E&F related Policies are reviewed/updated and in place for all Regularly reviewed and updated Policies. E&F related aspects Jan-19 For the majority of non freehold premises that are managed Assurance from landlords and attendance at externally we have leases and Heads of Terms in place and the stakeholder meetings. provision of assurance regarding compliance with recognised Jan-19 standards.
Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or absent Ref Actions required to mitigate the weakness for controls / assurance completion Local Estates Forum is a relatively new group and is trying to Forum to develop and react as necessary to react to emerging clinical strategies across the STP changes in clinical strategies 31-Mar-19 Need to ensure that the BCHC Estates Strategy aligns with the Finalising the Estates Strategy in preparation for BCHC Clinical and IT Strategies Trust Board March 2019 31-Mar-19 For the non freehold premises that are managed externally we Need to ensure that private landlords are able to need to have systems in place to provide assurance regarding provide the assurance BCHC requires. To compliance with recognised standards. support this an additional and dedicated BCHC E&F member of staff is being recruited to ensure 30-Jun-19 compliance and audit those assurances.
Facilities staff currently going through a transformation process Transformation process needs to be completed and there are a number of key vacancies which will need to be and then vacancies filled 31-Dec-19 recruited to Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 8 Committee W&OD Score BAF19/11: If we do not recruit and retain staff and develop a workforce with the right Current skills to deliver our strategy due to inadequate workforce planning and an ineffective Executive Risk 20 David Holmes recruitment and retention strategy we may fail to attract and retain the most capable and Lead Score ambitious staff and deliver our Fit for 2022 Strategy Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group Failure to have robust, effective and appropriate Mandatory Training processes in place due to inadequate mapping and training needs analyses will 2293 Heather Wilby FPC 16 16 16 result in failing to appropriately support staff in delivering their role and would result in financial and reputational impacts upon the organisation. There is a risk of maintaining standards of safe, high quality and continuity of care QSC, at Moseley Hall Hospital 1957 Amanda Hoult Workforce 9 12 15 15 because of a reduced number and OD of registered substantive nurses on wards 5 and 6 in particular. Loss of flexibility to recruit additional staff to address waiting times due to recent changes to the OT contract, from cost per case to block, on top of a background of QSC, 2220 insufficient capacity to meet Sarah Acton Workforce 15 15 15 15 demand, will result in and OD children's needs not being met, an impact on patient experience, staff health and wellbeing and may have a reputational impact on the Trust. Inability to recruit significant HV staff due to national shortages will result in QSC, 2058 reduced service delivery, Cheryl Newton Workforce 15 15 15 15 reduced quality and impact and OD on staff health and well being.
Failure to meet CDC and pre- school child assessment waiting times due to demand QSC, and capacity issues will result 1944 Sarah Acton Workforce 15 15 15 15 in a negative impact on and OD children, families, staff and other services. Due to a lack of capacity of appropriate Orthodontic dental clinicians to support specialist and training clinics QSC, 1611 there is a waiting list for Helen Lappin Workforce 12 16 16 16 treatment of up to 5 years and OD resulting in treatment delay and potential harm to patients. There are increased waiting times to access SLT assessment and management for dysphagia QSC, 2254 and communication as a Louise Oldnall Workforce 20 16 16 16 result of a lack of capacity and OD within the Service, which result in a risk of harm to patients .
Due to sustained clinical staff shortages, increasing clinical acuity and over performance in district nursing, there is an increased workload pressure on clinical staff which may QSC, 2286 result in a reduction in morale Rupinder Chal Workforce 15 15 15 and health and wellbeing in and OD these teams. This may further impact on increasing sickness levels leading to further capacity/demand issues across the city wide service
Failure to manage current sickness absence levels across the Division, due to the inability to effectively 2219 support staff to remain fit and Victoria Clarke W&OD 16 16 16 16 at work, may result in an increase in staff sickness levels and turnover.
Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Trust wide Recruitment and Retention Strategy in place. Recruitment and 'Leavers' closely monitored through Divisional and Trust Committees to Jan-19 provide assurance to the Board on a monthly basis There are a number of people development mechanisms in place Mandatory training is monitored and assured, with linked to mandatory training, professional development etc. rectification plans put in place to address any Jan-19 areas of non-compliance. Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion No current Education and Development Strategy in place. Talent Management Strategy in draft form to be 2022 tabled at ETM Jan 2019, to include staff awareness linked to career progression/equality of access to education and learning.
People development approach is not cohesive and coordinated Cohesive and coordinated people development 2022 across the whole Trust mechanism needs to be put in place across the whole Trust which should include a competency framework/policy We do not have robust systems to identify and map staff skill sets Will form part the Talent Management Strategy 2022 and qualifications in order to better target skills to areas of highest need. Risk Appetite Strategic Making Good use of Resources Objective MODERATE
Initial Strategic Risk Risk 8 Committee FPC Score BAF19/12: If Commissioners reduce funding for services or fail to increase funding to meet Current Executive increasing demands, we may be unable to provide a safe, high quality service and/or to meet Risk 12 Ian Woodall lead service demands Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Ref Description Lead Overseeing group Q1 Q2 Q3 Q4 1971 Due to the over performance of the IMT contract, there is a risk of this impacting on the QSC, Workforce quality of care being provided Liza Walsh 20 20 20 16 and OD, FPC to patients and the wellbeing of staff.
1904 Due to changes in national funding from HEE, the Trust is likely to face a loss of income up to the School of QSC, Workforce Dental Hygiene and Therapy Carolyn Inman 20 20 20 16 and OD, FPC of approximately £1.5M recurrently, which will have a financial impact on Trust income. 2307 The School of Dental Nursing will fail to deliver an accredited training programme due to decommissioning of training Tina Gorman FPC 12 12 12 15 funded by Health Education England. The impact will reduce the pool of suitably qualified Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the controls Date of Ref The main controls/systems in place to manage principle risks are effective assurance The key controls that make the biggest contribution to mitigating Assurances (internal or external) that suggest the the risk controls are working effectively, i.e. vacancy or Jan-19 turnover, safe staffing reporting or CQC findings. Planning Round negotiations will ensure 2019/20 Contract value The Planning Round will commence in Q4, however, in and activity plans are based on 2018/19 normalised forecast Q3, all Divisions will have signed off their normalised outturn with additional demographic growth factored in based on forecast outturn position and business cases pending local authority growth statistics. The Commissioners will approval enabling Contracting and Commercial determine the level to which funding is agreed or activity plans Finance to submit the model to FPC for approval. The adjusted to reflect budget. Planning Round teams will also be agreed in Q3 per Jan-19 Service. In Q4, Contracting will commence the Planning Round aiming to secure the funding detailed within the model approved by FPC. Escalation procedures are in place. Progress reported to EMT weekly when positions emerge. Business cases for cases in funding, changes to delivery and/or Business cases have been submitted to the case management can be presented in year to Commissioners to Commissioner for Community Paeds (CiC), offset the risk of under-funding. neurodevelopment pathway and SLT, these are awaiting approval by the Commissioner. Jan-19 Two other business cases have been approved and are in effect, namely, Children's Physiotherapy and Children's Occupational Therapy, collectively worth ~£1.1m. Under service condition 29 (SC29) of the NHS standard contract An AQN has been served in relation to the IMT over there is a requirement for both the commissioner and Provider to performance. A meeting is scheduled to take place 30 monitor and manage the levels of activity and referrals into Jan 19 with Commissioners to discuss a method of services. The condition also enables either party to raise an either a) increasing capacity through funding or b) Jan-19 ‘Activity Query Notice’ which requires both parties, within a managing the waiting list to reduce over performance defined timeframe, to develop a plan to manage increases in to plan. An update will be given to the Division and demand to services. into PPMB. Negotiation with HEE is to take place to mitigate the risk and Negotiations are underway with Contracting and report to FPC in Q4. Commercial Finance. A February update is planned to Jan-19 be shared with FPC. Significant gaps in control / assurance Actions Deadline Target date The main areas of weakness which result in ineffective or absent Ref Actions required to mitigate the weakness for controls / assurance completion Awaiting the Commissioner's confirmed allocation of funding, this Continue to meet with Commissioners during the Mar-20 may impact the opportunity to fund all areas as requested. planning round, following the planning round structure and guidance to resolve or escalate the emerging issues. Due to commissioner restructuring there can sometimes be a lack Keep accurate records and filing of meetings and Mar-20 of understanding regarding services and patient pathways decisions in order to ensure the corporate memory. Contracting ensures all CV are signed and recorded on the register. Risk Appetite Strategic Making Good Use of Resources Objective MODERATE
Initial Strategic Risk Risk 16 Committee FPC Score BAF19/13: If we fail to implement a clear strategic direction for research and Current innovation due to lack of commitment and/or resources, we will lose and/or fail to Executive Risk 12 Ian Woodall attract research activity and income and the ability to contribute to evidence based lead care Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseei Ref Description Lead Q1 Q2 Q3 Q4 ng group
There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Revised Cost pressure budget submitted and to be tabled at ETM on 21 Jan 2019. Jan-19
Grants awarded valued at £3.7M (income £874,000) from 2020/21 Longer term the situation has improved. Jan-19 Strategic funding bid being submitted to the West Midlands This submission - if awarded - will mitigate Clinical Research Network in January 2019 for three additional the short term funding gap until 2020/21 posts. Jan-19
Significant gaps in control / assurance Actions Deadline
The main areas of weakness which result in ineffective or absent Target date Ref Actions required to mitigate the weakness controls / assurance for completion
The awarded grants will not commence until 2020/21 Cost pressure submission 21-Jan-19
Trust investment still required to sustain function in the short term - linked to 2019/20 cost pressure submission. Likely that cost pressure will only be funded for 2 clinical Divisions and not the whole Trust To be agreed
Innovation Engine 3 funding from the Regional Development Part of the cost pressure submission. Agency (EU) has been withdrawn, so an increased cost pressure Furthermore, BCHC is in partnership with for 1.8 x WTE Innovation post from April 2019. Surrey and Borders NHS Trust to apply for To be agreed funding (up to £25M) in the area of healthy ageing. The application with Surrey and Borders is in the early stages but Part of the cost pressure submission. process is delayed. Applications for funding likely to open March Furthermore, BCHC is in partnership with 2019 and if awarded funding this will be in Oct 2019. Surrey and Borders NHS Trust to apply for funding (up to £25M) in the area of healthy To be agreed ageing.
Research and Innovation Director and Research Pharmacy Lead both due to leave BCHC at end of march 2019. This equates to 50% of the senior management team. Recruitment process for these posts has not yet formally commenced. To be agreed Strategic funding bid submitted to the West Midlands Clinical Research Network is limited to funding for a 12 month period To be agreed Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/14: If we fail to engage with and build strong partnerships externally or to foster Current relationships and failure to align our priorities to those of our partners and the wider system Executive Risk 12 Angie Wallace due to a lack of leadership capability, may result in us being unable to secure contracts, sustain lead Score our services over the longer term and ultimately deliver integrated services for our community Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group 2304 If we do not have access to high quality information due to poor quality data input or inaccurate data input processing, there is a risk that poor clinical and business Ashley Murtagh FPC, 15 15 decisions are made as by relevant Trust managers / leaders, which will have a financial and reputational impact on the Trust
Key controls in place Assurance that controls are effective Date
Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance New Trust strategy explicitly indicates the importance of partnerships Programme delivery including 1) a model of neighbourhood (c 50k pop) multidisciplinary team working with GPs, social care and mental health 2) delivery of Birmingham Older Peoples Programme including new intermediate care service model working with UHB 3) deliver learning disabilities Jan-19 Transforming Care Partnership and Accountable Care Organisation opportunity with partners 4) develop collaborative systems with partners to develop an effective prevention and self-care offer for communities
Relationship management structure with named Executive with Attendance at GPPO governance meetings, notes responsibility for a locality, a GP Provider Organisation (GPPO) and the of GP Advisory Board Jan-19 CCG GP Locality lead. Setting up a GP Advisory Board to meet quarterly Strategic Partnership Log & Dataset and Collaborative Service Strategic Partnership Log Report and Collaborative Development templates to capture membership, leadership and contact Service Development templates completed and Jan-19 details for all GPPO's and record specific collaborative initiatives for reported each locality and GPPO Full engagement and participation in Birmingham and Solihull STP to Attendance at Early Intervention Workstream, develop partnerships including 1) Birmingham City Council 2) Maternity Children and Adolescent Portfolio, Birmingham and Solihull Mental Health Foundation Trust 3) GPs 4) Ageing and Later Life Portfolio, Birmingham Older Jan-19 University Hospitals Birmingham and Women's & Children's Hospital Peoples Programme Board, On-going Personalised Support Workstream and STP Development and Delivery Group Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion Absence of electronic stakeholder management system (CRM) CRM option has been tested and return on investment (recurrent and non-recurrent) not To be agreed evidenced. Local solutions in place Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 15 Committee FPC Score
BAF19/15: If we are unable to provide equity of access and/or quality across the entire Current Executive geography and population we serve or fail to successfully implement our locality model Risk 9 Angie Wallace lead due to recruit challenges in some areas, this may result in inequality of provision Score Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score
Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Recruitment campaign across the W Mids commenced in October Full impact not yet able to be assessed 2018 for all staffing groups. Jan-19 Supported the development of the Nursing Associate Role and this has enhanced skill mix Jan-19 Clear Recruitment Strategy and trajectory in place Recruitment trajectory is currently on track and continues to be closely monitored through Divisional and Trust Committees to provide Jan-19 assurance to the Board on a monthly basis
Significant gaps in control / assurance Actions Deadline
The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion
Unable to assess the effectiveness of the campaign at this time To be agreed and staff turnover remains high at approximately 10% National shortage of nursing staff including specialist roles To be agreed Aging workforce population may increase staffing shortfall Staff are being encouraged to return to work post retirement. To be agreed The risk of inequality due to insufficient staff to provide the right To ensure that staff are supported and their health care in the right place. and wellbeing is enhanced. To be agreed Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/16: If we fail to engage with the new primary care network model we will lose the Current contracts that make up the core of our community services and will as a result be unable Executive Risk 15 Angie Wallace to implement and successfully deliver on our strategy related to integrated community lead Score services. Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance New Trust strategy explicitly indicates the importance of Agree neighbourhoods with GPs, Mental health relationships with GPs/ Primary Care, including the implementation and social care providers, Commissioners and of a model of neighbourhood (c 50k pop) multidisciplinary team other stakeholders Jan-19 working with GPs, social care and mental health including setting up integrated neighbourhood teams Relationship management structure with named Executive with Attendance at GPPO governance meetings, responsibility for a locality, a GP Provider Organisation (GPPO) notes of GP Advisory Board and the CCG GP Locality lead. Setting up a GP Advisory Board to Jan-19 meet quarterly Strategic Partnership Log & Dataset and Collaborative Service Strategic Partnership Log Report and Development templates to capture membership, leadership and Collaborative Service Development templates contact details for all GPPO's and record specific collaborative completed and reported Jan-19 initiatives for each locality and GPPO Full engagement and participation in Birmingham and Solihull STP Attendance at Birmingham Older Peoples to develop partnerships (including GPs) across the City Programme Board, On-going Personalised Jan-19 Support Workstream and STP Development and Delivery Group Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion
Absence of electronic stakeholder management system (CRM) CRM option has been tested and return on investment (recurrent and non-recurrent) not To be agreed evidenced. Local solutions in place Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/17: If we do not change and redesign our services quickly enough to Current demonstrate the effectiveness of our model to partners and stakeholders we will be Executive Risk 12 Angie Wallace unable to retain key contracts which will result in us being unable to deliver our older lead Score people model. Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseei Ref Description Lead Q1 Q2 Q3 Q4 ng group There are no applicable corporate risk register risks related to this strategic risk
Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance All referrals have been assessed and evidence based linked to BCHC now has assurance that the data is localities and internal BCHC contracts and Primary Care robust and aligns with where our services are Jan-19 Contacts being delivered based on current use of the service Engagement and negotiation with GP Federations across the city. Jan-19 NHS Commissioners are fully engaged in the process and discussions Jan-19 BCHC is already redesigning services with stakeholders to This demonstrates that BCHC is moving at demonstrate the effectiveness of the new integrated care model. pace with partners and redesign is having an impact as Home Based Therapy and Early Jan-19 Intervention Programme are reducing bed days within the acute sector Significant gaps in control / assurance Actions Deadline
The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion
Other partners such as BCC and BSMHFT have not progressed this work at the same pace as BCHC. To be agreed Work needs to be undertaken to ensure that Team capacity Assessing the viability of being able to fulfils the need of the locality and is appropriate in size to meet operationalise the service delivery model. To be agreed this need GP Federations desired outcomes may not align with the Continued engagement with GP Federations optimum patient pathway/access To be agreed There is a risk that Commissioner funding will be based on geography and not on the health needs of that particular locality To be agreed
There is a risk that the estate required to support the locality Ongoing liaison with BCHC Estates to ensure model will not move at pace and be aligned to service delivery that internal and external partners are aligned To be agreed time requirements with the pace of change,. Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 12 Committee FPC Score BAF19/18: If we don’t have sufficient Commissioning Expertise in Learning Disability Services, we may be unable to demonstrate our system leadership model and Current Executive consequently may be unable to realise the benefits of being a commissioner of other Risk 6 Angie Wallace lead LD services Score
Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Briefing paper and proposal submitted to NHS E and CCG In principle NHSE, CCG and LA have all agreed regarding BCHC developing and leading the model the principles of the proposal Jan-19
Financial Bid submitted to NHS England in December linked to Work programme tabled and discussed at project. Transforming Care Partnership Board and the W Jan-19 Mids Provider Alliance in January 2019
Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion Financial bid rejected by NHS England;. CCG now considering a smaller financial bid submitted in Jan 2019 To be agreed
Local Authority lead meeting arranged in December, but meeting Further meeting to be rescheduled with LA and was cancelled CCG supporting. To be agreed Lack of a coordinated Project Group to coordinate actions and Project Group to be established between BCHC implement action plan and relevant partners To be agreed Complete funding not yet agreed If 100% funding from partners is not received then BCHC will propose a cost pressure for internal funding for BCHC to lead the development of the To be agreed project. Risk Appetite Strategic Integrated Care in Communities Objective MODERATE
Initial Strategic Risk Risk 9 Committee FPC Score BAF19/19: Failure to develop a strong partnership with BSMHT will reduce the chances to bring Executive together mental and physical community health services affecting our ability to provide the best 9 Angie Wallace care to our patients and service users. lead Assurance Q1 Q2 Q3 Q4 rating (quarterly) Contributory risks from the corporate risk register Risk Score Overseeing Ref Description Lead Q1 Q2 Q3 Q4 group There are no applicable corporate risk register risks related to this strategic risk Key controls in place Assurance that controls are effective Date Sources of assurance that demonstrate the Date of Ref The main controls/systems in place to manage principle risks controls are effective assurance Board to Board discussions taking place to progress partnership Notes from meetings working Q1
Medical Director meeting with Medical Director to ascertain best Development of TOR’s for MHC practice in relation to the Mental Capacity Committee Q1
DoN/exec discussions to co-create strategy to work in partnership Meetings between Directors of Nursing and Therapies to develop plan for areas of co-creating Q1 of work plans Co-working regarding STP Early Intervention and Ageing Well Initial work linked to Early Intervention working well and has received positive feedback from Patients, May-19 staff and referrers. Partnership Pilot between Moseley Hall Hospital and Juniper Linked to the Early Intervention pilot and testing Centre led by ASRD progressing. work May-19
Significant gaps in control / assurance Actions Deadline The main areas of weakness which result in ineffective or absent Target date for Ref Actions required to mitigate the weakness controls / assurance completion
Failure to build relationships between organisations Co-design work being developed Q4 Failure to build relationships between organisations DoN/exec discussions to co-create strategy to work in partnership to continue and agree next steps Q4
Failure to build relationships between organisations Medical Director meetings to create Medical Health Regulation common themes work to be completed Q1
As part of the STP Locality and Neighbourhood model, Multi- Net yet started as awaiting the development of disciplinary teams will be configured to align with Primary Care, PCN's. Q4 if agreed Social Care, BSMHT and Third Sector enabling effective with STP prevention and self-care for individuals e.g. Social prescribing.
Committee Escalation Report
Committee: Quality & Safety Committee
Date of Meeting: 30th May 2019
Presented by: Professor David Sallah, Chair/Non-Executive Director
The committee wants further information on the circumstances leading to grade 4 ulcers. The committee remains very concerned in relation to the recruitment of Significant health visitors, caseload sizes and performance against key risks/issues performance indicators. for escalation The Corporate Risk Register report should contain information on mitigating actions and clarity on the committee responsible for seeking assurance.
Reaffirmation of the importance of timeliness for paper submissions to ensure time for committee members to digest the enclosures. The committee heard a Deep Dive presentation from the Dental Division. Discussion on quality and safety issues and the progress made in in the Clinical Safety Short Life Working Group. There is a celebration event of patient safety and culture on 5.7.19. Division will link to Malcolm Parker to review risks and divisional processes. Committee agreed that future deep dives should focus on the CQC Key Lines of Enquiry; Safe, Caring, Responsive, Effective and Well-led. The committee will want to see information on patient safety, clinical effectiveness including outcomes and patient experience. This has been communicated to the Divisional Triumvirates. Presentations should be led by the clinical leaders. Key Children Improvement Group report was not available as with the issues/matters changes in committee meetings, that meeting is tomorrow. Acting COO discussed at provided a verbal update of the pertinent issues. Committee remains the Committee very concerned in relation to health visiting recruitment, caseload size and delivery of KPI’s. From the Medical Director and Director of Nursing and Therapies report, the committee noted the work developing the BCHC Quality Improvement approach and will have a paper on progress at the next meeting in June. The Corporate risk register paper was scrutinised and a request for the paper to include the mitigating actions and clarity about which committee is overseeing the risk, as currently there is duplication within the board sub committees assurance processes. In relation to serious incidents the committee noted progress. Concern about grade 4 pressure ulcers and a discussion about the role of transfers in these ulcers. Changes to the process for reporting pressure 1
ulcers have been raised previously and an increase in reported numbers is expected. The Director of Nursing and Therapies presented the detailed safe staffing paper. This report includes nursing, AHP colleagues and Health Visiting data. The month 1 Quality Impact Assessment report on the CIP process was considered with an appendix describing the Quality risks and benefits. The financial appendix does not need to be presented at this committee. The committee scrutinised the Quality and Performance Report. Discussion about the Essential Care Indicators for the Dental Division, the WHO checklist audit plan and the pathways >52 weeks were discussed. The role of the Quality report was discussed. Elements will be incorporated into the Director of Nursing and Therapies and Medical Directors report with an appendix of more detailed information in areas not already addressed in other reports to the committee. The committee received and noted the escalation reports from the Quality & Safety Executive and Risk Management Executive.
To receive a paper in June’s meeting on the plans for a BCHC Quality Decisions Improvement approach. made by the To institute an updated template to the Divisional Deep Dives based on Committee CQC KLOEs.
Implications for the Corporate Risk Register or the To receive mitigation information as part of the Corporate Risk Register Board and ensure committee accountability for each risk is clear. Assurance Framework (BAF)
Items/Issues The issue of the digital integration of the Community Dental Service for referral to and the Dental Hospital was referred to the Finance and Performance other Committee. Committees
2
Committee Escalation Report
Committee: Workforce and Organisational Development Committee
Date of Meeting: 28th May 2019
Presented by: Jacynth Ivey, Chair/Non-Executive Director
Significant risks/issues for No significant risks / issues were identified for escalation escalation
The committee considered the Corporate Risks allocated to the Great Place to Work strategic objective and noted the review and reduction of 3 Risk ratings. The committee noted the mitigating actions and were assured about the Risks reviewed. The activities, progress and plans in relation to improving attendance and developing a healthy workplace were noted by the committee. The committee received a comprehensive report in relation to progress on the EDHR recommendations which were integrated into the Great Place to Work and Well Led Implementation Plans. Progress in relation to EHRAs, Staff Networks and EDS2 was noted, recognising considerable work was still to be achieved. Key Concern had been raised in previous meetings in relation to progress issues/matters made in relation to EDHR data. A supplementary report was presented discussed at the which gave some assurance on recent actions undertaken. Committee The committee noted the Gender Pay Gap Report which declared a 16.6% Gender Pay Gap in favour of males on average pay (3.2% on median pay). The Trusts position was consistent with other NHS Trusts but an issue in relation to Bonus payments (Clinical Excellence Allowances) was highlighted. It appeared that female consultants applying for CEAs was a factor which would be addressed. The Adult Community Service Division presented their Workforce Deep Dive describing their current challenges, risks and plans. It was noted that there were considerable workforce transformation issues within the Division, and the management of sickness absence and vacancies remained crucial. The work within the Division focussing on EDHR, Flexible Working and Engagement was acknowledged.
The committee received the draft Workforce Strategy document which set out the forecast demand and supply for workforce in 2022 at Divisional and Trustwide level. The planning element of the document described the future shape and size of the workforce based on Decisions made commissioning outcome and financial planning in a ‘plan on a page’ by the Committee format. The strategy set out 5 key objectives Workforce Planning, Workforce Development, Workforce Deployment, Workforce Collaboration and Workforce Attraction and Retention. Subject to amendments regarding action plan phasing, a supply gap graphic and 1
a number of amendments to wording and format changes the Workforce Strategy was approved. The committee received a draft Strategy Statement setting out the Trusts approach to Apprenticeship development and noted the Trusts obligation as an Approved Apprenticeship Provider. Subject to amendments to strengthen the case for Apprenticeships and describe the future scope for Widening Participation the Strategy was approved. This would be received at the next meeting. The Leadership offer, describing a 5 level framework was presented to the committee. Following appropriate discussion and suggested amendments to give greater clarity regarding the leadership model providing the foundation for the programme, it was approved. The committee approved the extension of the Stress Prevention and Management Policy until 1st January, 2020 to enable a comprehensive review and the need for extensive consultation. The revised Flexible Working Policy was approved.
Implications for the Corporate Risk Register or There were no issues for the Corporate Risk Register. the Board Assurance Framework (BAF)
Items/Issues for referral to other There were no items identified for referral to other committees. Committees
2
Public Trust Board
Reference: Agenda Item no: 7a Enclosure no: 11 Date of Meeting: 5th June 2019 Document Title: Primary Care Networks Responsible Director: Micky Griffith, Interim Director of Strategy & Partnerships Author: Micky Griffith, Interim Director of Strategy & Partnerships
Purpose of the To update Trust Board on the practice membership and footprint of Primary Paper & Key Care Networks submitted to Birmingham and Solihull CCG and Sandwell Points and West Birmingham CCG in May 2019.
Action The Board is recommended to: required by the Committee NOTE the current position.
Prior Trust Board seminar 14th May 2019 discussion
Safe, A Great Place Integrated Care in Making Corporate High to Work Communities Good Use Governance Quality of Implications: Care Resources Impact on: Team configuration and partnerships Risks: Failure to engage with and build strong partnerships externally or to foster relationships and failure to align our priorities to those of our partners and the wider system due to a lack of leadership capability, may result in us being unable to secure contracts, sustain our services over the longer term and ultimately deliver integrated services for our community.
Page 1 of 2
Acronyms BAF Board Assurance Framework PCN Primary Care Networks GPPO GP Provider Organisations EBHO East Birmingham Health Organisation OHP Our Health Partnership MMP Midland Medical Partnership BSMHFT Birmingham and Solihull Mental Health NHS Foundation Trust BCC Birmingham City Council UHB University Hospitals Birmingham DN District Nurse BSol Birmingham and Solihull SWB Sandwell and West Birmingham LTP NHS Long Term Plan ACS Adult Community Services
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Primary Care Network Update
Trust Board 05/06/19
Responsibilities of a PCN
During 2019 and 2020, NHS England will develop seven specifications and seek to agree these as part of annual contract changes
The seven national service specifications are: i. Structured Medications Review and Optimisation; ii. Enhanced Health in Care Homes, to implement the vanguard model; iii. Anticipatory Care requirements for high need patients typically experiencing several long term conditions, joint with community services; iv. Personalised Care, to implement the NHS Comprehensive Model; v. Supporting Early Cancer Diagnosis; vi. CVD Prevention and Diagnosis; and vii. Tackling Neighbourhood Inequalities
Timetable District Nursing Analysis • District Nursing referral distribution by proposed PCN • Geographic distribution of patient postcode for DN referrals for the practices associated with each of the PCNs. • As expected where practices are geographically close the DN distribution is concentrated whereas where practices are spread across a locality or localities the referral activity is similarly dispersed.
NHS Birmingham and Solihull CCG
NHS Sandwell and West Birmingham CCG I3 PCN
Constituency / Locality PRAC NAME PCN East Pak Health Centre Alum Rock East Pearl Medical Centre Alum Rock Central Balsall Heath Health Centre (S) Balsall Heath and Sparkhill Central Balsall Heath Health Centre (W) Balsall Heath and Sparkhill Central Fernley Medical Centre Balsall Heath and Sparkhill Central Firstcare Health Centre Balsall Heath and Sparkhill Central Highgate Medical Centre Balsall Heath and Sparkhill Central Sparkbrook Health Centre (Sparks Medical Group) Balsall Heath and Sparkhill Central Springfield Medical Practice Balsall Heath and Sparkhill Central St Georges Surgery (Sparks Medical Group) Balsall Heath and Sparkhill Central The Hill General Practice Balsall Heath and Sparkhill East BUCKLANDS END LANE SURGERY Birmingham East Central East CHURCH LANE - KHAN Birmingham East Central East DRUID GROUP - Belchers Lane Surgery Birmingham East Central East DRUID GROUP - Ejaz Medical Centre Birmingham East Central East DRUID GROUP - Glebe Farm Road Surgery (branch) Birmingham East Central East DRUID GROUP - Hobmoor Road Surgery Birmingham East Central East OMNIA PRACTICE Birmingham East Central East YARDLEY GREEN MEDICAL CTR Birmingham East Central South GARRETTS GREEN LANE SURGERY Bordesley East East IRIDIUM MEDICAL PRACTICE, RICHMOND PCC Bordesley East East POOLWAY MEDICAL CENTRE Bordesley East East SMALL HEATH MEDICAL PRACTICE Bordesley East East SWAN MEDICAL CENTRE Bordesley East East VICTORIA ROAD SURGERY Bordesley East South BG Health (Bunbury Road) Bournville and Northfield South BG Health (Griffin Brook Rd) Bournville and Northfield South GRANTON MEDICAL CENTRE Bournville and Northfield South Northfield Health Centre (Ali) Bournville and Northfield South ST HELIERS MEDICAL PRACTICE Bournville and Northfield South Woodland Road Surgery Bournville and Northfield South Wychall Lane Surgery Bournville and Northfield South Bath Row Medical Practice Edgbaston South Karis Medical Centre Edgbaston South The Wand Medical Practice Edgbaston North EDEN COURT MEDICAL PRACTICE Erdington and Castle Vale North POPLARS SURGERY Erdington and Castle Vale North RESERVOIR ROAD SURGERY Erdington and Castle Vale North SHAH ZAMAN SURGERY Erdington and Castle Vale North STOCKLAND GREEN PRACTICE (Dr Khuroo's Practice) Erdington and Castle Vale North SUTTON ROAD SURGERY Erdington and Castle Vale North COLLEGE ROAD SURGERY (85087) Erdington and Kingstanding North COTMORE SURGERY Erdington and Kingstanding North DOVE MEDICAL PRACTICE Erdington and Kingstanding North DR MCQUILLAN PRACTICE (Bloomsbury Surgery) Erdington and Kingstanding North KINGSBURY ROAD MEDICAL CENTRE Erdington and Kingstanding West NECHELLS PRACTICE Erdington and Kingstanding North THE OAKS MEDICAL CENTRE Erdington and Kingstanding North THE OAKS MEDICAL CENTRE - Streetly Surgery Erdington and Kingstanding North APOLLO SURGERY GOSK North AYLESBURY PRACTICE GOSK North HILLCREST SURGERY (twickenham Road) GOSK North HILLCREST SURGERY/ KINGSTANDING SURGERY (Dyas Road Surgery) GOSK North KINGSGDALE AND PERRY PARK (Kingdale Surgery) GOSK North KINGSGDALE AND PERRY PARK (Perry Park Surgery) GOSK North KINGSTANDING CIRCLE SURGERY GOSK North TUDOR STOCKLAND GREEN LTD GOSK Central HALL GREEN HEALTH Hall Green Central NORTHBROOK GROUP PRACTICE Hall Green Central SWANSWELL MEDICAL CENTRE Hall Green Central Bournbrook Varsity Medical Centre Harborne South Harborne Medical Practice Harborne South SHERWOOD HOUSE MEDICAL PRACTICE Harborne South UNIVERSITY MEDICAL PRACTICE Harborne Central MMP - All Saints Medical Practice MMP Central Central MMP - Broadmeadow Clinic MMP Central Central MMP - Dudley Park Medical Centre MMP Central Central MMP - The Old Priory Surgery MMP Central Central MMP -Stratford House Surgery MMP Central North MMP - Erdington Medical Centre MMP North North MMP - Jockey Road Medical Centre MMP North North MMP - Mere Green Surgery MMP North North MMP - The High Street Surgery MMP North North MMP Kingsmount Medical centre MMP North North MMP-Eaton Wood Medical Centre MMP North Central BALDWINS LANE SURGERY Moseley, Billesley and Yardley Wood Central GREENRIDGE SURGERY Moseley, Billesley and Yardley Wood Central POPLAR PRIMARY CARE CENTRE Moseley, Billesley and Yardley Wood Central WAKE GREEN SURGERY Moseley, Billesley and Yardley Wood Central YARDLEY WOOD HEALTH CENTRE Moseley, Billesley and Yardley Wood East COTTERILS LANE SURGERY Nechells and Saltley East SALTLEY & FERNBANK MEDICAL PRACTICE (FERNBANK MP) Nechells and Saltley East SALTLEY & FERNBANK MEDICAL PRACTICE (SALTLEY HC) Nechells and Saltley North ST.CLEMENTS SURGERY Nechells and Saltley East YARDLEY MEDICAL CENTRE Nechells and Saltley Central Bournville Surgery Pershore Central FEATHERSTONE MEDICAL CENTRE Pershore South Kingsfield Medical Centre Pershore South MOSELEY MEDICAL CENTRE Pershore Central Riverbrook Medical Centre Pershore Central Selly Oak Health Centre Pershore Central Selly Park Surgery Pershore Central University Southgate Practice Pershore South HIGHFIELD LANE MEDICAL CENTRE Quinton and Harborne South LORDSWOOD HOUSE GROUP MEDICAL PRACTICE (Lordswood House) Quinton and Harborne South LORDSWOOD HOUSE GROUP MEDICAL PRACTICE (Quinbourne) Quinton and Harborne South LORDSWOOD HOUSE GROUP MEDICAL PRACTICE (Quinton FP) Quinton and Harborne South RIDGACRE HOUSE SURGERY Quinton and Harborne Solihull Church Road Surgery Shard End and Kitts Green East FIRS SURGERY Shard End and Kitts Green East HARLEQUIN SURGERY Shard End and Kitts Green East HODGE HILL FAMILY PRACTICE Shard End and Kitts Green East MIRFIELD SURGERY - SAHAY Shard End and Kitts Green East SCHOOLACRE ROAD SURGERY Shard End and Kitts Green Solihull Tile Cross Surgery Shard End and Kitts Green East BORDESLEY GREEN SURGERY Small Heath Central Charles Road Surgery Small Heath East HEATHFORD GROUP PRACTICE - Coventry Road MC Small Heath Central Khattak Memorial Surgery Small Heath Central Khattak Memorial Surgery- Branch site, Mansel Road Small Heath East Park Medical Centre Small Heath West The Limes Medical Centre ( also Finch Rd Primary Care - 0121-25500280) Small Heath East THE SURGERY Small Heath Central College Road Surgery SmartCare Central East Cranes Park surgery SmartCare Central Central Greet Medical Practice SmartCare Central Central Oakwood Surgery SmartCare Central Central Springfield Surgery SmartCare Central Central Strensham Road Surgery SmartCare Central Central The Balaji Surgery SmartCare Central Central Weather Oak Medical Centre SmartCare Central East ACE Med. Partnership - Birmingham Heartlands Surgery SmartCare Kings Heath Central ACE Med. Partnership -Druids Heath Surgery SmartCare Kings Heath Central ACE Med. Partnership -Hillmeads Medical Centre (Branch Surgery) SmartCare Kings Heath Central ACE Med. Partnership -Maypole Health Centre (Aneja) - (formerly M85059)now branch surgery SmartCareof Druids Heath Kings Heath Central GOODREST CROFT SURGERY SmartCare Kings Heath Central Maypole Health Centre (Yap) SmartCare Kings Heath Central Moor Green Lane MC SmartCare Kings Heath Central Vicarage Road Surgery SmartCare Kings Heath Solihull Grafton Road Surgery Solihull and Sheldon Solihull Hobs Moat Medical Centre Solihull and Sheldon Solihull Richmond Medical Centre Solihull and Sheldon Solihull St Margaret's Medical Practice Solihull and Sheldon East THE SHELDON PRACTICE Solihull and Sheldon South Alvechurch Medical Centre (linked to Northwood HC) South Birmingham South Ash Tree Surgery South Birmingham South Cofton Medical Centre South Birmingham South Frankley Health Centre South Birmingham South Hawkesley Medical Practice South Birmingham South Hollymoor Medical Centre South Birmingham South KEYNELL COVERT South Birmingham South Kings Norton Surgery South Birmingham South Ley Hill surgery South Birmingham South Northwood Medical Practice South Birmingham South SHENLEY GREEN SURGERY South Birmingham South West Heath PCC South Birmingham South West Heath Road Medical Centre South Birmingham North SUTTON COLDFIELD GROUP PRACTICE (Falcon Medical Centre) Sutton North North SUTTON COLDFIELD GROUP PRACTICE (Four Oaks Medical Centre) Sutton North North SUTTON COLDFIELD GROUP PRACTICE (Leyhill Surgery) Sutton North North SUTTON COLDFIELD GROUP PRACTICE (Sutton Park Surgery) Sutton North North SUTTON COLDFIELD GROUP PRACTICE (Tudor) Sutton North North SUTTON COLDFIELD GROUP PRACTICE (Versy Practice) Sutton North North ASHFIELD SURGERY Sutton South North ASHFURLONG Sutton South North HAWTHORNS SURGERY Sutton South North MANOR PRACTICE Sutton South East AMAANAH MEDICAL PRACTICE Washwood Heath East HAMD MEDICAL PRACTICE Washwood Heath East OAKLEAF MEDICAL PRACTICE Washwood Heath East ALPHA MEDICAL CENTRE Washwood Heath East ALUM ROCK MEDICAL CENTRE Washwood Heath East GATE MEDICAL CENTRE Washwood Heath East GREENFIELD MEDICAL PRACTICE Washwood Heath East NASEBY MEDICAL CENTRE Washwood Heath East WARD END MEDICAL CENTRE Washwood Heath South BARTLEY GREEN MEDICAL PRACTICE Weoley and Rubery South Grange Hill Surgery (Branch) Weoley and Rubery South JIGGINS LANE SURGERY Weoley and Rubery South LEACH HEATH MEDICAL CENTRE Weoley and Rubery South MILLENNIUM MEDICAL CENTRE Weoley and Rubery South Weoley Park Surgery Weoley and Rubery South WOODGATE VALLEY HEALTH CENTRE Weoley and Rubery West Al-Shafa Medical Centre West Birmingham West Burbury Medical Centre West Birmingham West Cavendish Medical Practice West Birmingham South City Health Centre West Birmingham West Finch Rd Primary Care - 0121-25500280) West Birmingham West Lozells Medical practice West Birmingham West Queslett Medical Centre West Birmingham West Summerfield PCC (Dr Kulshretha) West Birmingham East ACOCKS GREEN MEDICAL CENTRE
Public Trust Board Reference: Agenda Item no: 8a Enclosure no: 12 Date of Meeting: 5th June 2019 Document Title: Quality and Performance Report (QPR) Responsible Director: Ian Woodall, Chief Finance Officer Doug Simkiss, Medical Director/Marcia Perry, Director of Nursing & Therapies Angie Wallace, Interim Chief Operating Officer David Holmes, Director of Workforce & Organisational Development Author: Ashley Murtagh, Director of Performance Mark Chapman, Head of Performance
Executive The QPR has undergone a significant revision following input for the Summary / Executive Team at BCHC. The key changes are: Purpose of the Paper & Key Revision to the Scorecard Domains – These now mirror the Trust’s Points Strategic Objectives with the Key Performance Indicators (KPIs) within each having been reviewed and consolidated where possible. Domain on a Page – Each domain now has an Exec Summary (provided by the relevant Exec lead), Actions and RAG indictor on a single page. Conciseness and presentation – The QPR has been overhauled to ensure the information presented is accurate, visually appealing and concise, focusing on the key and immerging issues in month. Statistical Process Control (SPC) – The QPR now includes SPC charts when a Trust Scorecard KPI triggers an SPC principle along with explanatory narrative.
The QPR is a statutory required report which must be published publically on our Internet page; it is also shared with our Commissioners.
Action The Board is recommended to: required by the NOTE the QPR Committee
Prior Quality & Safety Committee – 30th May 2019 discussion Finance & Performance Committee - 28th May 2019 Management Board – 28th May 2019
Safe, High A Great Integrated Care Making Good Corporate Quality Place to in Communities Use of Governance Implications: Care Work Resources Impact on: X X X X Risks:
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Quality and Performance Report May 2019
Performance Department Birmingham Community Healthcare NHS Foundation Trust Caring | Open | Respectful | Responsible | Inclusive
Reporting Period: April 2019 Within this report
Contents Introduction
Section 1: Safe, High Quality Care The monthly Quality and Performance Report (QPR) provides an overview of the Trust’s performance against the balanced scorecard Key Performance Indicators (KPI) that underpin the delivery of the Trust’s four Strategic Objectives: Section 2: A Great Place to Work Safe, High Quality Care, A Great Place to Work, Section 3: Integrated Care in Communities Integrated Care in Communities, and Making Good Use of Resources. Section 4: Making Good Use of Resources These objectives are used as the four Scorecard Domains with relevant KPIs grouped by Domain. Executive leads are tasked with ensuring the KPIs are relevant, achievable, Section 5: Compliance & Governance measurable, monitored and managed. The QPR includes Executive summaries of Domain performance, a copy of the Trust Scorecard, key narrative with agreed actions and Statistical Process Control (SPC) analysis. The SPC principles for inclusion in the QPR are as follows: Breach of control limits (upper or lower) Consecutive linear trajectory for six data points or more (up or downwards) Six or more consecutive data points above or below the statistical mean A Red rated Scorecard KPI The QPR is published on the Trust’s Internet site and shared with Commissioners. * Safe, High Quality Care Green ●●● Amber ●●● Red ●●● No Target Total 1 11 2 1 6 13/14 (93%) Executive Summary Assessment of Performance & Actions
Currently the Essential Care Indicator for Dental Services is showing no data as this is a The Adult Community Services Division report a number of Service new measure and is currently being rolled out within the service. This month we also improvement schemes which whilst presenting opportunities for report no data against the WHO checklist compliance as processes for delivering the development are also impacting on their workforce and performance at audit are refreshed and reviewed. Reporting will continue next month with improved present. A paper will be taken to the Finance and Performance Committee visibility of where any breaches occur (FPC) in June which will outline the recruitment challenge and agree a Health Visitor WTE in Post Average Caseload is the only red, with an average caseload support package for the service and a planned end of year trajectory to of 434 against a target of 350. This average is expected to increase as new babies are monitor performance against added to the caseload and drops in September as a new school year starts. As a result the services continue to underperform against delivery of the mandatory contacts at Noting that some use of Agency is unavoidable at present the service are key stages in a child’s development Actions to address this are being monitored via the considering a tender exercise to agree a number of Agency Staff over a fixed Child Health Information Group (CHIG). period which the service could then use flexibly in order to maintain safe All the other measures are on green, except for 2, which are Infection Prevention staffing levels but at a controlled and lower cost than agency with greater Control Audit and IMT Safe Staffing. ability to build in quality measures and respond to service needs . This would be a cost pressure and so will be linked into the paper referenced in the A new KPI is reported for April showing compliance with Infection Control Audits action above. across the Trust. For M1 we report a marginal breach at 94% against a 95% target. Areas of concern have been raised directly with Team Leaders and Matrons as the process for the audit is refined and staff communications are sent out to support understanding of and engagement with the audits. A detailed Safe Staffing Report is received each month by Quality and Safety Committee and we continue to report amber against our in-house IMT Safe Staffing target. Over-performance against district nursing contractual targets combined with high sickness and difficulties recruiting to clinical posts continue to be a key challenge to the service * Total excludes KPIs which do not have a target (No Target) 1 Safe, High Quality Care Trust Scorecard 1 Safe, High Quality Care Statistical Process Control (SPC) Analysis
IMT Safe Staffing shows a slight trend towards improvement with the last 5 month’s performance all above the mean average. However the scale of the challenge facing the service is underlined by the fact that the target is clearly shown to be above the Upper Control Limit. This suggests that we are highly unlikely to achieve the target based on the current approach with staff recruitment and increasing workload remaining the key challenges. Note – SPC is an indicative graph based on only 13 months data. Reason for Inclusion : Red Rated Performance
Health Visitor WTE ininin Post Average Caseload continues to be red RAG rated performance, with an average caseload of 434 against a target of 350 in April 2019 . The challenging nature of this target is highlighted by Note – SPC is an indicative graph based on only 13 months data. Reason forforfor Inclusion ::: Persistent Amber Performance Green ●●● Amber ●●● Red ●●● No Target Total * 2 A Great Place to Work 1 1 3 4 2/5 (40%) Executive Summary Assessment of Performance & Actions
There are 3 reds in this domain; percentage of vacancies, percentage Adult Community Services Division plan to recruit 69 WTE by end of March 2020. of sickness absence and percentage of staff appraised (12month However turnover indicates that around 62 WTE staff will leave in this period with a net rolling average). Percentage of vacancies in March was showing red, gain of 7 WTE. The Divisional Director is meeting with Bank Leads to discuss their needs however increases in Establishment Headcount have been noted in for more support and options to tender for a group of agency staff for a defined period Corporate Estates Services, Children and Families and Dental are also being explored. Services. Facilities and Cleaning staff have been formally moved into Estates Establishment and as a result an increase in overall Vacancies is reported. Estates intend to recruit an Mandatory training cluster has been reset for 2019/20 to include additional 20 WTE staff and are being supported by HR to develop a recruitment plan. only Core Skill training requirements. In April performance is showing as Amber at 86.71%, with an increased target from 85% to Noting vacancies and high sickness rates in Estates and Facilities staff, a fixed term HR 90% from April. advisor post has been established in the service to support managers with HR workload and options are being explored to develop bespoke manual handling courses specifically Average length of time to recruit in days (date advertised to offer) for the equipment which the cleaning staff are using. continues to remain on target. Trust Bank will review and refresh Training Needs Analyses for Bank Staff in June 19 with A slight drop is reported in the percentage of staff with a current a view to ensuring that Bank staff are fully compliant with training requirements before Appraisal (PDR). This has dropped to 82.85% in April. Recent data they are put into clinical roles. Staff who are not compliant are not offered work and staff from NHS Benchmarking shows the Trust with a 6 month average who do not work for 3 months are removed from the Bank. The Director of Nursing and PDR compliance of 81.1% against an average for Community Trusts Therapies will be involved in reviewing Bank processes and whether Trust Induction is of 86.1% (as of March 19). sufficient to meet requirements. Learning and Development plan to roll out the Moodle tool in May 19 aiming to make it easier for staff to log onto e-learning. The Learning Disabilities services note continued turnover and have requested options to recruit over their establishment when students graduate. Finance have requested a trajectory showing how over establishment would be covered by turnover of staff.
* Total excludes KPIs which do not have a target (No Target) 2 A Great Place to Work Trust Scorecard 2 A Great Place to Work Statistical Process Control (SPC) Analysis
Percentage ofofof vacancies increased in April, therefore going from Amber to Red RAG rating. Performance in April also is above the upper control limits of the SPC. An increase in vacancies has been seen in Corporate, Children and Families and Dental Services. Increases are largely as a result of new Establishment being created in Month 1 with no time yet to recruit to the posts. Reason for Inclusion : Breach of Upper Control Limit
Percentage ofofof sickness absence continues to be Red Ragged, with a slight improved position from March and continual improved position. A new sickness policy has also been launched in April as a way to improve the management of sickness going forward. The SPC chart highlights that sickness over winter was particularly high. Comparison of the Lower Control Limit with the Target line highlights the scale of the challenge the Trust faces to reduce sickness to target levels with the current target seeming statistically highly unlikely of being achieved without changes to current practices. Reason for Inclusion : Red Rated Performance Green ●●● Amber ●●● Red ●●● No Target Total * 3 Integrated Care in Communities 4 2 5 4 6/11 (55%) Executive Summary Assessment of Performance & Actions
The Domain of Integrated Care in Communities has been reset for 2019/20, The Children and Families service are targeting clinics with high DNA rates by increasing from 9 measures to 15 measure. phoning families to remind them of appointments. Two new KPIs reporting patient waits are shown this month. The first reports Un-outcomed activity lists are being set sent monthly to teams and action taken. patient pathways over 52 weeks from referral with no contact, and the second patients who have had no contact for at least 52 weeks (and who have no Early Years Outreach Workers are being trained to undertake assessment to future appointments booked). We recognise that data quality issues and increase staffing capacity to support delivery of assessments within the information from legacy systems affects these KPIs and Business Intelligence Birmingham Forward Steps (BFS) service. and RIO staff are supporting services to improve. Both of these measures have currently been set a zero target and are showing as Red. Two reds further are reported for Health visitors mandated visits;1) 12 month review, 2) 2 and a half year review. The fifth and final red is for Delayed transfer days as percentage of occupied bed days for NHS reasons. All 3 continue to remain red over the last few months. The remaining two Health visitors mandated visits continue to report as amber. An improvement from amber to green was seen for Total delayed transfer days as a percentage of occupied bed days. . 3 Integrated Care in Communities Trust Scorecard 3 Integrated Care in Communities Statistical Process Control (SPC) Analysis
Health visitor mandated visits ––– 666 tototo 888 week contact is showing current performance as being below the lower control limit. Health visitor mandated visits ––– 121212 month review andHealth visitor mandated visits ––– 222andandand aaa half year show similar patterns abeit without breaching the lower control limit in April. All areas show the impact of CQC assessment in May 18 and the focus on antenatal visits which followed has clearly impacted on performance in other areas of Health Visiting Activity Note – SPC to be used with caution, indicative graph only based on 13 months data Reason forforfor Inclusion ::: RedRedRed Rated Performance /// Breach ofofof Lower Control Limits 3 Integrated Care in Communities Statistical Process Control (SPC) Analysis
181818week pathway consultant ledledled services (incomplete pathways)pathways), continues to perform above target with an improvement trajectory which began in September. The chart is now showing performance slightly above the upper control limit. The SPC chart suggests therefore that current performance is unlikely to be sustained however Children and Families have appointed locums to fixed term posts with a view to longer term recruitment and this is likely to have led to the increased activity in recent months. Reason forforfor Inclusion ::: Breach ofofof Upper Control Limit Green ●●● Amber ●●● Red ●●● No Target Total * 4 Making Good Use of Resources 6 1 3 6 7/10 (70%) Executive Summary Assessment of Performance & Actions
The Domain of Making Good Use of Resources has been refreshed 2019/20, although The phase 1 rollout of Total Mobile is planned for completion by the number of measures stay the same, some measures have been updated or moved August 19 with planning for phase 2 taking place now. Rollout of Total to a different domain. Mobile devices will enable the Adult Communities staff to outcome appointments remotely and is predicted to significantly improve their Although the Contractual – RAP/financial penalty or Activity Management Plan remains level of un-outcomed appointments. red, the number of breaches has dropped from 5 to 1. The 1 relates to Paediatric Sexual Assault Service with NHS England and is pending closure. Learning and Disabilities staff are reviewing ‘DNAs and Was Not Broughts’. In particular they intend to explore links between frequent Within this domain there have been 5 new measures around activity monitoring for DNAs and disengagement with the services for patients who have DNA’s and Cancellations. DNA’s – contact type not defined is one of the new measures poor outcomes in other areas of the Trust, but who are not flagged as and is showing as red. LD patients At Month 1 the Trust is reporting a break-even against a planned surplus of £171k. The Trust is expecting to deliver its planned surplus of £4,229k at the year end. Cash at month end totalled £34.2m (£37.1m Month 12), representing over one month’s payments. Better Payment Practice Code (BPPC) - The number of invoices paid in accordance with the BPPC in Month 12 was 92.93%. The national target is 95%. At Month 1 the Trust CRES program show a small shortfall of £9k. Capital – At Month 1 the Trust is reporting year to date expenditure of £349k against a plan of £249k, mainly due to completion of works spanning 2018/19 and 2019/20, including works on Ward 9 at Moseley Hall Hospital. Agency YTD spend shows a year end small favourable variance of £22k. The Trust annual NHSI plan is £9.047m 4 Making Good Use of Resources Trust Scorecard 4 Making Good Use of Resources Statistical Process Control (SPC) Analysis
DNA Rates (Clinical Appointments) show an increase above the Upper Control Limit in April suggesting Special Cause Variation. However whilst slight increases are shown across the Trust with a sizable increase in Children & Families it is not immediately clear what the cause of the increase in DNAs is.
Reason for Inclusion : Breach of Upper Control LimitLimit 5 Compliance and Governance Workforce Race Equality Scheme (WRES)
The Performance team are working with HR department to disaggregate and report data from the WRES (Workforce Race Equality Scheme) at a Divisional level. In particular we intend to focus on the likelihood of Black Asian Minority Ethnicity (BAME) staff entering formal disciplinary processes versus white staff and also focus on whether shortlisting and eventual recruitment of candidates is equitable. Initial data shows a range of performance across the Trust. We are investigating the data which we can extract from the new recruitment tool TRAC to support this analysis
Committee Escalation Report
Committee: Finance & Performance Committee
Date of Meeting: 28th May 2019
Presented by: Jerry Gould, Chair/Non-Executive Director
Committee was concerned with the level of duplication and potential for conflicting sub-committee recommendations arising from the way we are reviewing the BAF / Corporate Risk Register and is of the view that the Board needs to reconsider how different risks are scrutinised through the committees The committee considered the new format for the new format of QPR and was concerned that, whilst the use of statistical process control provides benefits, we have lost too much of what provided assurance Significant in the previous format. The committee therefore recommends that the risks/issues for new format is fully considered at the next Board Seminar. escalation Whilst the committee was happy to adopt the recommendation to award a new EPR contract (as part of the Digital Strategy) to the current provider, it was not convinced of the proposal for a 5+2 term given the system developments currently being considered through the STP, etc. The committee was unsure of its continuing role in relation to scrutinising sickness given the creation of the new Workforce and OD Committee and asks the Board to clarify responsibilities of the two committees.
Key Issues / Matters discussed by the committee comprised: the Trust Service Level Report and undertook a deep dive review of Children & Families service lines Changes to the BAF/Corporate Risk Registers for Integrated Care in Communities and Making Good Use of Resources latest quarterly Sickness Absence report on-going business development opportunities and progress in relation Key to these issues/matters the latest Activity Variance discussed at the Committee the month 2 Waiting list report the new QPR format and performance illustrated through it and its potential effectiveness to provide assurance to the Board the award of a new contract to the current EPR provider as part of the Digital Strategy the Annual Procurement Review It also received the escalation reports from the Digital Transformation Executive & the Performance and Programmes Management Executive.
1
Recommendation to Trust Board to award the new EPR contract to the Decisions made Trust’s existing provider on a single tender basis subject to Board by the Committee consideration of the proposed contract term.
Implications for the Corporate Risk Register or None the Board Assurance Framework (BAF)
Items/Issues for referral to other None Committees
2