SEPT Meeting of the Board of Directors held in Public at 10.30am on Wednesday 22 February 2017 TR1, The Lodge Runwell Chase, Wickford SS11 7XX
Our Vision “Providing services that are in tune with you”
PART ONE – MEETING HELD IN PUBLIC AGENDA
1 APOLOGIES FOR ABSENCE CL (verbal) 2 DECLARATIONS OF INTEREST LC (verbal) PRESENTATION: POPLAR ADOLESCENT INPATIENT UNIT – APPROACH TO RESTRICTIVE PRACTICE BY DR JOSHUA WESTBURY, CONSULTANT CHILD & ADOLESCENT PSYCHIATRIST AND LOUISE SUMMERS, CLINICAL UNIT MANAGER 3 MINUTES OF THE LAST MEETING HELD ON 25 JANUARY 2017 (attached) 4 ACTION LOG (attached) 5 QUALITY AND OPERATIONAL PERFORMANCE (a) Board of Directors Quality & Performance Scorecard SM (attached) 6 ASSURANCE, RISK AND SYSTEMS OF INTERNAL CONTROL (a) Board Assurance Framework NL (attached) (b) Sub-Committees (i) Finance & Performance JW (attached) (ii) Quality Committee JW (attached) (iii) Audit Committee JW (attached) (iv) Investment & Planning Committee LC (attached) (v) Interim Board JW (attached)
7 STRATEGIC INITIATIVES (a) NEP/SEPT Merger Update NL (attached) (b) National and Local System Updates: STPs, West Essex SM/ (verbal) ACO and Essex Mental Health Strategy Update MMc
Board of Directors Part 1 Meeting 22 February 2017 FINAL
8 REGULATION AND COMPLIANCE (a) Review of SEPT Linked Charities and Granting of Bedford RC (attached) and Luton Funds to ELFT (b) SFIs: Approval of High Value Invoice MM (attached) (c) Board Governance Update NL (attached) 9 OTHER REPORTS
(a) Use of Corporate Seal SM (verbal) (b) Correspondence circulated to Board members since the last LC (verbal) meeting (c) New Risks identified that require adding to the Risk Register All (verbal) or any items that need removing 10 ANY OTHER BUSINESS 11 DATE AND TIME OF NEXT BOARD OF DIRECTORS PART 1 MEETING Wednesday 22 March 2017 in TR1, The Lodge, Runwell Chase, Wickford, Essex, SS11 7XX at 10:30 12 ‘QUESTION THE DIRECTORS‘ SESSION There will be a 15 minute session for members of the public to ask questions of the Board of Directors 13 RESOLUTION To exclude members of the Public and Press
Lorraine Cabel Chair
Board of Directors Part 1 Meeting 22 February 2017 FINAL SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017
SEPT MINUTES OF PUBLIC BOARD OF DIRECTORS PART 1 held on Wednesday 25 January 2017 at The Lodge, Runwell Chase, Wickford SS11 7XX
Members present: Lorraine Cabel (Chair) Chair of the Trust Andy Brogan (AB) Executive Director Mental Health & Executive Nurse/Deputy CEO Randolph Charles (RC) Non-Executive Director [part from agenda item 3] Steve Cotter (SCo) Non-Executive Director Steve Currell (SCu) Non-Executive Director Alison Davis (AD) Non-Executive Director [part from agenda item 3] Nigel Leonard (NL) Executive Director Corporate Governance Mark Madden (CFO) Executive Chief Finance Director Malcolm McCann (MMc) Executive Director Community Health Services & Partnerships Mary-Ann Munford (MAM) Non-Executive Director Janet Wood (JW) Vice-Chair/Non-Executive Director
In attendance: Brian Arney (BA) Public Governor David Bowater (DB) Appointed Governor Sarah Browne (SB) Acting Executive Nurse & Director of Clinical Governance Gill Brice (GB) Associate Director Planning Sue Deighton (SD) F2SU Principal Guardian Harry Few (HF) Member Max Forrest (MF) Associate Director Communications, SEPT Colin Harris (CH) Public Governor Paula Grayson (PG) Public Governor John Jones (JJ) Public Governor Cathy Lilley (CL) Trust Secretary [Minute Taker] Ruby Umbreville (RU) Finance Team Ceanne West (CW) Member
LC welcomed members of the public, staff and Governors to the meeting and in particular welcomed Sarah Browne as Acting Executive Nurse & Director of Clinical Governance. She reminded members of the Trust’s vision: providing services in tune with you.
001/17 APOLOGIES FOR ABSENCE
Apologies for absence were received from: Dr Milind Karale (MK) Executive Medical Director Sally Morris (CEO) Chief Executive
CL confirmed that the meeting was quorate.
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002/17 DECLARATIONS OF INTEREST
There were no declarations of interest.
003/17 PRESENTATION: FREEDOM TO SPEAK UP INITIATIVE UPDATE
The Board received a presentation from Gill Brice, Associate Director Planning, and Sue Deighton, F2SU Principal Guardian, on the F2SU national initiative. The Board was reminded that all Trusts must promote a culture where staff feel safe and are encouraged to speak up, with concerns being investigated properly and the right support available. The aim is to protect vulnerable groups from intimidation and prevent discrimination against those who speak up.
An update on national activities was provided as well as the F2SU guardian service activities at the Trust that complements the current arrangements in the organisation or staff to raise concerns.
On behalf of the Board, the Chair thanked GB and SD for an interesting and informative presentation, and for raising the Trust’s profile nationally with this initiative.
004/17 MINUTES OF THE MEETING HELD ON 30 NOVEMBER 2016
The minutes of the meeting held on 30 November 2016 were agreed to be a correct record.
005/17 ACTION LOG AND MATTERS ARISING
The Board noted that all actions were due in February and March 2017.
006/17 BOARD OF DIRECTORS QUALITY & PERFORMANCE SCORECARD
AB reminded the Board that this is the third time the scorecard has been presented since its introduction into the Trust’s governance arrangements.
AB advised that both the Finance & Performance and Quality Committees have considered the reported content in detail in respect of performance against target in the month of December 2016 and trends. He stated that the report includes a summary of performance in respect of all metrics/key performance indicators monitored by NHS Improvement (NHSI) but pointed out that at this time there was not absolute clarity regarding the implications of any individual or collective under- performance identified; there was a risk that this could have a negative impact on the Trust’s NHSI segmentation rating. AB advised that consideration would be given to including all NHSI performance metrics in the scorecard in future but was cognisant of how this would increase the size of the report.
AB reported that six hotspots had been identified at the end of December 2016 of which two relate to key NHSI operational performance metrics. He provided assurance that where performance was under target action was being taken and is
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In the Chair, Board of Directors Meeting Page 2 of 13 SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017 being overseen and monitored by the Board’s standing committees. The Board noted that there continued to be challenges with the PbR clustering and SCo queried the reason for this. The CFO explained that there had been a significant improvement during the last financial year as a result of detailed monitoring, scrutiny and support. However, the Trust had received a performance notice from the CCGs for not meeting the clustering requirements. Assurance was provided that further analysis would be undertaken and data quality issues investigated. In addition, resources would be allocated to support target achievement.
Referring to the harm free care KPI, SCu suggested that although the target of 95% had been exceeded by nearly 3%, additional narrative to explain about those who had experienced ‘harm’ should be included in the report.
In response to a question by MAM, AB confirmed that the Quality Committee reviews in detail the safer staffing report including the reliance on temporary/bank/agency staff, staff turnover, bed occupancy, etc.
Following a suggestion by MAM, AB agreed to include more detailed narrative under restraints reporting to provide an explanation and balance for the high figures. He provided assurance that the Quality Committee regularly reviews and monitors the Trust’s quality priorities.
The Board discussed the format and content of the new quality and performance scorecard and agreed that in order to ensure this provided appropriate and relevant information, Board members could discuss any concerns or areas for clarification directly with the chair of either the Finance & Performance or Quality Committees.
The Board received and discussed the Quality and Performance Scorecard.
007/17 BOARD ASSURANCE FRAMEWORK (BAF)
NL presented the Board Assurance (BAF) report and reminded the Board that the BAF was a living document which was subject to changes, which provided a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board.
NL reported that there were various changes recommended in this months’ BAF following review by the EOSC at its meetings on 20 December 2016 and 17 January 2017 and these were approved by the Board.
In addition, the Board noted that there was one risk escalated to the Corporate Risk Register (CRR) and five risks removed from the CRR.
The Board reviewed the BAF: 1 Approved the increase to the risk rating for R4 2 Approved the removal of risks R5, R6, R8 and R9 from the BAF 3 Noted that risk R11 would be re-worded and a review of the mitigating action would be undertaken 4 Did not identify any updates or changes required to the BAF
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5 Noted the review and approval of the CRR by the EOSC including the escalation of one risk and the removal of five risks.
008/17 SUB-COMMITTEES
(i) Finance & Performance Committee JW as Chair of the Committee presented the report of the meeting held on 19 January 2017 and provided assurance that the performance and governance arrangements of the Trust as at December 2016 (month 9) were subject to appropriate and robust scrutiny. She reminded members that an assurance report would now be provided following the changes to the quality and performance reporting arrangements.
JW reported that the Committee received an update on the progress with addressing the issues in respect of producing community mental health service data and was pleased to report that the data was now available. She pointed out that a report on the IT and data reporting system transformation process was provided including the lessons learnt.
The Committee also reviewed the six hotspots three of which relate to an NHSI indicator and were advised that the EOSC had reflected on the number of hotspots and emerging risks relating to mental health services and as a result a task and finish group will be established to review all current performance issues. It was acknowledged that improving performance in some areas was entirely in the gift of the service, it was also identified that performance should not be looked at in isolation of the context of service delivery. A review of the acuity of patients would therefore also be undertaken. Fifteen other areas of risk were also reviewed and assurance provided that mitigating actions were either in place or being put in place.
JW also advised that a summary of performance against the revised NHSI quality surveillance and key operational metrics that came into effect on 1 October 2016 was also discussed. The Committee noted that NHSI has not clarified how the metrics will be monitored and reviewed as there is no longer a requirement for the Trust to submit a compliance report nor for the Board to submit self-certification in respect of compliance with financial and governance metrics or exceptions. However, the requirement to submit the Board Assurance Statement, if an adverse change to financial forecast in year is required, remains. She reported that the Committee agreed that performance against the key NHSI financial and operational metrics and the quality surveillance metrics should be explicitly identified in future finance, quality and performance reports and included in the Board of Director Scorecard going forward to ensure that the Board of Directors and public are sighted on the Trust’s performance.
JW stated that the Trust’s financial position remained strong with a Use of Resources rating of 1 (1 being the best rating). She highlighted that although there was a gap of £400k in relation to community health services CIPs, this was compensated by an underspend in the services. However, all other CIPs had been implemented and this was the best performance for many years. The Committee welcomed the position and commended directors and staff for the efforts in delivering the efficiency target.
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The CFO reported that the Trust has achieved a surplus of income over expenditure of £2.4m and the year-end forecast remained at a surplus of £257k as at month 9. Based on this position the Trust has achieved a Use of Resources rating of 1, being the highest rating. However, he pointed out that following a request by NHSI, the Trust has agreed to reforecast (and improve) its year end position. The revised forecast would be an underlying deficit of £173k which was an improvement of c£1m, and the planned surplus was now £2.57m which includes the receipt of additional £1m STF funding.
In response to a question by SCo, the CFO advised that although managers were aware of the spend on agency as a result of local systems and monthly budget statements, plans were in place to strengthen local management reports that would include more granular detail providing more enhanced information to support with controlling the spend. The Board, however, noted that it was anticipated that there would be challenges with managing the spend due to increased clinical demands and the number of vacancies. AB pointed out that there was a national shortage particularly of medical staff.
Following a question by SCu, the CFO confirmed that there are controls and escalation processes in place to manage the agency spend. He advised that it was expected that the Trust would not breach the agency spend by more than the 25% threshold.
The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified.
(ii) Quality Committee The Chair presented the report of the meeting held on 16 January 2017 and provided assurance that robust discussions were held on a number of issues some of which had already been covered by the Board as separate agenda items including the Board Performance, Quality & Finance Scorecard. The Chair also extended an invitation to Directors who were not members of the Committee to attend a future meeting as an observer. In addition, minutes were available on request.
The Chair drew the Board’s attention to the two case studies of patients who had been supported by the Rapid Assessment Interface Discharge Team (RAID) in Basildon that demonstrated the positive impact the team had on patients. She also highlighted the update report on unexpected deaths, one of the Trust’s quality priorities, and the progress with the action plan for the work on reducing avoidable suicides in the Trust’s mental health services that had been extended to over a two-year period recognising the time required to implement system and cultural change.
The Chair advised that the Committee had received an update on the NHS England (East) report on Reporting and Investigation of Unexpected and Expected Deaths and was pleased to note the positive assurance received by the Trust in relation to its investigation of deaths.
An update position on the work being undertaken to follow up the recommendations from the CQC comprehensive inspection was also received by the Committee. The Chair reported that the action relating to Access to Psychological Therapies remained
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In the Chair, Board of Directors Meeting Page 5 of 13 SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017 open but there continued to be excellent progress with other actions; three areas on the improvement plan have shown evidence of improvement and would therefore be moved to the sustainability plan for internal monitoring. She also advised that the internal CQC intelligence system had continued to be populated with data to mirror the system used for CQC intelligence monitoring report with the aim of bringing together one picture of Trust services. In addition, internal CQC comprehensive inspections have continued.
The Chair pointed out that there had been a data breach regarding missing data from a department within the Trust. SB advised that the ICO had confirmed that no action would be taken and provided assurance that the investigation would be completed to identify any learning.
The Chair confirmed that no risks had been identified.
The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified.
(iii) Mental Health & Safeguarding Committee SCu presented the report of the meeting held on 23 November 2016 and provided assurance that robust discussions were held on a number of issues and that no risks were identified.
SCu advised that the ligature issues raised following two recent CQC visits were discussed and provided assurance that a small working group was being established to review this together with the themes that were being consistently raised following the visits.
SCo asked if there were sufficient Associate Hospital Managers to undertake hearings in a timely manner. SCu confirmed that there was an appropriate complement of AHMs following a recent recruitment drive.
In response to a question by SCo, SCu advised that discussions with the NEP MHA team had commenced in preparation for the merger. He confirmed that SEPT’s policies, procedures and operational guides would be adopted by the new Trust.
The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified.
(iv) Interim Board On behalf of the CEO, NL presented the report from the Interim Board to provide assurance that as a standing committee of both NEP and SEPT Boards is discharging its terms of reference and responsibilities effectively, and that the risks that might affect the achievement of its responsibilities are being managed effectively. He reminded the Board that prior to the completion of the merger, the Interim Board is constituted as a committee of both NEP and SEPT Board and has no delegated executive powers relating to statutory and regulatory powers of the Board.
NL provided an update report on the meetings of the Interim Board that took place on 22 December 2016 and 16 January 2017. He reported that the Interim Board standing
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In the Chair, Board of Directors Meeting Page 6 of 13 SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017 committee membership including chairs effective from the establishment of the new Trust had been received and the Quality Committee and Interim Executive Operational Sub-Committee terms of reference (pre-merger) had been approved. The process for the Board committees’ handover had also been presented. The Chairs of both Trust Boards’ committees will be requested to provide an ‘end of year’ summary report that includes a copy of the committee’s workplan, up to date action log, a note of any risks and outstanding mitigating actions that have been identified, any new learning and/or good practice that the new committee would find helpful.
NL pointed out that the Interim Board had supported the recommendation to appoint Janet Wood as the nominated Interim Vice-Chair and Steve Currell as the nominated Interim Senior Independent Director with immediate effect, noting that as both Janet and Steve were currently fulfilling these roles, the appointments would provide continuity and take account of the wealth of experience and knowledge gained from undertaking these responsibilities. The Board noted the constitutional requirements in relation to both appointments.
NL reported on the merger communications and engagements activities that had included attending meetings with three Health Overview & Scrutiny Committees, staff Q&A sessions across the main locations covered by both Trusts, and the public/members question time event arranged for 25 January 2017 with over 100 people registered to attend.
The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified.
(v) Audit Committee JW as Chair of the Committee provided a verbal update on the meeting held on 17 January 2017 and confirmed that a full written report would be presented at the February Board meeting.
JW advised that the Committee had reviewed the revised internal audit plan for the remainder of 2016/17 and had discussed the audit arrangements for the new Trust as well as for SEPT.
SCu sought assurance that there would not be a double cost for internal audit arrangements once the new Trust is established. JW confirmed there would not be a double cost for the new Trust as the internal audit function for 2017/18 will be provided by SEPT’s internal auditors and the LCFS requirements by NEP’s auditors. A tender process for the internal auditors would be undertaken in year with a view to commencing on 1 April 2018.
The Board received and noted the verbal report, and confirmed acceptance of assurance provided in respect of action identified.
009/17 NEP/SEPT MERGER UPDATE
The Board received a progress report from NL on the proposed merger with NEP. He advised that following authorisation from both Trust Boards, the draft Full Business Case and draft Post Transaction Integration Plan had been submitted to NHSI
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Provider Assessment Team in December 2016. The PMO has managed the response to NHSI’s information requests, questions and clarifications and there are no outstanding actions.
NL provided an update of the work of Grant Thornton who have begun their assessment of the transaction to allow them to provide each Board with an independent expert opinion regarding working capital, proposed financial reporting procedures, proposed quality governance procedures and integration planning. This report would also be shared with NHSI’s Provider Assessment Committee to help provide the transaction with a risk rating.
The Board was pleased to note that there were no major slippages in the merger work plan and the transaction remained on time for completion on 1 April 2017.
The Board received and noted the report.
010/17 NATIONAL AND LOCAL SYSTEM UPDATES
MMc presented the detailed report on the progress of the three STPs: Mid and South Essex (Success Regime); Herts and West Essex; and Bedford, Luton and Milton Keynes (BLMK). He reminded the Board that the aim is to create a system that is financially and clinically sustainable.
MMc highlighted the impact the three STP footprints would have on SEPT services. He explained that there is an expectation that organisations are committed to system working with a great emphasis on the collective good rather than concentrating on individual organisations. There is transformation funding associated with the STPs that might be accessible to individual organisations; these funds are to support programmes agreed through the STP process and are held by CCGs. However, part of the CQUIN funds payable to each provider is dependent on supporting the STP processes.
MMc pointed out that the thread that runs through each of the plans is the emphasis upon integrated services. This will involve SEPT staff in working more closely with partners with an expectation that organisational boundaries should not prevent staff from working in integrated teams for the benefit of the patient. He commented that the emphasis upon integration, MDT working, integrated team development, will require considered leadership.
MMc advised that SEPT currently operates within seven CCGs and there is an expectation that we play a significant part in leading the transformation. He reminded the Board that the Trust has good relationships in place across these seven health and care systems. However, as the individual systems consider the best way of facilitating integration, there may be changes in the design of systems: reference is increasingly being made to Accountable Care Organisations (ACO), Multi-Speciality Community Providers, Acute and Primary Care, with commissioners beginning to develop their thinking about what system redesign is required to best deliver the transformed health and care services for their locality.
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The Board discussed the report in detail and in particular the impact the STPs would have on the Trust’s services and finances. Members confirmed they were assured that the Trust is fully involved in the system discussions about system redesign and is well placed within the respective forums but recognised the challenges and uncertainties. The Board noted that any material change affecting the Trust going forward would be brought to its attention.
The Board received and discussed the report.
011/17 BOARD GOVERNANCE UPDATE
NL presented the update report on a range of governance and procedural issues. He drew the Board’s attention to the Learning, Candour and Accountability Report that has been published following a national review of the quality of investigation processes led by trusts into patient deaths. The report highlights the failure to prioritise learning from deaths so that action can be taken to improve care for future patients and their families. NL confirmed that the Trust has been undertaking reviews into this and was being monitored through the Quality Committee and EOSC. He also drew the Board’s attention to the Suicide Prevention Annual Report that details the activity that has taken place across England to reduce deaths by suicide in the year ending March 2016. The report is being used to update the 2012 strategy which will help meet the recommendation of the 5YFV for Mental Health to reduce the number of suicides.
NL reported on the annual review of monitoring the MHA that identified that faster improvements were needed in how people are cared for when detained under the MHA. He provided assurance that the recommendations in the report were being reviewed by the Board’s Mental Health & Safeguarding Committee.
NL also highlighted the CQC and NHSI consultation on their approach the use of resources assessments for NHS providers, and the development of a new joint well- led framework.
The Board received and noted the report.
012/17 DE-REGISTRATION OF SEPT SERVICES WITH THE CQC
The Board received a report from NL on the application to de-register all current SEPT activities with the CQC which is required in order to make an application for registration of activities to be provided by the new Trust – Essex Partnership University NHS FT (EPUT) – with effect from its establishment on 1 April 2017. This application is to be submitted on 27 January 2017.
NL reported that the de-registration application process requires the Directors of the organisation seeking de-registration to see the application; that there is confirmation that services users and partners have been informed of the de-registration of activities; and that details of how activities will continue to be delivered until the de- registration comes into effect are provided. He advised that a meeting was held with CQC registration representatives on 11 January 2017, during which the draft de- registration application was presented and discussed. He confirmed the CQC
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In the Chair, Board of Directors Meeting Page 9 of 13 SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017 registration representatives were satisfied with the Trust’s approach and with the contents of the de-registration application.
In response to a question by SCo, NL confirmed that de-registration of SEPT activities and registration of EPUT activities would be concurrent. He also confirmed that account had been taken of the transfer of the 0-19 services.
The Board: 1 Received and noted the report 2 Approved the application to de-register current SEPT activities for submission to CQC.
013/17 USE OF CORPORATE SEAL
The Board noted that the seal had not been used on six occasions since the last meeting.
014/17 CORRESPONDENCE TO THE BOARD SINCE THE LAST MEETING
(i) JW confirmed that Chair’s action had been taken with regards to the Modern Day Slavery statement that was a legal requirement to publish a statement that had been signed off by the Board on the Trust’s website by 13 January 2017. Correspondence had been circulated to the Board on 21 and 22 December 2016.
(ii) The Chair confirmed that a briefing note with regards to an Article 2 inquest had been circulated to Board members on 9 January 2017.
The Board noted the update.
015/17 NEW RISKS IDENTIFIED THAT REQUIRE ADDING TO THE TRUST RISK REGISTER OR REMOVED FROM THE REGISTER
The Board noted there were no new risks identified.
016/17 ANY OTHER BUSINESS
None.
017/17 DATE AND TIME OF NEXT MEETING
The next meeting will take place on place on Wednesday 22 February 2017 at 10:30 at The Lodge, Runwell Chase, Wickford SS11 7XX.
018/17 RESOLUTION TO EXCLUDE MEMBERS OF THE PUBLIC & PRESS
In accordance with provision 14.20.2 of the Constitution and paragraph 18E of Schedule 7 of the NHS Act 2006, the Board of Directors resolves to exclude members of the public from Part 2 of this meeting having regard to commercial sensitivity and/or
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In the Chair, Board of Directors Meeting Page 10 of 13 SEPT: Board of Directors Meeting Part 1 Minutes 25 January 2017 confidentiality and/or personal information and/or legal professional privilege in relation to the business to be discussed.
The Board noted and agreed the resolution.
018/17 STAFF RECOGNITION SCHEME
The Chair and CEO were delighted to present certificates to:
Individual ‘In Tune’ Awards - Akeemm Alao, Assessment Unit - Judith Dimmock, Macmillan Nurse - Andy Harris, Palliative Care - Kellie Miles, Bank Office – Thurrock - Carolyn Squire, OT & Clinical Coordinator Bedfordshire Acquired Brain Injury Service - Sue Stewart, Secure Services – Brockfield House - Suzie Williams, Paediatric Diabetes Nurse - Sandra Woolford, Support Worker Team ‘In Tune Awards’ - Beech Ward, Rochford Hospital: o Mahmuda Ahmed o Robyn Carpenter o Sue Cowell o Kristian Day o Sophie Gregory o Nic Paddon o Anna Templeman o Tony Winter - Brockfield Catering & Retail, Support Working & Security o Lauren Cowen o Francis Mena o Beverly Simpkin o Lee Tarling - Community Diabetes/Respiratory Specialist Teams o Linda Barr – Latton Bush Centre o Jean Duffell – St Margaret’s Hospital o Irene England – Saffron Walden Community Hospital o Jackie Heffer – St Margaret’s Hospital o Carole Rolland – Saffron Walden Community Hospital - Contact Centre, the Lodge: o Debbie Barrett o Tony Barwick o Jane Baylis o Heidi Crawford o Jullie Davies o Julie Dennis o Sophie Forrest o Eunice Kenealy o Siphilisiewe Nyoni
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o Angela Phinn o Gail Potter o Fran Sacchi - Valkyrie South HV Clerks, Children’s Services: o Helen Poland o Rachel Rolph.
019/17 MEMBERS OF THE PUBLIC/STAFF/GOVERNORS QUESTIONS
Questions from member of the Public, Staff and Governors are detailed in Appendix 1.
The meeting closed at 13:00.
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Appendix 1: Governors/Public Query Tracker (Item 019/17)
Governor Query Assurance provided by the Trust Actions /Member of Public BA Queried if the Basildon Assessment AB agreed to provide Unit met its 90% target for patient an update at the next hours and a maximum stay of 5 meeting days over the last three months JJ (on behalf Asked if any SEPT patients are Patients with schizophrenia are treated with Atypicals (2nd - of Clive being prescribed Haloperidol, and if generation or newer antipsychotic mediations). It is very Travis, so what is the feedback unusual nowadays for core schizophrenic symptoms to Governor) be treated with Haloperidol.
Haloperidol is however an effective drug for calming a disturbed and aggressive patient, and is sometimes used in short term control of disturbed behaviour (rapid tranquilisation) in patients with schizophrenia and other psychotic conditions.
Certain patients with psychosis due to medical/neurological conditions are likely to be treated with low dose Haloperiodol. JJ Queried if the F2SU initiative was for F2SU is an initiative for staff only within a Trust to provide - staff culture where staff feel safe and are encouraged to speak up. This is part of a range of initiatives that promotes and open culture including the Whistleblowing policy and procedure, the ‘I’m Worried’ about facility on the intranet, etc
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In the Chair, Board of Directors Meeting Page 13 of 13 Agenda Item 4 Board of Directors Part 1 Meeting 22 February 2017
SEPT Board of Directors Meeting: Action Log (following Part 1 meeting held on 25 January 2017)
Lead Initials Lead Initials Lead Initials Andy Brogan AB Alison Davis AD Sally Morris SM Requires immediate attention /overdue for action Lorraine Cabel LC Milind Karale MK Mary-Ann Munford MAM New action or required next meeting Randolph Charles RC Nigel Leonard NL Janet Wood JW Action Completed Steve Cotter SCt Malcolm McCann MMc Future Actions Steve Currell SCl Mark Madden MM Cathy Lilley CL
Minutes Action Owner Dead- Outcome Status RAG Ref line Comp/ rating Open Nov PLACE: Confirm if any of the site assessments related to MM Feb17 Woodlea has been subject to PLACE assessment Open 243/16 Woodlea Clinic visits as can be seen for the actions in Appendix 2 of the report. It was missed from the covering report and the report is being re-run to rectify
Nov Quality & Performance Scorecard/Complaints: Provide NL/PM Feb 17 Verbal update to be given at Feb Board Open 243/16 confirmation of the number of complaints have been upheld and partially upheld YTD compared with last year Jan Questions: Confirm if Basildon Assessment Unit met its AB Feb 17 Verbal update to be given at Feb Board Open 019/17 90% target for patient hours and a maximum stay of 5 days over the last three months July Board of Directors Self-Assessment 2016: Update on NL Mar 17 Open 166/16 progress with action plan to be presented at Jan Board June Children, Young People & Families Strategy 2016-19: MMc/ Mar 17 Recommend it would be more timely to present an Open 013/16 progress update to be presented at Nov meeting TS update in the new year
Board of Directors Meeting Part 1 22 February 2017
Agenda Item No: 5a
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: Quality & Performance Scorecard
Executive Lead: Sally Morris Chief Executive Officer Report Author(s): Faye Swanson Director of Compliance & Assurance Report discussed previously at: Content discussed at Finance & Performance Committee 16 February 2017 Quality Committee 13 February 2017
Level of Assurance: Level 1 2 3
Purpose of the Report The Board of Directors Scorecard presents a high level summary of Approval performance against quality priorities, safer staffing levels, financial targets and NHSI key operational performance metrics and confirms quality/ performance “hotspots” agreed by the Finance and Performance Discussion Committee.
The scorecard is provided to the Board of Directors to draw attention to the key issues that are being considered by the standing committees of Information the Board. The content has been considered by those committees and it is not the intention that further in depth scrutiny is required at the Board meeting.
Recommendations / Action Required
The Board of Directors is requested to:
1. Note the content of this report 2. Request further information and/ or action by Standing Committees of the Board as necessary 3. Provide feedback on format/ content presentation
Summary of Key Issues
The Finance & Performance (FPC) and Quality Committees (as standing committees of the Board of Directors) have considered the reported content both in respect of performance against target in the month of January 2017 and trend over the period April – December 2016.
Five hotspots (variance against target/ambition) have been identified as at the end of January 2016.
Last month at the request of the Chair of the FPC summary performance in respect of all metrics monitored by NHS Improvement was included in the report presented. It has been agreed that from this point the key operational metrics only will be presented in the scorecard each month .
1
Two of the hotspots reported relate to key NHSI operational performance metrics.
Where performance is under target, action is being taken and is being overseen and monitored by standing committees of the Board of Directors.
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework Are any existing risks in the BAF affected? Yes If yes, insert relevant risk Following risks already included on the BAF: Trust will remain compliant with CQC standards in all services at all times. Increased intervention by regulators following introduction of the new NHS I Single Oversight Framework. Transformation Programme Do you recommend a new entry to the BAF is No made as a result of this report? Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? No If yes, EIA Score
Acronyms / Terms used in the Report FPC Finance & Performance Committee Supporting Documents &/or Further Reading Scorecards attached
Executive Lead Sally Morris Chief Executive
2 Board of Directors Scorecard – Quality Priorities Month 10 – January 2017
HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE 40
35
In January there were 35 prone restraints. (22 were due 30 to administering IM 25 Total Prone Restraints We will have less 2016/17 medications.) Out of the 272 YTD prone prone restraints in Due to Administration of 20 Below threshold = restraints 187 were (70%) 2016/17 compared Medication YTD April to January 2016/17 Threshold (below = good good performance Reduction in performance) were carried out to to 2015/16. 15 Prone Restraint there have been 272 incidents 2 per. Mov. Avg. (Total Prone administer medication. Average Trendline of prone restraint which (TotalRestraints Prone 2016/17) 10 Restraints2016/17) suggest FOT of 326 (2015/16 266). 5
0
Jul
Apr Oct
Jun Jan Mar
Feb
Aug Sep Nov Dec May
4
3.5 The Trust was slightly above the benchmark (2.80) at 2.85 In January there were 2.85 3 in January 2017. restraints per 10 beds 2.5 We will have fewer compared to benchmark of Trust Total 2016/17 Benchmarks vary for each restraints than 2.80. 2 National Average / Threshold Below threshold = specific service. In January similar providers Rate of Restraint 1.5 good performance 2017 Forensic Services were per 10 beds. On average 2016/17 there 2 per. Mov. Avg. (Trust Total Average Trendline per 10 Bed Days 2016/17) above the service benchmark have been 2.87 restraints 1 (Trust Total 16/17) (1.6) at 2.42, and Poplar Unit per 10 beds. 0.5 was also above the service
0 benchmark (12.6) at 18.33.
Jul Oct
Apr
Jun Jan
Feb Mar
Nov Dec
Aug Sep May
2.5
We will have less YTD there have been 11 2 In January there was 1 SI avoidable falls in SI falls resulting in Total SI Falls 2016/17 fall on Clifton lodge that Avoidable 2016/17 that result moderate or serious 1.5 Below threshold = resulted in moderate / Falls in moderate or harm (2015/16 = 2). Avoidable Falls 2016/17 good performance serve harm. resulting in serious harm 1 Threshold Avoidable Falls Serious compared to YTD 4 have been Harm 0 falls were identified as 2015/16. identified as avoidable 2Average per. Mov. Trendline Avg. (Avoidable Falls(Trust 2016/17) Total 16/17) avoidable during January. falls 0.5
Page 1 of 6
0
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE
30 25 In January there were 16 patients who During January 16 Fewer patients will 20 No. Patients more than 1 fall Reduction in experienced more than 1 2015/16 Below threshold = patients experienced experience more fall. more than one fall. number of than 1 fall in 15 good performance No. Patients more than one patients who 2016/17 compared fall 2016/17 YTD there were 159 10 4 patients on Maple experience to 2015/16. patients who had Ward experienced more than 1 Threshold experienced more than 1 5 more than one fall. fall fall (2015/16 = 203). 2 per.Average Mov. Avg. Trendline (No. Patients 0 (Trust Total 16/17)
more than one fall 2016/17)
Jul
Apr Oct
Jun Jan
Feb Mar
Nov Dec
Aug Sep
May
140
120 The top 5 wards
where falls occurred 100 Below threshold = during January: In January there were 81 Trust Total Falls Per Month good performance We will have less 2016/17 falls. YTD there were 957 80 falls in 2016/17 Trust Total Falls Per Month Maple Ward: 24 Number of falls incidents (2015/16 = 2015/16 compared to 60 Threshold Clifton Lodge: 13 Falls 2015/16 1242). Plane Ward (SMH): 10 40 2Average per. Mov. Trendline Avg. (Trust Total Mountnessing Court:8 Falls(Trust Per Total Month 16/17) 2016/17) Rawreth Court: 7 20
0
Jul
Apr Oct
Jun Jan
Feb Mar
Aug Sep Nov Dec May
In January there were 10 4 serious incidents in 9 Mental Health. YTD 8 MH Total 2015/16 There were 2 46 serious incidents unexpected deaths in We will have less 7 Below threshold = (2015/16 = 61). MH Total 2016/17 January: unexpected deaths 6 good performance
Serious in 2016/17 MH Inpatient Unexpected YTD there were 21 5 Deaths 2016/17 1 RWB Southend Incidents (exc. compared to unexpected deaths 4 MH Unexpected Deaths 1 FRT East PU) (MH) 2015/16. 2015/16 (2015/16 = 28). 3 MH Unexpected Deaths 2016/17 2 YTD there has been 3 MH Target 1 unexpected inpatient
deaths. 0
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec Page 2 of 6 May
HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE
In January there 1.2 were 0 serious incidents in CHS. 1
YTD 2 serious CHS 2015/16 Below threshold = In January there were incident (2015/16 0.8 good performance 0 serious incidents in Serious = 5). CHS 2016/17 CHS Incidents (exc. 0.6 CHS Unexpected Deaths PU) (CHS) *Please note 2 2015/16
incidents have CHS Unexpected Deaths 0.4 2016/17 been downgraded CHS Target following RCA. 0.2
0
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May
100.00% Breakdown:
99.00% Bedfordshire CHS
98.00% 99.65% South East Essex CHS 97.00% Above threshold = 97.56% >95% of our In January 97.42% of 96.00% good performance South Essex MH Harm Free patients will receive Trust Total Care patients have received 95.00% 90.97% *This is being harm free care. harm free care. Target investigated. 94.00% NHS UK Average West Essex CHS
93.00% 97.81% 92.00%
91.00%
90.00%
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May
In January there were 21 35 complaints received. YTD there have been 175 30 January breakdown complaints (2015/16 = complaints received: 237). 25 Below threshold = Bedfordshire CHS (2) We will receive good performance Number of South East CHS (1) fewer complaints 20 In January 100% of South Essex MH (12) Formal this year compared Trust Total 2016/17 complaints were resolved West Essex CHS (2) Complaints to last year. 15 within timescale. YTD Number completed within Specialist service (2) Received timescale 99% have been resolved 10 Threshold Medical (2) within timescale Average2 per. Mov. Trendline Avg. (Trust Total (2015/16 98%) 5 (Trust2016/17) Total 2016/17) Page 3 of 6 0
Jul
Apr Oct
Jun Jan
Feb Mar
Aug Sep Nov Dec May HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE
30
In January there were 5 25 medication omissions. Below threshold = *Due to the NRLS We will have less 20 good performance upload at the end of medication Trust Total 2016/17 January 2017 the omissions in YTD there have been 94 15 2016/17 compared medication omissions Threshold numbers between April – January have Medication to 2015/16. MH & LD (43) and CHS 2 per.Average Mov. Avg. Tredline (Trust Total 10 2016/17)(Trust Total 2016/17) changed as incidents Omissions (51) (2015/16 340) are audited prior to 5 external upload.
0
Jul
Apr Oct
Jun Jan
Feb Mar
Nov Dec
Aug Sep
May
8
7
6 YTD there have In January there were We will meet our been no duty of 5 2 applicable mental duty of candour candour breaches health cases. There requirements when 4 Total applicable cases out of the 30 were no breaches. things go wrong Contact made within 10 days Duty of applicable cases. 3
Candour 2
1
0
Jul
Apr Oct Jan
Jun
Mar
Feb
Aug Sep Nov Dec May
Training on the use of the MEWS, including a basic understanding of As at end of vital signs monitoring MEWS Scores are measured twice a year and the We will increase September 80% of and its’ role in 80% was achieved August / September the % of MEWS patients have a detecting patients who Early The next audit will be undertaken in February scores recorded in MEWS score are becoming Detection of 2017. 2016/17 compared recorded (baseline physically unwell Deteriorating to 2015/16. 70%) continues. Staffs also Patient receive guidance on the use of a simple tool to communicate concerns and record accordingly. Page 4 of 6
HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE
We will increase As at end of the % of patients September 65% of The next audit will be undertaken in Early with a MEWS score patients with a MEWS Scores are measured twice a year and February 2017. Detection of greater than 4 (or a score of 4 were the 65% was achieved August / September Deteriorating simple score of 3) escalated that are escalated appropriately Patient appropriately (baseline 57%)
80 In January there were 70 Grade 3/4 pressure 70 grade 3/4 pressure ulcer's for January: ulcers. Bedfordshire CHS (20) 60 Below threshold = We will have less Trust Total Grade 3 & 4 South Essex Mental 2016/17 good performance avoidable grade 3 & YTD there were 395 50 Health (1) Avoidable Grade 3 & 4 Pressure 4 pressure ulcers in grade 3/4 pressure ulcers 2016/17 South East Essex (33) 40 Ulcers 2016/17 than in (2015/16 453) Threshold (Total Pressure West Essex (16) Ulcers) 2015/16. There are 70 RCA's in 30 Threshold (Total Avoidable YTD there have been 6 Pressure Ulcers) progress avoidable grade 3 & 4 20 Average2 per. Mov. Trendline Avg. (Trust Total In January there were (TrustGrade Total 3 & 4 2016/17) 2016/17) 0 avoidable pressure pressure ulcers 10 compared to 17 2015/16 ulcers.
0
Jul
Apr Oct
Jun Jan
Feb Mar
Sep Nov Dec
Aug May
100.0%
In January 97% of 95.0%
Patients patients were likely Above national In January there were We will have higher Friends and or extremely likely 90.0% benchmark = good a total of 616 satisfaction with Family Test to recommend the performance responses received for our services than CHS 16/17 (CHS) service to friends 85.0% Community Health the national National Bench Mark CHS and family (YTD Services. average (95%) Average2 per. Mov. Trendline Avg. (CHS 16/17) 96.5%) 80.0% (Trust Total 2016/17)
75.0%
Page 5 of 6 70.0%
Jul
Apr Oct
Jun Jan Mar
Feb
Nov Dec
Aug Sep May HOTSPOTS AMBITION POSITION (YTD) TREND TREND CURRENT MONTH PERFORMANCE KEY NARRATIVE
100.0%
In December 82% 95.0% of patients were We will have higher likely or extremely Above national In January there 90.0% Patients satisfaction with likely to benchmark = good were a total of 51 performance Friends and our services than recommend the MH 16/17 responses received Family Test 85.0% the national service to friends National Bench Mark MH for Mental Health (MH) average (87%) and family. (YTD 2Average per. Mov. Trendline Avg. (MH (Trust 16/17) services. 84.1%) 80.0% Total 2016/17)
75.0%
70.0%
Jul
Oct
Apr
Jun Jan
Feb Mar
Nov Dec
Aug Sep May
100%
In December 89% 90% Our staff will be as a place for treatment more likely to of staff would 80% as a place to work recommend SEPT recommend SEPT as a place for Above national In January there Staff Friends as a place to work National Average (Treat) 70% benchmark = good were a total of 157 and Family and/or recommend treatment and 92% National Average (Work) performance responses received. Test the services to as a place to work., (YTD 84% as a 60% friends and family 2Average per. Mov. Trendline Avg. (as (as a placea members place for treatment forplace treatment) for treatment) and YTD 77% as a 50% 2Average per. Mov. Trendline Avg. (as (as a place to work)a place to work ) place to work)
40%
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May
Page 6 of 6
SINGLE OVERSIGHT FRAMEWORK KEY OPERATIONAL PERFORMANCE METRICS Board of Directors Scorecard – Month 10 – January 2017
HOTSPOT METRIC FREQUENCY TARGET JAN 17 NOTES
101%
100% 99%
Patients requiring 98% % of Adult Acute Admissions Gate-Kept In January 2017 100% pf admission have a 97% Gatekeeping by the CRHT gatekeeping Above 95% 96% patients requiring admission Assessment Quarterly Threshold assessment by 95% had a gatekeeping CRHT 94% assessment by CRHT
93% 92%
Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug Nov
Mar May
NICE recommend As per hotspot ed package
of care
Cardio Metabolic As per hotspot
Assessment
Page 1 of 3
HOTSPOT METRIC FREQUENCY TARGET JAN 17 NOTES
101.00% The identifier metrics are: 100.00% - Date of Birth Complete and 99.00% - Patient's current gender Complete and valid MHMDS valid submission 98.00% submission of metrics - Patient's NHS Number
in the MHMDS of metrics in the 97.00% - GP Practice Code (Identifier a)Identifier metrics MHMDS Quarterly Above 95% 96.00% - Postcode of residence Metrics) Threshold - Commissioner Code 95.00% a) Identifier 94.00% 99.9% complete and valid metrics 93.00% submissions of metrics in the 92.00%
Jul MHMDS in January
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar May
86%
84% The priority outcome
82% metrics are: Complete and valid 80% - Employment Status submission of Complete and valid 78% submission of metrics - Accommodation status MHMDS metrics in the in the MHMDS - Ethnicity 76% b) Priority metrics (Priority MHMDS Monthly Above 85% 74% Target Metrics) 74% complete and valid b) Priority 72% submissions of metrics in Metrics 70% the MHMDS in January rd 68% Final Submission 23
66% February
Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar May
80.00%
70.00%
60.00% BB January 2017: CPR IAPT % 50.00% Basildon & Brentwood 59%
Moving to IAPT SOS 40.00% Castle Point & Rochford Recovery % moving to Quarterly 50% 41.9% Threshold recovery 30.00% Southend on Sea: 37.1% 2 per.Average Mov. Trendline Avg. (BB) 20.00% (BB) 2 per.Average Mov. Trendline Avg. 10.00% (CPR)(SOS) 2 per.Average Mov. Trendline Avg.
Page 2 of 3 0.00% (SOS)(CPR)
Jul
Jan
Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar
May HOTSPOT METRIC FREQUENCY TARGET JAN 17 NOTES
120%
100% Within 6 weeks In January 75% of patients 80% IAPT waiting waited less than 6 weeks IAPT Waiting Within 18 weeks time to begin 60% to begin treatment and time to begin 6 weeks: 75% treatment Quarterly Threshold (within 6 100% of patients waited 18 weeks: 95% Treatment 40% weeks) less than 18 weeks. Within 6 weeks Within 18 weeks Threshold (within 6 weeks) 20%
0%
Jul
Jan Jun
Oct
Apr
Sep Feb
Dec
Aug
Nov Mar May
Page 3 of 3
Board of Directors Scorecard – Month 10 – January 2017 Safer Staffing TREND HOTSPOTS AMBITION POSITION (YTD) TREND PERFORMANCE KEY NARRATIVE PERFORMANCE KEY 100.0%
95.0%
All Trust 2016/17 90.0%
We will achieve >90% 98.4% of expected Target Above target = good Registered Staff Day of expected day time Registered Nurse day 85.0% No hotspots in January performance Time shifts filled. time shifts were filled. All Trust 2015/16 80.0%
Linear (All Trust 75.0% 2016/17)
70.0%
Jul
Apr Oct
Jun Jan
Feb Mar
Nov Dec
Aug Sep May
100.0%
95.0%
All Trust 2016/17 90.0% Registered Staff Night 98.9% of expected Target Time We will achieve >90% 85.0% No hotspots in January of expected night Registered Nurse night Above target = good time shifts filled. time shifts were filled. All Trust 2015/16 performance 80.0%
Linear (All Trust 75.0% 2016/17)
70.0%
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May 100.0%
95.0% All Trust 2016/17 90.0% Unregistered Staff Day Target Hotspots in January: Time We will achieve >90% 98.3% of expected Above target = good 85.0% Beech Ward (SEMH) 83.9% of expected day time Unregistered Staff day performance All Trust 2015/16 (Full details overleaf) shifts filled. time shifts were filled. 80.0% Linear (All Trust 75.0% 2016/17)
Page 1 of 3 70.0%
Jul
Apr Oct
Jun Jan
Feb Mar
Nov Dec
Aug Sep May TREND HOTSPOTS AMBITION POSITION (YTD) TREND PERFORMANCE KEY NARRATIVE PERFORMANCE KEY 105.0%
100.0%
95.0% All Trust 2016/17
We will achieve 100.6% of expected Unregistered Staff 90.0% Target Above target = good >90% of expected Unregistered Staff night No hotspots in January Night Time performance night time shifts time shifts were filled. 85.0% All Trust 2015/16 filled. 80.0% Linear (All Trust 2016/17) 75.0%
70.0%
Jul
Apr Oct
Jun Jan
Feb Mar
Nov Dec
Aug Sep May
Page 2 of 3
Page 3 of 3
BOARD OF DIRECTORS SCORECARD – HOTSPOTS MONTH 10 – JANUARY 2017
TREND HOTSPOTS AMBITION POSITION (YTD) TREND PERFORMANCE KEY NARRATIVE
120.00% The Trust is not commissioned to provide a NICE recommended 100.00% package of care as required to
In January 90% of patients meet this target and data New Early 50% of patients with 80.00% Above threshold = first episode psychosis referred to EIP service were good performance presented relates to under 35's Intervention in seen in 14 days. YTD 81% of seen within 14 days and will be seen within 14 60.00% Seen < 14 days Psychosis Access days and commence a patients were seen in 14 allocated to a care coordinator. days (2015/16 71%) Threshold NICE compliant care 40.00% package. Contract negotiations for 17/18 20.00% have resulted in confirmation of
additional funding for South 0.00% East Essex provision but yet to
Jul
Apr Oct
Jun Jan
Feb Mar
Aug Sep Nov Dec May be agreed for South West Essex.
140% Average including leave per month 2016/17 Below Threshold = Adult & OP Acute MH Wards 120% good performance have occupancy levels above The Trust will have Average excluding 100% leave per month threshold: bed occupancy For January YTD the Bed 2016/17 Occupancy of 90% or Ward Inc Leave Exc Leave levels in line with Occupancy rate is: 80% Threshold more is red rated, 85- Adult Acute 110% 95% Bed Occupancy Royal College of 89% is amber and less MHAU 114% 113% Psychiatrists 102% (including leave) 60% (Acute) Average than 85% is green OP Functional 96% 86% recommended 92% (excluding leave) 40% Trendline 2 per.including Mov. LeaveAvg. PICU 99% 82% levels (<85%). (Average including per Month 20% leave per month 2016/17)Average 0% 2 per.Trendline Mov. Avg.
(Averageexcluding excluding Leave
Jul Oct
Apr per Month Jan
Jun leave per month
Feb Mar
Nov Dec
Aug Sep May 2016/17)
100.00% The proportion of 90.00% users assigned to
80.00% a cluster The Trust will cluster CPN issued by CCG has 95% of patients; will 70.00% 81 % clustered The proportion of not been achieved. PBR Clustering review clusters in 58% patients initial 60.00% initial clusters Above threshold = good review periods (90%) adhering to "red clusters met red rules 50.00% Rules" performance Data Quality issues are and achieve red rules 57.3% clusters being investigated and for initial clustering 40.00% Clusters reviewed reviewed in review in review period resources allocated to (70%). period 30.00% support target 20.00% achievement. Threshold 10.00% Page 1 of 2 (assigned to a 0.00% cluster)
Jul
Apr Oct
Jun Jan
Mar
Feb
Aug Sep Nov Dec May TREND HOTSPOTS AMBITION POSITION (YTD) TREND PERFORMANCE KEY NARRATIVE
9.0% 8.0% In January MH and Sickness Trust The Trust will achieve 7.0% Specialist services were Total Overall the Trust sickness a sickness absence Below threshold = good above the sickness 6.0% MH Sickness Total rate for January is 4.7% Sickness Absence rate of less than performance 4.8% (MH absence benchmark of 5.0% (YTD figure of 4.7%)
MH benchmark) and aim 4.8% and Trust Target of Specialist which is above the Trust 4.0% Sickness Total 4.3%: corporate target (4.3%) to reduce this to 3.0% MH 5.2% Trust target 4.3% (Trust target). Specialist services 6.6%. 2.0%
1.0% MH Benchmark
0.0%
Jul
Oct
Apr
Jun Jan
Feb Mar
Nov Dec
Aug Sep May
100.00% At the end of January 60% 90.00% of patients had a cardio- Inpatient Wards 80.00% metabolic assessment This is a new target in the Early Intervention in The Trust will carry out based on the audit carried 70.00% NHSI Single Oversight out. Psychosis Above threshold = good Framework. The a cardio metabolic 60.00% Community Mental assessment routinely performance requirement has been part Cardio Metabollic Health on 90% of people (60% Breakdown at the end of 50.00% of a CQUIN scheme for two Assessment January: Threshold (Inpatient years. NHSI has introduced community patients) 40.00% Inpatients: 69% Wards) stretch targets into the with psychosis. 30.00% Early Intervention: 84% Threshold (Early oversight framework. Intervention) Community Patients on 20.00% CPA: 27% 10.00% Threshold (Community MH) 0.00%
Jan Dec
Page 2 of 2
Board of Directors Scorecard - Month 10 - January 2017 Finance RATING AMBITION POSITION TREND NARRATIVE
From April to September the Trust was assessed against the Financial Services Risk Rating. Against this metric, good performance was indicated by a rating of To achieve NHS 4. The planned risk rating was 3, during this period Financial Risk Improvement's the Trust risk rating was 4 each month. From Rating / Use of Resources metric of September 2016 the Trust has been assessed against financial risk the Use of Resources Rating, good performance is indicated by a rating of 1. The planned risk rating is 2, the month 10 actual risk rating is 1.
Actual ytd surplus is £3,151k against a planned ytd To achieve surplus of £2,978k. The surplus is expected to remain agreed plan for at this level with a forecast outturn of £3,220k at year Year to Date Operating Operating end including the increased £1m STF allocation. Total Income and Surplus/ Deficit STF funds now included in the forecast is £2.4m giving Expenditure a trading position of £0.8m surplus.
To achieve In 2016/17 the Trust has a Cost Improvement Target of Cost planned £12.7m. At M10, £12.2m savings have been identified Improvement improvement in and actioned and a further £0.1m identified to be Programmes productivity and actioned during Q4. £0.4m remains unidentified. efficiency
In 2016/17 the Trust has an Agency expenditure cap of To achieve £9.85m. Year to date expenditure is above plan, costs Agency Costs agreed Agency are still increasing month on month and at current Costs Plan expenditure levels it is anticipated that the Trust will breach its agency cap by £0.5m (5%) at year end. Board of Directors Scorecard - Month 10 - January 2017 Finance
Cash is £54.1m which is £11m more than plan. This is due to the slippage on the capital programme, lower To achieve than plan debtor balances and the year to date I&E Cash Balance agreed Cash surplus. Balance Plan Agenda Item No: 6a
SUMMARY REPORT BOARD OF DIRECTORS 22 FEBRUARY 2016
Report title: Board Assurance Framework 2016-17 Summary Report Executive Lead: Nigel Leonard Executive Director of Corporate Governance Report Author(s): Joanne Sims Head of Assurance Report discussed previously at: Executive Operational Committee 14 February 2017 Level of Assurance: Level 1 Different levels of assurance apply to each risk on the 2016-17 Board Assurance Framework (BAF). 2
Internal Audit provided “full assurance” in respect of the Assurance Framework and 3 Risk Management arrangements in March 2016.
Purpose of the Report This report presents the Board of Directors with the Board Assurance Approval Framework summary report as at the 16 February 2017 for discussion, update and approval. Discussion
The associated BAF and associated BAF risk actions plans are available on Information request from the Head of Assurance.
Recommendations / Action Required The Board of Directors is recommended to: 1. Review and approve the Board Assurance Framework 2016-17 summary report as at the 16 February 2017 and identify any updates/ amendments/additions required.
2. Approve the recommendation made by the Director of Contracting & Business Development to reduce the risk scoring and remove from the BAF the following risk: Significant pressure to achieve a number of transformational programmes creates increased demands on existing management and resource capacity that may impact on delivery of the programme.
3. Approve the recommendation made by the Executive Director of Corporate Governance to reduce the risk scoring for following BAF risk: As a result of a number of risks relating to regulatory approval and delivery of a comprehensive and compelling business case there is a risk that the merger will not be completed by April 2017, or at all, resulting in the benefits identified in the merger proposal (clinical and patient benefits, commissioner benefits and financial benefits) not being delivered.
4. Identify further mitigating actions, controls and enhanced monitoring arrangements as appropriate.
5. Note the new risks agreed for escalated to the CRR by the EOC on the 14 February 17: If the Trust fails to meet the PBR targets agreed by the CCG the CCG could withhold payment up to 2% of total contract income until resolved.
Poor discharges by the acute trust may led to potential drug errors, delay in
1
treatment and disruption to our own services who have had to seek clarification for missing information, equipment and medication.
Summary of Key Issues
The EOC received the BAF and CRR summary report on the 14 February 17. Risk scores in respect of two BAF risks are recommended to be reduced. Two new risks have been identified and are recommended for escalation to the CRR.
The Finance and Performance Committee received the Quality and Performance Report for January 2017 and identified one new potential risk that is currently being assessed. Relationship to Trust Strategic Priorities
SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness Relationship to the Board Assurance Framework
Are any existing risks in the Board Yes Assurance Framework affected? If yes, insert relevant risk All risks identified on the BAF
Do you recommend a new entry to the One new risk is currently being assessed. Board Assurance Framework is made as a result of this report? Corporate Impact Assessment OR Board Statements: Assurance(s) against:
Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) No If yes, EIA Score
Completed? Acronyms / Terms used in the report
Supporting Documents &/or Further Reading
BAF and associated action plans available on request. Executive Lead
Nigel Leonard Executive Director of Corporate Governance
2
Agenda item 6a Board of Directors 22 February 2017
SEPT
BOARD ASSURANCE FRAMEWORK UPDATE REPORT 2016-17 AS AT FEBRUARY 2017
PURPOSE OF THE REPORT
This report presents the Board of Directors with the Board Assurance Framework Update Report for 2016/17 as at 16 February 2017 for discussion, update and approval.
FEBRUARY 2017 UPDATE
1. Board Assurance Framework 2016/17
1.1 The Board Assurance Framework (BAF) provides a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board of Directors.
1.2 The BAF 2016/17 was last considered and approved by the Board of Directors on the 25 January 2017 and was reviewed by the Executive Operational Committee (EOC) on the 14 February 2017.
1.3 The EOC, Executive Directors and Service leads have reviewed the risks detailed in the 2016/17 BAF as at the 16 February 2017 and updates are set out in Table 1 below.
Table 1 – BAF 2016/17 Overview as at 16 February 2017
No. Real Risk Exec Overview Update Risk scoring status Lead Aim 1 Safe Care R12 The findings and recommendations AB Reviewed by the Deputy Current risk scoring identified in the review of patient Director of Nursing (9/2/17). 4 x 3 = 12 deaths in the care of southern Comprehensive Mortality health could identify gaps in the Review action plan developed Risk scoring reviewed trusts processes for reviewing and continues to be remains unchanged mortality which will require implemented. A total of 22 following self- significant action. actions identified; 7 rated green, assessment against 11 currently rated amber and 3 CQC findings. rated red. The CQC has published results of national review of mortality review practice and identified significant gaps nationally. An assessment of Trust practice compared to CQC findings has been undertaken and a detailed workplan is in place. National guidance is due to be published and this will be incorporated into the workplan.
R3 If services fall short of the NL Reviewed by the Director of Current risk scoring standards required to remain Compliance and Assurance 4 x 3 =12 compliant with the Health and (10/2/17). Action continues to be Social Care Act there is the taken to mitigate risk but this Risk scoring remains
1
No. Real Risk Exec Overview Update Risk scoring status Lead potential for CQC enforcement should be considered as on unchanged. action or in extreme cases closure going so Trust is not of services. complacent. 27 actions currently detailed on the action plan, 18 rated green, 8 rated amber and 1 red.
R4 If record keeping standards are not MMc, Reviewed by the Deputy Current risk scoring in line with Trust policy quality of AB Director of Nursing (10/2/17). 4 x 4 = 16 care may be compromised. Care planning task and finish group established and actions Risk scoring remains agreed and incorporated into the unchanged. BAF risk action plan; 3 actions . rated green, 7 actions rated amber and 3 rated red (related to the development of Mobius eforms due to the complexities of Mobius and further data requirements.
Aim 7 Financially Sound R13 There is a potential risk that the NL / Reviewed by the Director of Current risk rating introduction of the new NHS I MM Compliance and Assurance 4 x 3 = 12 Single Oversight Framework results (10/2/17). Risk remains that the in increased intervention by Trust may not meet all the NHSI Risk scoring remains regulators as a result of the Trust KPIs in 16/17(EIP access target, unchanged. failing to meet new thresholds for metabolic assessment financial and quality performance monitoring, IAPT recovery rate required to achieve maximum and data completeness metrics) autonomy under the new and there is a risk that this will monitoring regime. continue into 17/18 (EIP specifically as this is linked to CCG funding).
Aim 8 Clear Strategy for Securing Our Success As a result of a number of risks NL Reviewed by the Executive Current risk rating relating to regulatory approval and Director of Corporate 4 x 4 = 16 delivery of a comprehensive and Governance. Due diligence compelling business case there is a completed. Reporting Recommendation is risk that the merger will not be Accountant draft report received. made to reduce the risk completed by April 2017, or at all, Nothing relating to those pieces scoring to 4 X 3 =12 resulting in the benefits identified in of work will stop the merger from the merger proposal (clinical and proceeding from the 1 April patient benefits, commissioner 2017. Only outstanding issue benefits and financial benefits) not relates to control totals and the being delivered. trust is working closely with NHSI to minimise the impact and this will be the first risk discussed at the board to board meeting (21 February) with NHSI at the meeting.
Priority 4 – Innovation and transformation R11 Significant pressure to achieve a MM Reviewed by the Director of Current risk rating number of transformational Contracting & Business 5 x 4 =20 programmes creates increased Development (9/2/17). Detailed demands on existing management project and/or mobilisation plans Recommendation is and resource capacity that may are in place. Currently no impact made to reduce the risk impact on delivery of the on capacity. scoring to programme. Corporate restructure. Linked to 4 x 2 = 8 as there is merger however a number of currently no impact on
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No. Real Risk Exec Overview Update Risk scoring status Lead individual consultations are capacity and remove underway and outcomes to be from the BAF implemented. Dementia/Challenging Behaviour Pathway. Implementation now 17-18 due to CGG inability to secure GP contractors . CQC application remains reliant of GP contractors being identified to enable registration application to be submitted post 1april 17. Estates rationalisation. A number of initiatives being undertaken at a range of sites. Workforce redesign. Links to merger. Introduction of 12 hour shifts implemented and impact will be assessed for a further 6 months. 5 workstreams being progressed including workforce strategy, absence management, agency and bank, mental health development group, establishments and staff in post. Inpatient redesign. Linked to merger. Income generation opportunities continue to be identified and progressed.
Risks on the BAF should (in most cases) have a detailed risk mitigation action plan. Risk mitigation action plans for 6 of the 6 risks on the BAF 2016/17 are available on request from the Head of Assurance.
2. Corporate Risk Register (CRR)
The EOC last received the CRR on the 14 February 2017. Following feedback the CRR will now be reviewed by the EOC on a quarterly basis and is available in full on request from the Head of Assurance.
The EOC agreed the escalation of the following risks set out in table 4 for escalation to the CRR;
Table 4 Source Potential risk Risk scoring Mitigation Medical If the Trust fails to meet the PBR 4 X 3 =12 All consultants actioned to ensure all patients SMT targets agreed by the CCG the are clustered correctly. Further information to be CCG could withhold payment up to requested from the information team to address 2% of total contract income until anomalies. resolved. Beds Poor discharges by the acute trust 4 X 4 = 16 SEPT shared data regarding poor discharges CHS SMT may led to potential drug errors, with CCG and Bedford Hospital. Process agreed delay in treatment and disruption to for sharing poor discharges was reviewed and our own services who have had to agreed. Escalated to A&E Strategic board. seek clarification for missing Karen Hall and Helen Smart to agree a number information, equipment and of further actions. Note that this is a potential
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medication. risk also identified by SEECHS. 11 poor discharges recorded via Datix in December 16
In addition a risk assessment has been undertaken and agreed by the Director of Mental Health in relation to Clifton Ward’s staffing levels (qualified fill rate to cover the night and day shifts) following discussions at the January 17 Quality Committee. This has been risk rated at 3 x 3 =9, as mitigating actions have had a positive impact.
3. Directorate Risk Registers
Work continues to be undertaken to review all directorate risk registers against the corporate aims and directorate objectives for 2016-17 and presentation of those risk registers to EOC.
4. Hotspots from the Quality Report
The Finance and Performance Committee considered the hotspots identified within the January 2017 Quality and Performance Report on the 16 February 2017. The following risk was identified and is currently being assessed in order to determine allocation to the appropriate risk register:
If the Trust does not meet contractual targets this will result in contract performance notices and potentially financial sanctions and could damage reputation and relationships with commissioners (in the context of, as at month 10, the Trust has had 6 CPNs and there is a risk that 6 more could be issued in light of under-performance against agreed targets)
5. Recommendations
The Board of Directors is recommended to:
1. Review and approve the Board Assurance Framework 2016-17 summary report as at the 16 February 2017 and identify any updates/ amendments/additions required.
2. Approve the recommendation made by the Director of Contracting & Business Development to reduce the risk scoring and remove from the BAF the following risk:
Significant pressure to achieve a number of transformational programmes creates increased demands on existing management and resource capacity that may impact on delivery of the programme.
3. Approve the recommendation made by the Executive Director of Corporate Governance to reduce the risk scoring for following BAF risk:
As a result of a number of risks relating to regulatory approval and delivery of a comprehensive and compelling business case there is a risk that the merger will not be completed by April 2017, or at all, resulting in the benefits identified in the merger proposal (clinical and patient benefits, commissioner benefits and financial benefits) not being delivered.
4. Identify further mitigating actions, controls and enhanced monitoring arrangements as appropriate.
5. Note the new risks agreed for escalation to the CRR by the EOC on the 14 February 17:
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If the Trust fails to meet the PBR targets agreed by the CCG the CCG could withhold payment up to 2% of total contract income until resolved. Poor discharges by the acute trust may led to potential drug errors, delay in treatment and disruption to our own services who have had to seek clarification for missing information, equipment and medication.
Prepared by: Joanne Sims Head of Assurance
On behalf of:
Nigel Leonard Executive Director of Corporate Governance
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Agenda Item No: 6b(i)
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: Finance and Performance Committee Assurance Report
Non-Executive Lead: Janet Wood Chair of the Finance and Performance Committee Executive Lead: Sally Morris Chief Executive Officer Report Author(s): Faye Swanson Director of Compliance & Assurance Report discussed previously at: n/a
Level of Assurance: Level 1 2 3
Purpose of the Report To provide assurance to the Board of Directors that the Finance and Approval Performance Committee (FPC) is discharging its terms of reference and delegated responsibilities effectively, and that the risks that may affect the achievement of the Trust’s objectives and impact on quality are being Discussion managed effectively.
This report also provides assurance to the Board of Directors that the Information performance (operational and financial) of the Trust as at Month 10 – January 2017 was subject to appropriate and robust scrutiny.
Recommendations / Action Required The Board of Directors is asked to:
Note the contents of the report Confirm acceptance of assurance given in respect of risks and actions identified Request further action/information as required
Summary of Key Issues The Finance and Performance Committee considered the following matters:
Quality and Performance report as at Month 10- January 2017 Financial Performance report as at Month 10- January 2017 Four sets of Executive Operational Committee Part One minutes relating to meetings that took place in January 2017 Workforce Transformation Group assurance report NHSI Self Certification requirements in 2017 Risk Management and Assurance annual update Self assessment of efficacy and handover arrangements
The committee approved revisions to the SEPT Grievance Policy (HR2)
One risk was identified for assessment and allocation to the appropriate risk register.
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Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness Relationship to the Board Assurance Framework Are any existing risks in the BAF affected? Yes If yes, insert relevant risk Following risks already included on the BAF: Trust will remain compliant with CQC standards in all services at all times. Increased intervention by regulators following introduction of the new NHS I Single Oversight Framework. Transformation Programme Do you recommend a new entry to the BAF is No made as a result of this report? Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? No If yes, EIA Score Acronyms / Terms used in the Report CQC Care Quality Commission NHS National Health Service BAF Board Assurance Framework CIP Cost Improvement Programme CHS/CH Community Health Services NHSI NHS Improvement CFO Chief Finance Officer OP Older People FPC Finance & Performance Committee CCG Clinical Commissioning Group EOC Executive Operational Committee MHS/MH Mental Health Services NCA Non Contractual Activity EPUT Essex Partnership University Trust AWOL Absent Without Leave YTD Year to Date PBR Payment by Results OOA Out of Area ECR Extra Contractual Referrals IAPT Improved Access to Psychological ACAS Advisory Conciliation and Arbitration Therapies Service Supporting Documents &/or Further Reading Main report
Non-Executive Lead
Janet Wood Chair of the Finance and Performance Committee
2 FINANCE AND PERFORMANCE COMMITTEE ASSURANCE REPORT
Agenda Item 6b(i) Board of Directors Meeting 22 February 2017
FINANCE AND PERFORMANCE COMMITTEE ASSURANCE REPORT
1.0 Purpose of Report
This report is provided by the Chair of the Finance and Performance Committee to provide assurance to Board members that the performance (operational and financial) and governance arrangements of the Trust as at Month 10 – January 2017 were subject to appropriate and robust scrutiny.
The Finance and Performance Committee (FPC) is constituted as a standing committee of the Board of Directors. The Board of Directors has delegated responsibility to this committee for the oversight and monitoring of the Trust’s financial, operational and organisational performance in accordance with the relevant legislation, national guidance, the Code of Governance and current best practice.
The committee is required to ensure that risks associated with the performance and governance arrangements of the Trust are brought to the attention of the Board of Directors and/ or to provide assurance that these are being managed appropriately by the Executive Directors.
2.0 Summary Of Discussions
2.1 Minutes of last meeting
The minutes of the meeting held on 19 January 2017 were agreed as an accurate record.
2.2 Quality and Performance Report
The Director of Compliance presented the committee with a summary of performance for Month 10 – January 2017.
An update on progress with addressing previously reported issues in respect of data reporting was provided and it was noted that whilst the majority of data is now able to be produced routinely, the absence of having data has resulted in a significant amount of data validation now being required to determine if reported under-performance is due to data quality or completeness. Confirmation was provided that Internal Audit has commenced a data quality audit, the outcome of which will be available at the end of March 2017. Assurance was provided that a full patient level validation has been undertaken of the First Response Team caseloads and this had been the subject of positive discussion with CCG commissioners and GP clinical leads and action is underway to address issues identified. It was also confirmed that validation of consultant caseloads has now been completed and this means that the service improvement initiative previously underway, but suspended due to lack of data, can now be re-commenced.
During January 2017 there were four serious incidents (2 unexpected deaths, 1 fall/fracture and 1 AWOL) reported in Mental Health Services. YTD there have been 46 serious incidents which means that the forecast outturn (55) is less than 2015/16 outturn (61).
No Serious Incidents were reported in community health services in January 2017. Year to date three community serious incidents have been reported.
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Six hotspots were brought to the attention of the committee as a result of reviewing performance relating to January 2017 against agreed targets, two of which relate to an NHSI indicator. Five of the hotspots were agreed to be brought to the attention of the Board of Directors in the scorecard.
1. New Early Intervention in Psychosis Access Target (previous hot spot). The committee were reminded that this remains a potential risk for 17/18 if full funding is not received from CCGs. 2. % Bed Occupancy (previous hot spot) 3. Cardio Metabolic Assessment of Patients with Psychosis (previous hotspot). The Medical Director advised that achieving 65% compliance in community mental health services will be an ongoing risk. Training and systems to support implementation was explored by the committee. 4. PBR Cluster Data (previous hot spot) 5. Sickness Absence (mental health and specialised services) (previous hot spot)
The committee agreed that one of the hotspots should be articulated as a risk and assessed for inclusion on a risk register:
SE MH Contractual Reporting (new hotspot)
Over the past 9 months performance against SE MH KPIs has deteriorated with 34 commissioning KPI’s below threshold for December 2016 (latest reported position). Year to date there have been 6 contract performance notices that have been issued by Commissioners and they are also considering issuing contract performance notices in respect of under-performance against a further 6 KPIs. The committee was also advised that the CCG has confirmed that it will pursue a £10 breach payment for each reported breach in respect of ethnicity recording below a 90% threshold that occurred in September and December 2016. It was accepted that under-performance could be due to data reporting issues but also that this is not the only reason. Assurance was provided that action is being taken in respect of all reported areas of under-performance and that a T&F Group is to be established to look at whether there are any underlying issues that need to be addressed.
In addition the following risks were identified and discussed:
1. Patient Safety Related Incidents: Reporting Rate 2. AWOL (Detained – return after midnight) and AWOL (Detained – return same day) 3. Restraint (Number, Rate, Prone and Restrictive 4. % Outpatients Appointments cancelled 5. Consultant Caseload and Appointment Data 6. DNA Rates Community Health Services. 7. ALOS older peoples in-patient service 8. 7 Day Post Discharge Follow ups 9. IAPT – Recovery rate (NHSI key operational performance metric). 10. % of patients extremely likely / Likely to recommend SEPT (Mental Health) 11. Out of area placements 12. Data Completeness MH Patient Outcomes (NHSI key operational performance metric) 13. Vacancy Rate % unfilled posts 14. Turnover Rate 15. Complaints referred to PHSO 16. Falls (moderate/ severe harm (avoidable)) 17. Safety Thermometer (mental Health)
The committee considered safer staffing performance and agreed that whilst this should remain within the report it was not necessary to discuss in detail unless issues were identified.
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FINANCE AND PERFORMANCE COMMITTEE ASSURANCE REPORT
The committee received a summary of performance against the revised NHSI quality surveillance and key operational metrics that came into effect 1 October 2016. The Chair confirmed that following presentation of all of these metrics in the BOD Scorecard in January, only the key operational metrics should be presented monthly going forward.
The committee discussed the content of the report, requested action where necessary and accepted the assurance provided in respect of action being taken.
2.3 Financial Performance Report
The Chief Finance Officer (CFO) presented the committee with a detailed report on financial performance as at Month 10 – January 2017. In summary the reported position was confirmed as:
Annual Forecast YTD Position Plan Outturn 2016/17 Plan Actual Operating (Surplus)/Deficit £000 (£257k) (£3,220) (£2,978k) (£3,151k) Capital Expenditure £5,011k £5,011k £3,962 £2,136 Cash Balance £41,068k £44,000k £43,154k £54,073k Use of Resources Rating 2 1 2 1
The Trust achieved a surplus of income over expenditure of £3.2m and the year-end forecast has been improved further since last month (£2.257m) to a planned surplus of £3.2m. Based on this position the Trust has achieved a Use of Resources rating of 1, being the highest rating.
The CFO advised that the re-forecast of year end position does not require a self- certification process to be followed as it is an improved, not worse, forecast. He did though advise that if this position changes next month, a self-certification process may be required.
The committee noted and discussed the following key items:
Cost Improvement Plan (CIPs) – there has been an improvement in Month 10; the target efficiency requirement is £12.7m, of which £2.3m is being met from CQUIN. This leaves a delegated target of £10.436m to divisions and departments. The year-to-date CIP identified on the overall efficiency requirement is £12.336m. Only £0.07m of the identified CIPs remain to be actioned in the ledger. The committee welcomed this reported position.
Cumulative adverse variance on contract income of £524k is mainly due to the following factors:
The on-going contract dispute with Circle relating to delays with the theatre space for Podiatry / Podiatric surgery in BCHS, under-performance on income c£262k. Year-to-date underachievement relating to lower than planned bed activity on the NHSE specialist contract c£231k.
Operational Services (Mental Health) - adverse variance of £0.485m is due to the following reasons:
The IAPT service continues to overspend, in month c£19k and cumulatively c£109k. The over spend is related to reducing waiting list and delivery of national targets.
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FINANCE AND PERFORMANCE COMMITTEE ASSURANCE REPORT
Out of Area placement (ECR) beds not funded - £335k remains as part of the overall cumulative overspend in Month 10.
Thorpe Ward – under spend in month due to additional income related to observations and cumulatively overspent c£93k. The ward was established and is currently funded for 10 beds, however the ward is being fully utilised for 20 – 28 beds and as a result is incurring high agency costs each month. The service director is looking to increase the establishment and therefore reduce agency costs. The ward is being utilised to alleviate the OOA (ECR) beds not funded and also the overspill from the Assessment Unit.
Within the month staffing cover and observation costs continue to be in excess of budget, this is contributing to the overall Pay overspend at Month 10 c£88k in the Assessment Unit, relating to a facility for people who are detained by the Police under Section 136 of the MH Act.
Underachievement against income of c£117k mainly attributable to NCA income in the Assessment Unit.
Older people inpatient services – there are a number of wards (Clifton and Rawreth) incurring high costs in relation to patients on high falls risks observations and also due out of criteria patients from BTUH due to critical alert. In addition, Beech is cumulatively overspent c£54k which is mainly attributable to high levels of observations and staffing issues e.g. sickness and maternity leave.
The above items have been offset by vacancies within the Community and Psychology teams and corporate business support.
Provide, who are the contract lead for the Essex Wide Sexual Health contract, has confirmed the latest known financial risk for 2016/17 is an overspend of c£1.7 million. The Trust’s percentage risk share for Year 1 of the contract is 18.36%. The overspend c£260k has been included in the cumulative position for Operations (Community Services & Partnerships) and forecast of c£312k. The Trust received an update from Provide regarding the financial risk for 2016/17; however the financial risk in relation to redundancies and the estates issue for the South quadrant hub are still to be fully quantified.
Learning Disability - the in month adverse variance is c£33k and the cumulative adverse variance c£188k. This is mainly attributable to Byron Court where the staffing levels are in excess of the establishment and is due to the increased levels of observations, particularly on level 3 obs, plus staff sickness levels. A task and finish group has been developed to consider how to address the financial pressure. The committee was advised that the Trust had received confirmation that the learning disability service is going to be subject to a procurement process. Essex CC is leading the procurement.
The CFO advised that the annual plan submitted to NHSI for 2016/17 for Employee Expenses included £9.865m for agency spend. This target has been allocated to directorates based on agency spend in 2015/16. The total expenditure as at Month 10 on Agency Staff was £8,605k against a target of £8,450k, resulting in a year to date adverse variance of (£155k). The discussion in respect of agency spend is recorded in section 2.5 below as it took place in connection with presentation of the workforce transformation assurance report.
The committee discussed the content of the report, requested action where necessary and accepted the assurance provided in respect of action being taken.
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2.4 Sub Committee Reports
The committee received four sets of the Executive Operational Committee part one minutes for noting:
10 January 2017 17 January 2017 24 January 2017 31 January 2017
It was identified that minutes of the EOC Performance meeting have not been provided to the committee and the Chair requested that clarification on the governance arrangements of these discussions was sought.
No further action was identified.
2.5 Workforce Transformation Update
An assurance report from the Workforce Transformation Group was presented by the Head of HR. Three hotspots were identified and discussed as followed:
Agency Spend The committee noted that the trust has achieved a 30% year on year reduction in spend already but that as at month 10 (see finance report) there is a risk that the Trusts agency cap agreed with NHSI will be breached. The committee explored the internal controls that have been put in place and those that are to be implemented to strengthen current systems. Assurance was provided that a range of actions are being taken by HR, operational teams and NHSI to support reduction in use and cost of agency staff.
The committee also explored in detail the ability of the Trust to deliver a further reduction in agency spend in 17/18 both in terms of the NHSI agreed cap and the internal CIP. The CFO acknowledged that this will be an ambitious and challenging target. The committee also acknowledged that the Board of Directors has committed to maintaining safe staffing levels which could prevent the agency cap/ CIP being achieved.
It was confirmed that the EOC are to receive weekly reports on services breaching the agency price cap and framework rules in addition to the monthly summary that has been provided in the performance report since May 2016.
Sickness Absence rate Assurance was provided that HR and operational managers are continuing to take action to manage absence more effectively.
EPUT Policies and Procedure The committee was advised that some delay has been experienced in merging “critical” rated policies that were planned to be in place on day 1. A recovery plan has been put in place and it is hoped that the majority will be developed for presentation to the FPC in March 2017 prior to Interim Board approval 30 March. Assurance was provided that, having reflected on the critical policy list only two must be in place from 1 April (organisational change and sickness), and these will be.
No further action was requested.
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2.6 Risk Management and Assurance Framework Annual Update
The Director of Compliance presented a report that outlined action taken in the past year to continue to develop the Trust’s risk management and assurance arrangements. It was noted that Grant Thornton had not made any recommendations in respect of the BAF arrangements in place. It was also noted that the BAF has become more fluid in 16/17 with risks being added and removed and changing in year and this was very positive. The development plan has progressed well. Any actions outstanding will be incorporated into the framework for EPUT which is due to be presented to the committee in March 2017. No recommendations were made for further development of the arrangements.
2.7 Self-Certification Update
The Director of Compliance advised the committee that NHSI has suggested (email 10 February) that the self-certification process is likely to be withdrawn from 1 April 2017. NHSI has also not been able to confirm the self-certification process that will be required of EPUT. In view of this the committee agreed that the Trust should suspend specific preparation for self-certification over and above normal good governance and taking forward the previously agreed governance development plan. It was agreed that the recent governance review by Grant Thornton as part of the merger preparation would provide adequate assurance to support a governance related declaration.
2.8 Self Assessment of FPC Effectiveness & Handover
The chair advised that the a decision has been made in light of the recent positive Grant Thornton report on governance arrangements and merger plans, that the annual efficacy review will not take place before 1 April 2017. The Chair of the committee confirmed that plans are in place to prepare a handover report to the new Chair of the EPUT Finance & performance Committee.
2.9 Policy and Procedure Approval
The committee approved revisions to the SEPT Grievance Policy (HR2) that had been made to ensure the Trust was compliant with the ACAS code of practice.
Report prepared by:
Faye Swanson Director of Compliance & Assurance
On behalf of:
Janet Wood Chair of the Finance and Performance Committee
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SEPT
Agenda Item No: 6b(ii)
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: Board of Directors Quality Committee Assurance Report Non-Executive Lead: Janet Wood, Vice-Chair, Chair of the meeting on 22.02.16 Executive Lead: Andy Brogan, Executive Nurse & Executive Director Mental Health Report Author(s): Cathy Lilley, Trust Secretary Report discussed previously at: Level of Assurance: Level 1
Purpose of the Report To provide assurance to the Board that the Quality Committee is Approval discharging its terms of reference and delegated responsibilities Discussion effectively, and that the risks that may affect the achievement of the Information Trust’s objectives and impact on quality are being managed effectively.
Recommendations / Action Required 1 To note the contents of the report 2 To confirm acceptance of assurance given in respect of risks and actions identified 3 To request further action/information as required.
Summary of Key Issues At its meeting on 13 February 2017, the Quality Committee: Received a report on two case studies of school-age children being supported by the school nursing team in Central Bedfordshire that demonstrated the nature of the different referrals to the school nursing team and the impact the team has in supporting young people through the school Received a detailed presentation on the Quality Priority – Restrictive Practices Reviewed the Quality Report that focused on quality performance and considered trends Received a detail briefing on the preparation and external audit of the Quality Report/Account 2016/17 noting the complexities associated with the production this year, in particular relating to the proposed merger with NEP Received an overview of the Trust’s responses to two consultations: CQC next phase of regulation, and Use of Resources and Well-Led Assessments Noted that the CQC intelligence system had continued to be populated with data to mirror the system used for CQC intelligence monitoring report with the aim of bringing together one picture of Trust services Advised that internal CQC comprehensive inspections and CQC MHA focused visits have continued Noted the progress with the AWOLS action plan Approved the Mortality Review Framework and the Security Management Framework 2017/20 Requested further information to support an effective and consistent Board committee handover report Approved essential changes to SEPT policies and the critical policies for the new Trust Received an assurance report from the Patient & Carers Steering Group Did not identify any risks for escalation to the CRR or BAF, or risks/issues to be raised with other standing committees; or recommendations to the Audit Committee linked to the internal audit programme.
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Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework Are any existing risks in the BAF affected? Yes If yes, 1 the findings and recommendations identified in the review of patient deaths in insert the care of Southern Health could identify gaps in the Trust’s processes for relevant reviewing mortality which will require significant action risk 2 if services fall short of the standards required to remain compliant with the Health & Social Care Act there is the potential for CQC enforcement action or in extreme cases closure of services 3 If record keeping standards are not in line with Trust policy quality of care may be compromised. Do you recommend a new entry to the BAF is made as a result of this report? No
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? No If yes, EIA Score
Acronyms / Terms used in the Report CQC Care Quality Commission SI Serious Incident EOSC Executive Operational Sub-Committee CCG Clinical Commissioning Group BAF Board Assurance Framework SUTS Sign Up To Safety CAMHS Children & Adolescence Mental Health Services FFT Friends & Family Test EPUT Essex Partnership University NHS FT NHSE NHS England NEP North Essex Partnership University NHS FT NHSI NHS Improvement MHS Mental Health Services MHA Mental Health Act CHS Community Health Services
Supporting Documents &/or Further Reading Main report
Non-Executive Lead
Janet Wood, Vice-Chair and Chair of the Quality Committee Meeting held on 13.02.17
2 SEPT Board of Directors
Agenda Item 6b(ii) Board of Directors Meeting Part 1 22 February 2017
BOARD OF DIRECTORS QUALITY COMMITTEE ASSURANCE REPORT
1 Purpose of Report
This report is provided to the Board of Directors by the Chair of the Board of Directors Quality Committee. As an integral part of the Trust’s agreed assurance system, the report is designed to provide assurance to the Board that:
risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively. This is an integral part of the Trust’s agreed assurance system the Committee is discharging its terms of reference and delegated responsibilities effectively.
2 Executive Summary
2.1 Minutes of meetings held on 12 January 2017 The minutes were approved on 13 February 2017 and are available in full to Board members via the Chair’s Office or on the intranet.
2.2 Summary of discussions and issues identified as well as assurances provided at the meeting held on 13 February 2017:
2.2.1 Patient Story: Two case studies of school-age children being supported by the school nursing team in Central Bedfordshire were presented. These demonstrated the nature of the different referrals to the school nursing team and the impact the team has in supporting young people through the school.
2.2.2 Quality Report: Although the Committee had agreed for this report to be presented bi-monthly, it was presented to the January meeting (containing October data) and also at the February meeting to provide the most recent quarter end position. The Committee agreed that the next report should be produced for the April meeting (year-end) and also in May for month 1 as this would provide a baseline for future reports and analysis. Thereafter it would be produced bi-monthly.
The Committee noted the continued positive developments to the report that now included information on safer staffing trends.
It was noted that as at December 2016, 42 mental health serious incidents (SIs) had been reported including 20 unexpected deaths. The trend in SIs (total and unexpected deaths) is slightly lower than 2015/16 (61 and 29 full year). In community health services, three SIs had been reported compared to a total of five for 2015/16.
Adverse trends were reported in respect of: Restraints (total number, prone incidents and the Trust exceeded the benchmark rate overall) Falls (with avoidable harm) Local How Did We Do survey results FFT (secure services, CAMHS, MHS community below benchmark)
Good performance is identified in respect of:
Board of Directors Part 1 22 February 2017 Page 1 of 5 SEPT Board of Directors
Grade 3 / 4 pressure ulcers (total less than 2015/16) Avoidable Grade 3 / 4 pressure ulcers (total less than 2015/16) Patients experiencing harm (average <2%) Safer staffing fill rate.
2.2.3 Quality Priority – Restrictive Practice: A detailed report was presented on the work of the Sign Up to Safety Restrictive Practice Workstream; the aim of the work is to reduce restraints as well as changing cultures around restrictive practices across the Trust. The Committee recognised the challenges associated with the use of physical restraint and restrictive interventions particularly as the services are working with a range of patients with differing and in some cases complex needs and acuity.
Ward data and trend analysis is used to identify the most challenging patients and can also be used to identify business strategies (i.e. safer staffing numbers) and clinical strategies (i.e. positive support plans, risk management, etc). The Committee noted the positive use of de-escalation that demonstrated the skilful actions deployed by staff and acknowledged that the use of de-escalation can contribute to reducing restraints and restrictive interventions.
The Committee received an update on the progress with the two year action plan and noted that a number of elements of the work had been achieved but recognised that work involving cultural and system change often requires longer timescales.
The Committee noted the concerns raised by both the Board and the Council about the rising number of restraints; however, following review, no clear reason for the increase could be identified. Assurance was provided that currently no patients had suffered any physical harm and that the data was regularly monitored by management.
2.2.4 Quality Report/Account: A detailed update on the preparation and external audit of the Quality Report/Account 2016/17 was provided . As in previous years, the Quality Report/Account is required to contain three parts and the content of each part is prescribed: Part 1: Statement on quality from the CEO Part 2: Priorities for improvement which is a forward looking section to show plans for quality improvement within the organisation and why these were chosen. It also includes mandatory statements relating to the quality of NHS services provided and mandatory reporting of nationally prescribed core set of quality indicators Part 3: Review of quality performance which is a report on the previous year’s quality performance which must include at least three indicators covering patient safety, clinical effectiveness and patient experience, as well as performance against key national priorities.
In addition annexes to the report include statements from commissioners, local Healthwatch organisations and Health Overview and Scrutiny Committees; statement of Directors’ responsibilities in respect of the Quality Report; and the independent auditor’s report to the Council of Governors on the annual Quality Report.
The complexities associated with producing the Quality Report/Account in light of the proposed merger with NEP were highlighted: The Council of Governors has provided a statement for publication in previous years. Whilst this is not a mandated requirement, it has provided valuable feedback and been a valuable part of the Quality Report /Account. However, the draft will not be available until the end of April and as such (subject to the proposed merger with NEP going ahead on 1 April 2017) the SEPT Council will
Board of Directors Part 1 22 February 2017 Page 2 of 5 SEPT Board of Directors
not exist at that date. At its meeting on 9 February the Council considered a detailed briefing on the production of the Quality Report/Accounts and agreed that the Lead Governor would prepare a general statement for inclusion on behalf of the Council. Should the merger not proceed and the SEPT Council is in existence in May 2017, the process followed in previous years will be implemented If the merger does proceed, the full Council will not be established until June 2017 earliest which is after the submission date. The external auditors have confirmed that it will be acceptable for the Quality Report/Accounts and the report of the external auditors to be presented once the full Council has been established.
The Committee was also briefed on other complexities. Guidance on external audit arrangements for Quality Reports indicated that NHS FTs providing a mix of different services should follow the guidance for the category of services from which they receive the majority of their income. In previous years this came from mental health services. However, month 9 financial projections for 2016/17 indicated that the majority of Trust income will come from community health services. As a result the Trust is required to follow the guidance for CHS which is yet to be issued.
However, two of the three indicators (from previous years) are not applicable to the Trust and so in line with NHSI guidance the Governors selected an alternative indicator, following consultation with the auditors, to ensure that at least two indicators are subject to a limited assurance report. Governors have also been requested to select a mandated indicator for external assurance from one of the three MHS mandated indicators. This will mean that this year there will be one CHS mandated indicator and one MHS mandated indicator being subject to external assurance. In addition, as in previous years, the Council has selected a local quality indicator for external assurance. In view of the queries raised by Governors in the past two years in respect of the accuracy of data presented in respect of complaints, the Council agreed the recommendation that the complaints data ( number of complaints received/number of complaints referred to PHSO/% of complaints responded to within agreed timescales) should be subject to external audit.
2.2.5 AWOLS Action Plan: The Committee received an updated action plan in relation to AWOLS and assurance was provided that actions were continuing to be taken forward with many actions completed within the timescales set.
2.2.6 CQC Update: An update on the CQC compliance processes, consultations, internal processes and MHA implementation was provided.
The Committee was advised that the application to register Essex Partnership University NHS FT (EPUT) as a new organisation and the application to de-register all SEPT services had been submitted to the CQC on 26 January 2017. The application is now being processed by the CQC and requests for further information have been received and responded to in a timely manner.
The Trust’s responses to CQC’s consultation on the next phase of regulation and the consultation on the Use of Resources and Well-Led Assessments were shared.
Internal CQC intelligence system has continued to be populated with data to mirror the system used for CQC intelligence monitoring report with the aim of bringing together one picture of Trust services. Analysis of this data identified two hotspots in relation to Hadleigh Unit and Thorpe Ward. Byron Court had also been identified as a hotspot but outside of the intelligence monitoring system. Discussions took place on
Board of Directors Part 1 22 February 2017 Page 3 of 5 SEPT Board of Directors
the length of time Hadleigh Unit had been identified as a hotspot; assurance was provided that mitigating actions have been developed and being taken forward.
Internal CQC comprehensive inspections have continued with two inspections completed in January and the Committee noted the outstanding actions outstanding from previously completed internal inspections.
Details of CQC MHA focused visits were also shared together with the status of the Provider Action Statements submitted to CQC. The Committee also noted the issues identified from the CQC MHA visits regarding Lagoon Ward, Dune Ward, Meadowview and Hadleigh Unit, and the issues raised and action taken following internal MHA spot checks.
2.2.7 Mortality Review Framework: The Committee received and approved the draft Mortality Review Framework that had been amended to take account of feedback from members. The importance of ensuring that the qualitative benefits of the framework are clearly articulated and the importance of supporting staff in the delivery of the framework were highlighted. The Committee agreed the importance of due consideration to be given to the resourcing impact for delivering the framework and agreed that this should be taken forward by the Executive Operational Sub- Committee.
The Committee noted that a definition for an ‘avoidable’ death had been agreed: an avoidable death is one which healthcare management causation is more likely than not.
2.2.8 Security Management Framework 2017/20: The Committee received and approved the new Security Management Framework 2017/20 noting that this was initially for SEPT with a revision post-merger for EPUT. The Framework is designed to support Trust staff in providing high quality healthcare through a safe and secure environment that protects patients, staff and visitors, their property and the physical assets of the organisation.
2.2.9 Board Committee Handover Report: The Committee requested that a template is developed and circulated to all Board standing committees to provide a consistent approach to the content of the handover report. In addition, the Committee requested that a guidance note is sent to all standing committees to explain the sub-committee handover arrangements. The Committee also requested that the scheme of delegation is developed to reflect the terms of reference for standing committees for the new organisation to ensure there is consistency and clarity in respect of delegated duties and responsibilities.
2.2.10 Policies: The Committee noted that the policies being presented for approval had been taken through the Trust’s policy approval control process. It was agreed that future reports would indicate whether the policies presented where essential changes to the Trust’s policies or were ‘critical’ policies for the new Trust should the merger proceed.
The following ‘critical’ policies and procedures were approved in preparation for the new Trust: Equality, Inclusion & Human Rights Policy and Procedure Records Management Policy CP9 Access to Records Policy and Procedure CPG9(d) Transfer, Transportation of Records/Information Procedure Corporate Health & Safety Policy and Procedure RM01 and RMPG01 Complaints Policy and Procedure
Board of Directors Part 1 22 February 2017 Page 4 of 5 SEPT Board of Directors
Adverse Incident Policy and Procedure
The following SEPT policies and procedures were approved: Legionella Policy and Procedure Catering Policy RM12
2.2.11 Patient & Carers Steering Group Assurance Report: There were no significant issues raised at the recent meeting held on 9 January 2017. The Committee noted that discussions were being held with counterparts in NEP with a view to establishing a new Patient & Carer Experience Steering Group for the new merged Trust.
2.3 Risks/hotspots: The Committee did not identify any risks for escalation to the CRR or BAF; risks or issues to be raised with other standing committees; or recommendations to the Audit Committee linked to the internal audit programme.
3 Action Required
The Board of Directors is asked to: 1 Note the contents of this report 2 Confirm acceptance of assurance given in respect of risks and action identified 3 Request further action/information as required.
Report prepared by Cathy Lilley, Trust Secretary On behalf of:
Janet Wood Vice-Chair of the Trust and Chair of the Quality Committee meeting on 13 February 2017 22 February 2016
Board of Directors Part 1 22 February 2017 Page 5 of 5 Assurance Report – Audit Committee
Agenda Item No: 6b (iii)
SUMMARY BOARD OF DIRECTORS MEETING 22 February 2017 REPORT PART 1
Report title: Board of Directors Audit Committee Assurance Report Executive Lead: Janet Wood, Chair Report Author(s): Carol Riley, Audit Committee Secretary Report discussed Assurance reports provided to the Board following previously at: Audit Committee meetings. Level of Assurance: 2
Purpose of the Report To provide assurance to the Board that the duties of the Audit Approval Committee, which include Governance, Risk Management Discussion and Internal Control, have been appropriately complied with. Information
Recommendations / Action Required 1. To note the contents of the report 2. To confirm acceptance of assurance given in respect of risks and actions identified 3. To request further action/information as required.
Summary of Key Issues The key issues discussed at the meeting held on the 17 January 2017
Joint Internal Audit & LCFS Progress Report External Audit Progress Report Waiver of standing Orders Terms of Reference Self Assessment Checklist Merger Update
The key issues discussed at the meeting held on the 14 February 2017
Internal Audit Progress Report Internal Audit Follow up on Recommendations External Audit Progress Report Sickness Absence Internal Audit Report – Feedback Impaired Debts Write Offs Wavier of Standing Financial Instructions
Brd Rpts/Secs SEPT 1
Assurance Report – Audit Committee
Statement of Financial position Draft Standing Financial Instructions, Detailed Scheme of Delegation and Scheme of Reservation and Delegation
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework Are any existing risks in the Board Assurance Framework affected? No If yes, insert relevant risk
Do you recommend a new entry to the No Board Assurance Framework is made as a result of this report?
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ N/A Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment No If yes, EIA Score No (EIA) Completed?
Brd Rpts/Secs SEPT 2
Assurance Report – Audit Committee
Acronyms / Terms used in the report CEO Chief Executive Officer ECFO Executive Chief Finance Officer SFIs Standing Financial Instructions DSoD Detailed Scheme of Delegation SoRD Scheme of Reservation & Delegation
Supporting Documents &/or Further Reading
Executive Lead
Janet Wood Audit Committee Chair
Brd Rpts/Secs SEPT 3
Assurance Report – Audit Committee
Agenda Item: 6b (iii) Board of Directors Meeting: 22.2.17
SEPT
ASSURANCE REPORT FROM THE AUDIT COMMITTEE CHAIR PART ONE
1.0 PURPOSE OF REPORT
This report is provided by the Chair of the Audit Committee, a sub-committee of the Board of Directors to provide assurance to Board members that the duties of the Audit Committee which include Governance, Risk Management and Internal Control have been appropriately complied with.
2.0 EXECUTIVE SUMMARY
Audit Committee meeting 17 January 2017 and the 14 February 2017
Audit Committee meeting of the 17January 2017 The Audit Committee met on the 17 January 2017 and approved the minutes of the meeting held on 3 November 2016. . These minutes are available to Board members on request.
At the meeting held on 17 January 2017 the following matters were discussed:
1. Internal Audit and LCFS
Internal Audit Progress Report: Since the last committee meeting in November 2017 there has been 7 final reports issued and 4 audits are in progress.
The revised Internal Audit Plan for the remainder of 2016/17 was approved.
Internal Audit Follow up on Recommendations
It was confirmed that all outstanding recommendations have been updated for 2016/17.
LCFS: Members received an update on LCFS work. It was noted that since the last meeting held in November 2016 there had been no new referrals.
Brd Rpts/Secs SEPT 4
Assurance Report – Audit Committee
2. Report from Ernst & Young (External Auditors)
External Audit ran through the financial statement risks and informed the Committee that an additional risk has been included within the financial statement relating to the proposed merger.
In relation to Economy, Efficiency and Effectiveness External Audit have not yet completed the risk assessment in relation to the proposed merger.
3. Waiver of Standing Orders During the period 20 October 2016 – 31 December 2016 standing orders for competitive quotations were waived on one occasion to the value of £5,814.
4. Terms of Reference The Committee agreed to extend the Terms of Reference to September 2017 or if the merger proceeds then to April 2017.
5. Audit Committee Self-Assessment Checklist Members noted the checklist for 2016/17.
6. Merger Update It was agreed that an update on the work carried out by Grant Thornton would be presented to the Audit Committee in February.
The new organisation would continue with Mazars for internal audit services. RSM would provide counter fraud services. Both contracts were due to expire at the end of April 2017 with an option for a one year extension.
7. Audit Committee Chairs Activity: The Audit Committee Chair reported that no issues had been raised with the Chief Executive, internal and external auditors.
Audit Committee Meeting of the 14 February 2017
At the meeting held on the 14 February the minutes of the 17 January 2017 were approved at the meeting held on the 14 February
At the meeting held on 14 February 2017 the following matters were discussed:
1. Internal Audit Progress Report: Since the last committee meeting in January 2017 there has been 1 final report issued, two draft reports and 3 audits are in progress
2. Internal Audit Follow up on Recommendations: The recommendations raised and agreed in 2015/16 related to 24 audits and 56 recommendations. With regard to 2016/17 there were 12 audits and 28 recommendations.
Brd Rpts/Secs SEPT 5
Assurance Report – Audit Committee
3. Report from Ernst & Young (External Auditors) No detailed work carried out at present relating to the proposed merger. Work will commence if the proposed merger is successful.
4. Sickness Absence Internal Audit Report – Feedback A member of the HR Department attended the committee to provide feedback relating to the Sickness Absence Report which received Limited assurance. It was noted that despite the short term absence being high the sickness absence is being managed effectively.
5. Impaired Debts Write Offs The Audit Committee noted the write off of debts considered irrecoverable totalling £10,505.60.
6. Waiver of Standing Financial Instructions
Competitive Quotes: During the period 1st January 2017 to 31st January 2017, standing orders for competitive quotations were waived on three occasions to the value of £30,312 (including VAT).
Competitive Tenders: During the period 1st January 2017 to 31st January 2017, standing orders for competitive tenders were waived on one occasion to the value of £114,048 (including VAT).
7. Statement of Financial Position Write Offs The Committee noted the write offs totalling £6,565.93 which relate to historical balances. The balances have been written off in line with the Detailed Scheme of Delegation.
8. Proposed SFI’s, Detailed Scheme of Delegation (DSoD) and Scheme of Reservation & Delegation (SoRD) The Audit Committee reviewed the above proposed documents for EPUT. It was noted that following the review of the SFI’s and DSoD by the Audit Committee, the Scheme of Reservation and Delegation will now be finalised and submitted to Hempsons for review. The NEP Audit Committee is also due to review the above documents at their meeting in February, and any comments will be incorporated as necessary.
A final version of the proposed SFI’s, DSoD and SoRD for EPUT will be presented to the March meeting of the two Trust’s Audit Committees, prior to being reported to the Interim Board in March. Following their consideration by the Interim Board, these will be recommended for final approval at the first Board meeting of EPUT in April.
Brd Rpts/Secs SEPT 6
Assurance Report – Audit Committee
9. Update on Grant Thornton Work re Merger
This item was discussed under Part II.
3.0 MANAGEMENT OF RISK
The Audit Committee is not responsible for managing any of the Trust’s significant risks (as identified in the Board Assurance Framework).
4.0 NEW RISKS
There are no new risks that the Audit Committee has identified that require adding to the Trusts’ Assurance Framework, nor bringing to the attention of the Board of Directors.
5.0 ACTION REQUIRED
The Board of Directors are asked to: 1. Note the summary of the meeting held on 17 January and 14 February 2017. 2. Confirm acceptance of assurance given in respect of risk 3. Request further action/information as required.
Janet Wood Non Executive Director Chair of Audit Committee
Brd Rpts/Secs SEPT 7
Assurance Report – Audit Committee
Brd Rpts/Secs SEPT 8
Investment and Planning Committee
Agenda Item No: 6b (iv)
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1 Report title: Investment & Planning Committee Executive Lead: Lorraine Cabel Report Author(s): Report discussed previously at: Level of Assurance: 1
Purpose of the Report This report is provided to the Board of Directors by the Chairman of Approval the Investment and Planning Committee. It is designed to provide Discussion assurance to the Board of Directors that risks that may affect the Information achievement of the organisations objectives are being managed effectively.
Recommendations / Action Required
1. Note the summary of the meeting held on 7 February 2017 2. Confirm acceptance of assurance given in respect of risk and the action identified 3. Request further action/information as required.
Summary of Key Issues The key issues:
Meeting of the 7 February 2017
Review of Successful/Unsuccessful Tenders Capital Projects Programme Group Assurance Report Review Terms of Reference – Committee Handover Plan Draft Corporate Objectives 2017/18
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness Relationship to the Board Assurance Framework Are any existing risks in the Board Yes Assurance Framework affected? If yes, insert relevant risk Do you recommend a new entry to the No Board Assurance Framework is made as a result of this report?
Brd Rpts/Secs SEPT 1 Investment and Planning Committee
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues N/A Involvement of Service Users/ Healthwatch N/A Communication and Consultation with stakeholders required N/A Service Impact/Health Improvement Gains N/A Financial Implications Capital £ Revenue £ Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Yes / No If yes, EIA Score
Completed?
Acronyms / Terms used in the report
NHSI NHS Improvement (formerly Monitor) EOSC Executive Operational Sub-Committee PCMHS Perinatal Community and Mental Health Services
Supporting Documents &/or Further Reading
Executive Lead
Lorraine Cabel, Chair
Brd Rpts/Secs SEPT 2 Investment and Planning Committee
Agenda Item No: 6b (iv) Board of Directors Meeting: 22.2.17
SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
INVESTMENT AND PLANNING COMMITTEE
PURPOSE OF REPORT
This report is provided to the Board of Directors by the Chairman of the Investment and Planning Committee. It is designed to provide assurance to the Board of Directors that risks that may affect the achievement of the organisations objectives are being managed effectively.
EXECUTIVE SUMMARY
Investment & Planning Committee Meeting 7 February 2017
Meeting of the 7 February 2017
The Investment and Planning Committee met on the 7 February 2016 and approved the minutes of the meeting held on the 7 November 2016. These are available to Board members on request.
At the meeting held on 7 February 2017 the following matters were discussed:
1. Review of successful/unsuccessful tenders –
Tenders in Progress There are 6 tenders in progress.
Tender – Negotiation for Direct Award
Integrated Healthcare Services HMP Chelmsford - SEPT is currently the preferred provider, subject to their Board approval and negotiations. If successful the contract would be for 2 years commencing from the 27 May 2017. It was noted that after this period the service would possibly go out to tender.
2. Capital Project Programme Board Assurance Report The Capital Project Programme Board Assurance report was presented to the Investment and Planning Committee. The Committee was updated on the following bids and received appropriate assurance of the effectiveness of business transacted.
The following bids were approved:
Beech Ward Shower Trays Additional Toilet in the Lounge Area – Beech Ward 1:1 Rooms – Ashingdon House Rochford Hospital 3 Heath Close – DDA Works
Leagrave Lodge The sale of Leagrave Lodge was completed on the 19th of January 2017 for the sum of £300k.
Brd Rpts/Secs SEPT 3 Investment and Planning Committee
3. Review of Terms of Reference – Committee Handover Plan Members agreed that no changes were required to the terms of reference and that these would be passed onto the new committee as part of the handover plan.
4. Draft Corporate Objectives 2017/18 The following Strategic Objectives will be applied to the new organisation.
Patient - safety, experience and outcomes Attract, develop and enable high performing individuals and teams Enable service improvement plans with system partners Top 25% performance for operational, financial and productivity measures
Members approved the draft corporate objectives for 2017/18.
Management of Risk This committee is not responsible for managing any of the Trusts’ significant risks (as identified in the Board Assurance Framework).
New Risks There are no new risks that the committee has identified that require adding to the Trusts’ Assurance Framework nor bringing to the attention of the Board of Directors.
ACTION REQUIRED
The Board of Directors are asked to:
1. Note the summary of the meeting held on the 7 February 2017
2. Confirm acceptance of assurance given in respect of risk and the action identified.
3. Request further action/information as required.
Lorraine Cabel Chair of Investment and Planning Committee
Brd Rpts/Secs SEPT 4 Agenda Item No: 6b(v)
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: NEP/SEPT Interim Board Assurance Report Executive Lead: Janet Wood, Acting Interim Chair – Interim Board Report Author(s): Cathy Lilley, Interim Trust Secretary – Interim Board Report discussed previously at: n/a Level of Assurance: Level 1 2 3
Purpose of the Report To provide assurance that the Interim Board, as a standing Approval committee of both NEP and SEPT Boards of Directors, is Discussion discharging its terms of reference and responsibilities effectively, Information and that the risks that may affect the achievement of its responsibilities are being managed effectively.
Recommendations / Action Required The Board of Directors is asked to: Note the contents of the report Confirm acceptance of assurance given in respect of risks and actions identified Request further action/information as required.
Summary of Key Issues The following matters were discussed by the Interim Board at its meeting on 15 February 2017: Update on the Interim Chair vacancy and confirmation of Janet Wood becoming Acting Interim Chair in line with Standing Orders (2.9) Proposals to manage the Interim Board balance and voting requirements Proposals to review Interim Board committee membership and chair allocation Update on Board committees’ handover arrangements for tiers 1 and 2 Receipt of Interim Executive Operational Sub-Committee minutes Review of a more detailed report of expenditure and merger budget Detailed discussions on the risk register particularly the achievement of the control total – no additional risks were identified for inclusion Confirmation that all merger project milestones was progressing with no material slippage report Drafts of the reporting accounts report and Board memorandum were reviewed; it was noted that it was expected that Grant Thornton would issue an unqualified opinion in their final report Update on the wide range of communications and engagement activities
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Page 1 of 5 Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? Yes If yes, insert relevant risk BAF 16032401 Do you recommend a new entry to the BAF is No the existing BAF entry has been updated to made as a result of this report? reflect the current situation.
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ TBC Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) A formal Equality Impact Assessment (EIA) TBC Completed? commenced in November.
Acronyms / Terms used in the report LTFM Long Term Financial Model NHSI NHS Improvement (formerly Monitor) PTIP Post Transaction Integration Plan NEP North Essex Partnership University NHSFT CQC Care Quality Commission EPUT Essex Partnership University NHS FT FBC Full Business Case
Supporting Documents &/or Further Reading None
Executive Lead
Janet Wood Acting Interim Chair
Page 2 of 5 Agenda Item 6b(v) Board of Directors Meeting Part 1 22 February 2017
NEP/SEPT INTERIM BOARD
1 PURPOSE OF REPORT
The purpose of this report is to provide assurance that the Interim Board, as a standing committee of both NEP and SEPT Boards of Directors, is discharging its terms of reference and responsibilities effectively, and that the risks that may affect the achievement of its responsibilities are being managed effectively. The report also provides updates on the progress with the proposed merger between NEP and SEPT.
2 SUMMARY
2.1 Background Pre completion of the merger, the Interim Board is responsible for the merger process between NEP and SEPT, in particular managing the final stages of the FBC process and especially liaising with NHS Improvement (NHSI) once the Full Business Case (FBC) has been submitted. In addition, it will be responsible for the transitional governance of the new Trust under S56(11) of the NHS Act 2006 until the appointment of the substantive Board of the new Trust.
Prior to the completion of the merger, the Interim Board is constituted as a working group/committee of both NEP and SEPT Trust Boards and has no delegated executive powers relating to statutory and regulatory powers of the Board.
2.2 Meeting held on 15 February 2017 The Interim Board met on 15 February 2017 and was joined by Sam Hepplewhite, Chief Officer at North Essex CCG. The following items were discussed:
2.1.1 Minutes of Meeting held on 26 January 2017: These were approved and an update on the action logs provided. The minutes are available on request from the Interim Trust Secretary.
2.1.2 Interim Chair: It was confirmed that Chris Paveley had stood down from his role as Interim Chair of the proposed new Trust due to changes in his personal circumstances relating to his responsibilities as a carer. Provision 2.9 of the Board of Directors Standing Orders within the constitution of the new Trust has been enacted resulting in Janet Wood, the Interim Vice-Chair, becoming the Acting Interim Chair until a new substantive Chair is appointed. The Interim Board members thanked Chris for his contribution on the Interim Board over the last few months.
2.1.3 Interim Board: It was noted that the Interim Board will comprise of an equal number of Interim Executive and Non-Executive Directors. However, it was agreed that the status quo should remain and the Board balance would be addressed under the ‘comply or explain’ requirements of Monitor’s Code of Governance that would be included in the new Trust’s Directors’ Report for 2017/18. Assurance was provided that under the Board of Directors Standing Orders (3.11) the Acting Interim Chair would have a second casting vote in the case of an equality of votes.
2.1.4 Interim Board Committees: The membership and chair allocation will be reviewed following the change to the Interim Board composition. In addition the terms of reference will also be reviewed to take account of any changes to either the
Page 3 of 5 membership of and/or attendees’ job roles/functions following the corporate restructure.
2.1.5 Board Committees Handover Arrangements: The Chairs of both Boards standing committees (tier 1) have been advised of the handover process and Interim Non- Executive Directors who are chairs of committees confirmed that they will be or are arranging to attend committee meetings and/or meet with the outgoing committee Chair. It was advised that a report template will be sent to all Chairs to support with the handover report so that there would be a consistent approach.
The handover arrangements for the sub-committees (tier 2) reporting to the standing committees were explained. The preparations and plans for amalgamating these will take place during quarter 1 with a view to the tier 2 committee framework being established by the end of quarter 2. It was pointed out that on day 1, it would be ‘business as usual’ for the sub-committees and there was no requirement to make any changes at this stage. However, it was noted that in some cases work has already commenced on the combining and establishment of the sub-committees.
2.1.6 Interim Executive Operational Sub-Committee Minutes: These were received for the meetings held during December 2016 and January 2017 as the Interim EOSC is a sub-committee of the Interim Board.
2.1.7 Merger Budget: A more detailed report was presented that provided an overview of expenditure to January 2017. The main items of expenditure as with previous months have been on the interim management support and PwC; Grant Thornton’s fee has yet to be invoiced but is accounted for within the budget. It was noted that the additional transitional support was being sought for the contracts workstream as neither Trusts’ procurement teams are at their established strength. The additional resource will allow the workstream to undertake the review of expenditure contracts and commence new procurement where necessary as required by the merger transaction. In addition, the contract for the PMO lead has been extended to April 2017 in line with the recommendations of Grant Thornton’s review to ensure an efficient handover to the substantive PMO team post-merger. The Interim Board noted that there has been significant underspend in some areas; the merger transaction therefore remained within budget overall and it was not expected that the allocated budget will be exceeded.
2.1.8 Risk Register: The risk register was reviewed and no additional risks were identified for inclusion. The Interim Board were advised that there had been no changes to the top five risks namely realistic control totals, depletion of cash balances in Essex Partnership University NHS FT (EPUT), staff leaving the respective Trusts, delivery of the clinical workstream and the revised clinical model for engagement, and the phasing of identified corporate savings.
As reported at the January Interim Board meeting, on the recommendation of Grant Thornton a review of the Post Transaction Integration Plan (PTIP) was being undertaken to merge effectively three risk registers, i.e. NEP, SEPT and risks from the merger risk register that carry into EPUT. There would be two sections covering programme risks and business risks. The Interim Board received the initial framework that defined the merger transaction risk and discussed in detail risk 114 (control total) and 115 (working capital). Members noted that the impact of not achieving the control total on the Use of Resources rating and segmentation of the Trust was currently not known as there was not sufficient clarity in the Single Oversight Framework guidance.
The Interim Board agreed the risk scoring framework.
Page 4 of 5
2.1.9 Merger Project Update: Progress towards all milestones was progressing with no material slippage reported.
2.1.10 Reporting Accountants and Board Memorandum Update: The Interim Board received the working draft Board Memorandum that Grant Thornton, the reporting accounts to the merger transaction, will use to provide a report that will form the basis of their formal opinion. The draft report from Grant Thornton was also shared and it was noted that this included some recommendations covering financial reporting procedures, quality governance arrangements and the PTIP but did not include the formal opinion. These advisory recommendations will be considered by the workstreams and the PTIP would be revised. However, it was expected that Grant Thornton would issue an unqualified opinion in the final report that will form part of the NHSI assessment and risk rating of the merger transaction.
2.1.11 Communications and Engagement Plan: An update was provided on the wide range of communications and engagement activities. A confidential summary Full Business Case had been produced for both Councils of Governors in response to requests from Governors. In addition a public prospectus for the proposed merger has been published and copies were distributed at the public ‘Question Time’ event in Brentwood on 25 January 2017; it is available on both Trusts’ websites and intranets. A staff guide to the proposed new Trust was also being prepared.
There is continuing involvement of the Stakeholder Reference Group (SRG) of service users, carers and Healthwatch mental health ambassadors who will be involved in the coproduction of the clinical model. Staff Q&A sessions have been held in the north, south and west of Essex and in Bedfordshire where discussions were led entirely by staff. Questions asked at each meeting are being turned into a FAQ that will be published on both intranets. In addition there has been a public ‘Question Time’ session with over 100 members and local people attending.
The Interim Board also heard about the plans for the membership of EPUT and the Council of Governors elections.
3 ACTION REQUIRED
The Board of Directors is asked to note the progress with the proposed merger project.
Report prepared by Cathy Lilley, Interim Board Trust Secretary On behalf of
Janet Wood Acting Interim Chair 22 February 2017
Page 5 of 5 Board of Directors
Agenda Item No: 7a
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22nd February 2017 PART 1
Report title: General update report regarding the proposed merger between South Essex Partnership University NHSFT and North Essex Partnership University NHSFT Executive Lead: Nigel Leonard, Executive Director Corporate Governance Report Author(s): Tom Wilson, Interim Project Manager Report discussed previously at: Level of Assurance: Level 1 2 3
Purpose of the Report This report provides a brief update on the progress of the merger Approval project over the past month. Discussion Information
Recommendations / Action Required The Trust Board of Directors is asked to: note the update with regard to the proposed merger with North Essex Partnership University NHSFT.
Summary of Key Issues NHSI and Grant Thornton (the merger Reporting Accountants) have now completed the information gathering phase of their assessment work.
NHSI is due to hold a ‘Board to Board’ meeting with the Interim Board of EPUT on 21st February.
Grant Thornton has provided each Trust Board with a formal opinion on the proposed financial reporting procedures, quality governance processes and integration plans.
Subject to both Boards being content with the opinion this will be shared with NHSI and marks the end of the assessment process.
NHSI are expected to provide a formal risk rating for the merger transaction by Friday 17th March 2017.
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework Are any existing risks in the BAF affected? Yes If yes, insert relevant risk BAF 16032401 Do you recommend a new entry to the BAF is made No the existing BAF entry has been updated as a result of this report? to reflect the current situation.
Page 1 of 3 Board of Directors
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ TBC Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Yes / No If yes, EIA Score Completed? TBC A formal Equality Impact Assessment (EIA) commenced in November.
Acronyms / Terms used in the report NHSI NHS Improvement (formerly Monitor) BAF Board Assurance Framework PTIP Post Transaction Integration Plan
Supporting Documents &/or Further Reading None
Executive Lead
Nigel Leonard Executive Director Corporate Governance
Page 2 of 3 Board of Directors
Agenda item 7a Board of Directors Meeting: Part 1 22nd February 2017
General regarding the proposed merger between South Essex Partnership University NHSFT and North Essex Partnership University NHSFT
1 PURPOSE OF REPORT
This paper updates the Board on progress with the proposed merger with North Essex Partnership University NHSFT over the past month.
2 EXECUTIVE SUMMARY
Assessment of the merger business case
Previous Board papers have described the assessment process following the submission of the draft Full Business Case and draft Post Transaction Integration Plan to NHS Improvement’s Provider Assessment team.
The culmination of the NHSI process will be a meeting with the Interim Board of EPUT with senior Directors at NHSI. This is scheduled for the 21st February and any relevant feedback will be given at the Board meeting.
Grant Thornton have been contracted to act as the merger’s Reporting Accountants to provide an independent opinion to each Trust Board on EPUT’s proposed financial reporting procedures, quality governance processes and overall integration planning. This report is being considered at each Trust Board and if approved will be submitted to NHSI.
It should be noted that usually a working capital opinion is also sought from Reporting Accountants. As NHSI’s merger guidance points out each transaction is unique and the Interim Board of EPUT gained permission from NHSI to not commission a working capital opinion for this specific transaction. Each Trust Board is being provided with assurances on working capital generated by the finance merger project team.
With the assessment process completed NHSI will provide a risk rating for the transaction to each Trust by Friday 17th March 2017.
RECOMMENDATION
The Trust Board is asked to note the progress over the last month of the merger project.
Report prepared by: Tom Wilson Interim Project Manager
On behalf of
Nigel Leonard Executive Director Corporate Governance 16th February 2017
Page 3 of 3 Agenda Item No: 8a
SUMMARY Board Report 22/02/2017 REPORT
Report title: Review of SEPT Linked Charities and Funds Classification and the Granting of Bedford and Luton funds to ELFT’
Executive Lead: Mark Madden
Report Author(s): Boroji Nwaokolo
Report discussed n/a previously at:
Level of Assurance: 1
Purpose of the Report
To advise the Board of the review of the SEPT linked charities Approval and classification of charitable funds and seek approval for the closure of the relevant linked charities and for the re- Discussion classification of the relevant funds as recommended below. Information
To update the Board on the transfer of the Bedford and Luton charitable funds to East London NHSFT (ELFT) and seek approval for the making of the grant required to complete this transfer.
Recommendations / Action Required
Approve the closure of the linked charities in Appendix A that have been recommended for closure;
Approve the reclassification of the restricted funds in Appendix B that have been recommended for reclassification to unrestricted funds;
Approve the grant of £620,888.95 to the Barts and The London Charity plus any transactional movements that arise by the grant date of not more than £10,000 and;
Delegate authority to the Financial Trustee and either Chief Executive or Deputy Chief Executive to agree and sign the final letter that will accompany the grant.
Summary of Key Issues
REVIEW OF LINKED CHARITIES AND FUNDS CLASSIFICATION
The Finance Department completed the review of the SEPT linked charities and concluded that of the 36 existing linked charities, 22 of them should be closed. As shown in Appendix A, most of these had either nil or below £5,000 balance as at the end of December 2016 and one linked charity has only ELFT fund which will become nil balance once the fund transfers to ELFT. Also one linked charity consists of an inactive fund which would become more beneficial if moved to a general purpose fund.
The Finance Department also reviewed the classification of the charitable funds and in the absence of clear restriction at the point of receipt of relevant donations, has concluded that the funds in Appendix B should be unrestricted but designated to the respective services, wards or teams.
The Charitable funds Committee has approved the closure of these linked charities and the reclassification of these funds and recommends these to the Board for approval.
EAST LONDON NHS FT FUNDS TRANSFER
ELFT have agreed to the transfer of the relevant Bedford and Luton services charitable funds. However, ELFT’s charitable funds are managed by the Barts and The London Charity and so the relevant funds will need to be transferred to Barts and The London Charity.
The Department of Health (DOH) has advised that the way to undertake this proposed transfer is by the SEPT Charity’s own grant-making powers. The Charitable Funds Committee therefore recommends to the Board, the granting of the sum of £620,888.95 to the Barts and The London Charity, being the total fund balance of all the charitable funds relating to the transferred Bedford and Luton services, as at the end of January 2017, subject to any transactional movements that arise by the grant date. The intended timescale for making the grant is before the end of the financial year, March 2017.
Relationship to Trust Strategic Priorities
SP 1: Quality Services
SP 2: Quality Leadership & Workforce
SP 3: Sustainability of Service Provision
SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework
Are any existing risks in the Board No
Assurance Framework affected?
If yes, insert relevant risk
Do you recommend a new entry to No the Board Assurance Framework is made as a result of this report?
Corporate Impact Assessment OR Board Statements: Assurance(s) against:
Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives
Data Quality Issues Nil
Involvement of Service Users/ Healthwatch
Communication and Consultation with stakeholders required
Service Impact/Health Improvement Gains
Financial Implications Capital £
Revenue £ Nil
Non Recurrent £
Governance Implications
Impact on Patient Safety /Quality
Impact on Equality & Diversity
Equality Impact Assessment Yes / No If yes, EIA Score
(EIA) Completed?
Acronyms / Terms used in the report
ELFT East London NHS Foundation Trust
Supporting Documents &/or Further Reading
Attached report.
Executive Lead
Mark Madden Executive Chief Finance Officer
Agenda Item: 8a Board of Directors Meeting: 22.217
SOUTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST GENERAL CHARITABLE FUND
REVIEW OF SEPT LINKED CHARITIES AND FUNDS CLASSIFICATION AND THE GRANTING OF BEDFORD AND LUTON FUNDS TO ELFT
PURPOSE OF THE REPORT
To advise the Board of the review of the SEPT linked charities and classification of charitable funds and seek approval for the closure of the relevant linked charities and for the re-classification of the relevant funds as recommended below.
To update the Board on the transfer of the Bedford and Luton charitable funds to East London NHSFT (ELFT) and seek approval for the making of the grant required to complete this transfer.
1. REVIEW OF LINKED CHARITIES
The Charitable Funds Committee agreed at its November 2016 meeting that the SEPT General Charitable Fund linked charities should be reviewed as some of them are outdated. Also as per the Charity Commission’s recommendation, linked charities with zero or low balances should be reviewed with a view to closing them as the threshold for registering a linked charity is £5,000.
The Finance Department completed the review and concluded that of the 36 existing linked charities, 22 of them should be closed. As shown in Appendix A, most of these had either nil or below £5,000 balance as at the end of December 2016 and one linked charity has only ELFT fund which will become nil balance once the fund transfers to ELFT. Also one linked charity consists of an inactive fund which would become more beneficial if moved to a general purpose fund.
Appendix A shows which linked charities the balances remaining in the linked charities to be closed, will be moved to.
The Charitable funds committee has approved the closure of these linked charities and recommends this to the Board for approval.
2. REVIEW OF FUNDS CLASSIFICATION
The Charitable Funds Committee also agreed that the charitable funds classifications should be tested with the aim of reducing the number of restricted funds and instead making these, where appropriate, unrestricted designated funds. This is mainly because in some cases, it would appear that donors wishes may have been taken as trusts and funds therefore restricted, rather than designated to the wards/services where the donations have been received. In keeping funds as restricted, the Charity Commission’s directive is that trustees should seek to match restricted funds to clear evidence of restriction at the point of receipt and in the absence of such evidence the Commission takes the view that the funds in question can properly be reclassified as unrestricted.
The Finance Department has reviewed the classification of the funds and in the absence of clear restriction at the point of receipt of relevant donations, has concluded that the funds in Appendix B should be unrestricted but designated to the respective services, wards or teams.
The Finance Department will continue to review these unrestricted funds and where funds need to be merged or moved to a general fund due to service or ward closures/merger/realignments, long term fund in-activities or where services or wards have been renamed, these will be done accordingly.
Appendix B lists the restricted funds that are recommended to be unrestricted but designated to respective services, wards or teams, where appropriate.
The Charitable funds committee has approved the re-classification of these funds and recommends this to the Board for approval.
3. EAST LONDON NHS FT FUNDS TRANSFER
In order to facilitate a more effective administration of the charitable funds relating to the services that transferred to ELFT and ensure that they are indeed optimally being used for the benefits of the patients and staff of ELFT, the Charitable Funds Committee agrees that it would be most appropriate to transfer these funds to ELFT.
ELFT have agreed to the transfer of the relevant charitable funds. However, ELFT’s charitable funds are managed by the Barts and The London Charity and so the relevant funds will need to be transferred to Barts and The London Charity which is an independent charity with objects sufficiently wide for it to receive and apply the charitable funds that the SEPT Charity wishes to transfer.
The Department of Health (DOH) has therefore advised that the way to undertake this proposed transfer is by the SEPT Charity’s own grant-making powers. A formal transfer by way of a statutory order is only possible where it occurs between two NHS bodies and since the Barts and The London Charity is independent, this is not an option.
The Charitable Funds Committee therefore recommends to the Board the granting of the sum of £620,888.95 to the Barts and The London Charity, being the total fund balance of all the charitable funds relating to the transferred Bedford and Luton services, as at the end of January 2017, subject to any transactional movements that arise by the grant date. The intended deadline for making the grant is before the end of the financial year, March 2017.
Attached is a draft copy of the letter (appendix C) that will accompany the grant stating its purpose including any applicable restrictions as well as clarification of the ongoing administration of the funds and acceptance of the grant. The final version of the letter will require the signatures of the SEPT Charity’s Financial Trustee and either the Chief Executive or the Deputy Chief Executive on behalf of the Board, in line with the Detailed Scheme of Delegation.
4. ACTION REQUIRED
The Board is asked to:
Approve the closure of the linked charities in Appendix A that have been recommended for closure; Approve the reclassification of the restricted funds in Appendix B that have been recommended for reclassification to unrestricted funds; Approve the grant of £620,888.95 to the Barts and The London Charity plus any transactional movements that arise by the grant date not more than £10,000 and; Delegate authority to the Financial Trustee and either Chief Executive or Deputy Chief Executive to agree and sign the final letter that will accompany the grant in Appendix C.
Report prepared by: Boroji Nwaokolo Assistant Chief Finance Officer
Mark Madden Executive Chief Finance Officer
Appendix A
Linked Charity Balance Funds Transferred to / from: Comment
Linked Charities to remain 1053793-5 PRIMARY CARE CHARITY Total 353,858.62 2,107.90 1053793-13 CANCER RELIEF FUND Total 290,769.77 1053793-4 MENTAL HEALTH CHARITY Total 211,770.52 3,136.32 1053793-24 THE MARGARET ETHEL BOLTON FUND Total 112,009.10 1053793-19 PRIMARY CARE TRUST STAFF WELFARE FUND Total 100,126.21 1053793-1 SOUTH ESSEX PARTNERSHIP NHS FOUNDATION TRUST GENERAL CHARITABLE FUND Total 735,078.59 1053793-29 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST CANCER CARE GENERAL FUND Total 51,196.70 1053793-17 PSYCHIATRIC RESEARCH FUND Total 32,226.69 1053793-39 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST GENERAL FUND Total 29,433.20 11,314.78 1053793-32 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS TRUST BEDS CHILDS HELATH DIRECTORATE FUND Total 8,870.83 1053793-23 LEARNING DISABLILITIES PSYCHIATRY ACADEMIC AND RESEARCH FOUNDATION Total 8,741.55 1053793-2 DISTRICT NURSES FUND Total 8,403.10 1053793-21 MENTAL HEALTH RESEARCH FOUNDATION Total 7,255.30 1053793-11 CONTINUING CARE SERVICES FUND Total 6,722.10 Total 1,956,462.28
Linked Charities to be closed
1053793-38 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST PATIENTS WELFARE FUND Total 28,618.86 To close following ELFT fund transfer 1053793-30 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST BIGGLESWADE AND DISTRICT GENERAL FUND Total 7,759.24 -7,759.24 To close due to long-term Fund inactivity 1053793-27 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST AMPTHILL AND DISTRICT GENERAL FUND Total 3,073.51 -3,073.51 To close due to low balance below £5k 1053793-8 PSYCHOLOGY SERVICES FUND Total 2,307.57 -2,307.57 To close due to low balance below £5k 1053793-15 PHYSIOTHERAPY SERVICES FUND Total 1,800.42 -1,800.42 To close due to low balance below £5k 1053793-3 LEARNING DISABILITY CHARITY Total 828.75 -828.75 To close due to low balance below £5k 1053793-34 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST OTHER LOCALITY SERVICES GENERAL FUND Total 482.66 -482.66 To close due to low balance below £5k 1053793-9 SPEECH AND LANGUAGE THERAPY FUND Total 150.24 -150.24 To close due to low balance below £5k 1053793-14 CONTINENCE CARE FUND Total 104.18 -104.18 To close due to low balance below £5k 1053793-12 HEALTH CENTRE AND CLINICS FUND Total 53.06 -53.06 To close due to low balance below £5k Appendix A
Linked Charity Balance Funds Transferred to / from: Comment 1053793-28 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MENTAL HEALTH TRAINING/EQUIPMENT FUND Total 0.00 To close due to low balance below £5k 1053793-36 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MENTAL HEALTH GENERAL FUND Total 0.00 To close due to low balance below £5k 1053793-31 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST BEDS RURAL GENERAL FUND Total 0.00 To close due to low balance below £5k 1053793-33 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST BEDS URBAN GENERAL FUND Total 0.00 To close due to low balance below £5k 1053793-35 SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST VERANDAH PROJECT FUND Total 0.00 To close due to low balance below £5k 1053793-22 BRENTWOOD SERVICES FUND Total -0.00 To close due to low balance below £5k 1053793-18 PRIMARY CARE TRUST GENERAL PURPOSE FUND Total -0.00 To close due to low balance below £5k 1053793-26, SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST LEARNING DISABILITIES GENERAL FUND Total -0.63 0.63 To close due to low balance below £5k 1053793-10 DIABETIC CARE CENTRE Total 0.00 To close due to low balance below £5k 1053793-16 CHILDRENS CENTRE FUND Total 0.00 To close due to low balance below £5k 1053793-6 BASIL BEAR FUND Total 0.00 To close due to low balance below £5k 1053793-7 DEPARTMENT OF NUTRITION AND DIETETICS FUND Total 0.00 To close due to low balance below £5k Total 45,177.86 -0.00 0.00 -0.00
SEPT General Charitable Fund Balance as at December 2016 2,001,640.14 Appendix B
Fund Fund Recommended Fund Name No. Classification Classification
21004 Thurrock Hospitals General Purpose Restricted Unrestricted 21006 Jubilee Centre Restricted Unrestricted 21008 Meadowview Restricted Unrestricted 21013 Mayfield Ward Restricted Unrestricted 21130 Psychology Services Fund Restricted Unrestricted 21131 Speech & Language Therapy Fund Restricted Unrestricted 21141 Learning Disabilities Gen Purpose Restricted Unrestricted 21180 LD Psychiatry Research Fund Restricted Unrestricted 22208 Mental Health Unit General Purpose Restricted Unrestricted 22209 Grangewaters Restricted Unrestricted 22211 Westley Restricted Unrestricted 22213 Mental Health Weymarks Restricted Unrestricted 22214 Mountnessing Day Hospital Elderly Restricted Unrestricted 22215 Psychiatric Research Fund Restricted Unrestricted 22216 Maple Day Hospital Restricted Unrestricted 22217 Drug & Alcohol Research Restricted Unrestricted 22218 Periphery House Fund Restricted Unrestricted 22219 Churchview Restricted Unrestricted 22220 Gloucester Restricted Unrestricted 22222 Thurrock Acute CPNS Restricted Unrestricted 22229 Family Therapy Restricted Unrestricted 22230 Mountnessing Court Restricted Unrestricted 22267 Sankey House/ Aston Court Restricted Unrestricted 22270 MH Research Foundation Restricted Unrestricted 27736 Physiotherapy Department (LD) Restricted Unrestricted 29900 Maple Ward Restricted Unrestricted 29902 Cedar Ward Restricted Unrestricted 29903 C F C S Restricted Unrestricted 29904 Willow Ward Restricted Unrestricted 29906 Clifton Restricted Unrestricted 29907 Community Alcohol Counselling Restricted Unrestricted 29909 Beech Ward Restricted Unrestricted 29911 Garden Fund Restricted Unrestricted 29912 Harman Restricted Unrestricted 29913 Dove (Heron) Restricted Unrestricted 29914 Hullbridge Restricted Unrestricted 29916 Leigh Centre Restricted Unrestricted 29917 Occupational Therapy Restricted Unrestricted 29918 OT Community Restricted Unrestricted 29919 Patients Entertainment Restricted Unrestricted 29920 Plashet Restricted Unrestricted 29921 Rawreth Restricted Unrestricted 29922 CDAS Southend (Roche Unit) Restricted Unrestricted 29923 Samaritan Fund Restricted Unrestricted 29925 Southend Centre Restricted Unrestricted 29926 Sydervelt Resource Centre Restricted Unrestricted 29927 Harland Centre Restricted Unrestricted 29928 Oakview (Westcliff) Restricted Unrestricted 29932 MAIDAY Restricted Unrestricted 29933 Fairview Restricted Unrestricted 29934 Steepleview Restricted Unrestricted 29935 Forensic Occupational Therapy Restricted Unrestricted 29936 Rochford Hospital General Purpose Restricted Unrestricted 29938 Rochford Hospital Art Group Restricted Unrestricted 29945 Southend Sourchers Restricted Unrestricted 29971 Meadowside Restricted Unrestricted 29974 Harland Centre Carers Group Restricted Unrestricted 29975 SEPT Global Health Charity Restricted Unrestricted 29976 Brockfield House Restricted Unrestricted Appendix B
Fund Fund Recommended Fund Name No. Classification Classification
29977 The Peoples Charity Restricted Unrestricted 34101 Harlow General Purpose Restricted Unrestricted 34102 Harlow Elderly Care Restricted Unrestricted 34103 Harlow District Nurses Restricted Unrestricted 34104 Harlow Williams Day Hospital Fund Restricted Unrestricted 34105 Harlow Diabetic Fund Restricted Unrestricted 34106 Harlow Pulmonary Rehab Restricted Unrestricted 34203 Uttlesford Outpatients Dept Restricted Unrestricted 34205 Uttlesford Curlew Ward Restricted Unrestricted 34206 Uford Ena Cox Legacy Saff Wal Restricted Unrestricted 34207 Uford Patient Comfort Saffron Walden Restricted Unrestricted 34208 Uford Dist Nursing General Fund Restricted Unrestricted 34209 Uford Dist Nursing Saffron Walde Restricted Unrestricted 34211 Uford Dist Nursing Thaxted Restricted Unrestricted 34212 Uford Dist Nursing Dunmow Restricted Unrestricted 34213 Uttlesford GP Out of Hours Restricted Unrestricted 34214 Uttlesford Dunmow Clinic Restricted Unrestricted 34215 Uttlesford Physiotherapy Dept S W Restricted Unrestricted 34301 Epping Occupational Therapy PAH Restricted Unrestricted 34303 Epping Physiotherapy Gen Purp Restricted Unrestricted 34304 Epping St Margarets Gen Purp Restricted Unrestricted 34305 Epping Poplar Ward Restricted Unrestricted 34306 Epping Plane Ward Restricted Unrestricted 34308 Epping Tissue Viability Restricted Unrestricted 34309 Epping Waltham Abbey Kids Fund Restricted Unrestricted 34311 Epping Speech Language Therapy Restricted Unrestricted 34312 Epping Ongar District Nurses Restricted Unrestricted 34313 Epping Community Occupational Therapy Restricted Unrestricted 34314 Epping Orchard Day Hospital Restricted Unrestricted 34315 Epping Intermediate Care Team Restricted Unrestricted 34316 Epping Falls Project Restricted Unrestricted 34601 West Essex Respiratory Care Restricted Unrestricted 34602 West Essex Respiratory Service Restricted Unrestricted 34107 West Essex Cancer Information Restricted Unrestricted 40000 Beacon House-CS00 Restricted Unrestricted 40003 ACE ENTERPRISES-CS06 Restricted Unrestricted 40004 COMMUNITY DOCTORS IN TRAINING-CS08 Restricted Unrestricted 40006 COMMUNITY MENTAL HEALTH-CS12 Restricted Unrestricted 40007 COMMUNITY SPECIFIC-CS16 Restricted Unrestricted 40009 CROMBIE HOUSE-CS20 Restricted Unrestricted 40010 ACADEMIC UNIT CAMH-CS21 Restricted Unrestricted 40011 FAMILY CONSULTATION CLINIC-CS22 Restricted Unrestricted 40013 EARLY INTERVENTION-CS29 Restricted Unrestricted 40015 CMHT-CS37 Restricted Unrestricted 40016 HEALTHLINK-CS39 Restricted Unrestricted 40018 MHSF SOCIAL WORKERS Restricted Unrestricted 40019 SOBEDAS-CS81 Restricted Unrestricted 40023 CHAPLAINCY FUND-FS02 Restricted Unrestricted 40025 LONDON RD STAFF-FS11 Restricted Unrestricted 40027 CEDAR HOUSE STAFF-FS13 Restricted Unrestricted 40029 OAKLEY COURT-FS20 Restricted Unrestricted 40030 OAKLEY COURT STAFF-FS21 Restricted Unrestricted 40031 THE POPLARS-FS32 Restricted Unrestricted 40032 THE POPLARS STAFF-FS33 Restricted Unrestricted 40033 WHICHELLOS WHARF-FS38 Restricted Unrestricted 40034 WHICHELLOS WHARF STAFF-FS39 Restricted Unrestricted 40035 ORCHARD UNIT-FS72 Restricted Unrestricted 40038 TOWNSEND UNIT MAYER WAY-FS76 Restricted Unrestricted 40040 CALNWOOD STAFF-FS98 Restricted Unrestricted Appendix B
Fund Fund Recommended Fund Name No. Classification Classification
40050 LEARNING DISABILITIES GENERAL-NS18 Restricted Unrestricted 40052 LEARNING DIS EPILEPSY GRANT-NS20 Restricted Unrestricted 40055 FOUNTAINS COURT-NS24 Restricted Unrestricted 40059 TARMO FUND-NS39 Restricted Unrestricted 40062 WELLER WING OT DEPT-NS46 Restricted Unrestricted 40063 THE LAWNS-NS56 Restricted Unrestricted 40073 PATIENT IN THE COMMUNITY-WS01 Restricted Unrestricted 40074 ACUTE/CRISIS FUND-WS02 Restricted Unrestricted 40076 LIME TREE-WS06 Restricted Unrestricted 40077 LIME TREE STAFF-WS07 Restricted Unrestricted 40078 YOUNG PERSONS SERVICE-WS08 Restricted Unrestricted 40083 MILTON WARD - WELLER WING-WS17 Restricted Unrestricted 40084 KEATS WARD - WELLER WING-WS18 Restricted Unrestricted 40085 CAMH TRAINING FUNDS-WS19 Restricted Unrestricted 40086 CHAUCER WARD - WELLER WING-WS20 Restricted Unrestricted 40087 BEDFORD CRISIS CENTRE TEAM-WELLER WING Restricted Unrestricted 40008 THE CONIFER, SILSOE-CS17 Restricted Unrestricted 40043 EVERTON LDS HOME-NS05 Restricted Unrestricted 40051 RENHOLD LDS HOME-NS19 Restricted Unrestricted 40054 RED HOUSE FARM HOME-NS23 Restricted Unrestricted 40058 STREATLEY LDS HOME-NS38 Restricted Unrestricted 40082 STAFF TRAINING MHOP-WS16 Restricted Unrestricted 40100 Bedford & Luton General Purpose Fund Restricted unrestricted 40012E GOLDEN HELIX AWARD-CS23 Restricted Unrestricted 40021E HR TRAINING-CS96 Restricted Unrestricted 40046E MENTAL HEALTH TRAINING EQUIP-NS14 Restricted Unrestricted 40047E MEDICAL PROFESSIONAL DEVELOPMENT-NS15 Restricted unrestricted 40048E MENTAL HEALTH FUND-NS16 Restricted Unrestricted 40069E ORGANISATION DEVELOPMENT-WG02 Restricted Unrestricted 40072E FOREIGN MEDICAL STUDENTS-WS00 Restricted Unrestricted 40075E CHILDREN IN NEED-WS03 Restricted unrestricted 71138 Continence Care Restricted Unrestricted 71142 S.E. Lymphoedema Support Group Restricted Unrestricted 76103 Nurse Training Restricted Unrestricted 76303 Southend Paed Community Nurse Team Restricted Unrestricted 77104 Staff Welfare-- Provider Restricted Unrestricted 79901 Speech Therapy Talk Fund Restricted Unrestricted 79902 District Nurses Restricted Unrestricted 79903 Cancer Relief South East Restricted Unrestricted 79904 Health Visiting Restricted Unrestricted 79905 Asthma Fund Restricted Unrestricted 79906 Heart Failure Team Restricted Unrestricted 79907 Podiatry Fund Restricted Unrestricted 79908 S E Essex Leg Ulcers Restricted Unrestricted 79909 Stroke Club Restricted Unrestricted 79913 Family Planning Restricted Unrestricted 79915 Primary Health Care Restricted Unrestricted 79917 Cumberlege Care Centre Restricted Unrestricted 79942 Community Diabetes Fund-Adult Restricted Unrestricted 79943 Community Diabetes Fund-Children Restricted Unrestricted 71141 Integated Palliative Care CHS SEE Restricted Unrestricted 76403 ESD (Early Supported Discharge) Restricted Unrestricted 76503 LTOT ( Long Term Oxygen Team) Restricted Unrestricted 60001 BRAMINGHAM HV-CS01 Restricted Unrestricted 60002 BRAMINGHAM DN-CS03 Restricted Unrestricted 60003 CONTINENCE FUND-CS18 Restricted Unrestricted 60004 DUNSTABLE DISTRICT NURSES-CS24 Restricted Unrestricted 60005 DUNSTABLE HEALTH CENTRE-CS26 Restricted Unrestricted 60006 DUNSTABLE SCHOOL NURSES-CS28 Restricted Unrestricted Appendix B
Fund Fund Recommended Fund Name No. Classification Classification
60007 HOUGHTON REGIS DISTRICT NURSES-CS44 Restricted Unrestricted 60008 HOUGHTON REGIS HEALTH CENTRE-CS46 Restricted Unrestricted 60009 LEG ULCER-CS52 Restricted Unrestricted 60010 LEIGHTON BUZZARD COMM NURSES 1-CS54 Restricted Unrestricted 60011 LEIGTON BUZZARD H VISITORS-CS55 Restricted Unrestricted 60012 LEWSEY FARM DISTRICT NURSES-CS60 Restricted Unrestricted 60013 LEWSEY FARM HEALTH VISITOR-CS62 Restricted Unrestricted 60014 INTERMEDIATE CARE SOUTH-CS72 Restricted Unrestricted 60015 NUTRITION & DIETETIC SERVICES-CS76 Restricted Unrestricted 60016 SPEECH & LANGUAGE THERAPY-CS82 Restricted Unrestricted 60017 DENTAL SERVICE-CS83 Restricted Unrestricted 60018 HEARTLANDS MACMILLAN SERVICES-CS86 Restricted Unrestricted 60019 DEVELOPMENT UNIT-CS95 Restricted Unrestricted 60020 HEARTLANDS HR TRAINING-CS98 Restricted Unrestricted 60022 BEDS & RURAL-NS00 Restricted Unrestricted 60023 BEDS URBAN GENERAL FUND-NS02 Restricted Unrestricted 60024 BEDFORD HR TRAINING-NS03 Restricted Unrestricted 60026 CANCER CARE FUND-NS06 Restricted Unrestricted 60028 STEPPINGLEY HOSPITAL-NS09 Restricted Unrestricted 60029 WOBURN DN-NS10 Restricted Unrestricted 60030 OTHER LOCALITY SERVICES Restricted Unrestricted 60031 CHILD HEALTH DIRECTORATE-NS22 Restricted Unrestricted 60032 SANDY DN-NS25 Restricted Unrestricted 60033 SHEFFORD DN-NS26 Restricted Unrestricted 60034 POLTON/GAMLINGAY DN-NS27 Restricted Unrestricted 60035 BIGGLESWADE DN-NS28 Restricted Unrestricted 60036 ARLES/STOT DN-NS29 Restricted Unrestricted 60037 APPLETREES STEPPINGLEY-NS30 Restricted Unrestricted 60038 CRANFIELD DN-NS41 Restricted Unrestricted 60040 AMPTHILL DN-NS43 Restricted Unrestricted 60041 SANDY HV-NS47 Restricted Unrestricted 60042 SHEFFORD HV-NS48 Restricted Unrestricted 60043 POTT/GAM HV-NS49 Restricted Unrestricted 60044 BIGGLESWADE HV-NS50 Restricted Unrestricted 60045 CRANFIELD HV-NS51 Restricted Unrestricted 60046 FLITWICK HV-NS52 Restricted Unrestricted 60047 AMPTHILL HV-NS53 Restricted Unrestricted 60048 ARLES/STOT HV-NS54 Restricted Unrestricted 60049 WOBURN HV-NS55 Restricted Unrestricted 60050 BEDFORD-NS58 Restricted Unrestricted 60051 ARCHER UNIT-NS59 Restricted Unrestricted 60052 ARCHER UNIT STAFF-NS60 Restricted Unrestricted 60053 ACQUIRED BRAIN INJURY SERVICE-NS62 Restricted Unrestricted 60055 CHILDREN IMC SERVICES-NS64 Restricted Unrestricted 60056 WHEELCHAIR SERVICES-NS65 Restricted Unrestricted 60058 PD NURSES EDUCATION-NS67 Restricted Unrestricted
APPENDIX C xx xxxx 2017 Finance Department Trust Head Office The Lodge Runwell Chase Wickford Essex SS11 7XX Barts and The London Charity London EC1A 9BU Tel: 01268 739666 E-mail: [email protected]
De ar Sir/Ma, Chair: Lorraine Cabel Chief Executive: Sally Morris South Essex Partnership NHS Foundation Trust General Charitable Fund
The trustees of South Essex Partnership NHS Foundation Trust General Charitable Fund are pleased to inform you that a grant has been approved for the benefit of the patients and staff of the Bedford and Luton services of the East London NHS Foundation Trust, i.e. the Luton and Bedfordshire mental health, learning disabilities, CAMHS, intermediate and community health services which transferred from South Essex Partnership NHS Foundation Trust to East London NHS Foundation Trust on the 1st of April, 2015.
Grant amount
The total grant amount is £620,888.95
Purpose of Grant and applicable funds and restrictions
The grant is given for the benefit of the patients and staff of the Bedford and Luton services of the East London NHS Foundation Trust, i.e. the Luton and Bedfordshire mental health, learning disabilities, CAMHS, intermediate and community health services which transferred from South Essex Partnership NHS Foundation Trust to East London NHS Foundation Trust on the 1st of April, 2015.
This grant consists of the following funds and restrictions:
Restricted to Cedar House/Bedfordshire Mental CEDAR HOUSE FUND £396,411.23 Health Services PROFESSOR BESAGS Restricted to Prof Besag's Bedford and Luton £19,236.53 LD SERVICE FUND Learning Disabilities Services
DR IQBALS LD SERVICE Restricted to Dr Iqbal's Bedford and Luton £242.33 FUND Learning Disabilities Services Unrestricted designated and general funds for BEDFORD AND LUTON the benefit of patients and staff of the relevant £204,998.86 UNRESTRICTED FUNDS Bedford & Luton services £620,888.95
Grant administration
The funds granted will be managed by Barts and The London NHS Trust on behalf of the East London NHS Foundation Trust, with East London NHS Foundation Trust (ELFT) as the decision maker(s) of the use of the funds for the purposes for which the funds have been granted. ELFT will also be responsible for reviewing and deciding on the designation of unrestricted funds to wards, services, teams or departments as appropriate and the pooling together of undesignated unrestricted funds as appropriate.
There is no reporting and updating requirement from the South Essex Partnership NHS Foundation Trust General Charitable Fund.
South Essex Partnership NHS Foundation Trust General Charitable Fund trusts that this grant will be put to good use and for the purpose for which it has been granted.
Acceptance
Please see appendix 1 for acceptance form which needs to be signed by all required parties and sent back to the address stated on the form no later than 3 March 2017.
Yours faithfully
______Mark Madden Sally Morris Financial Trustee Chief Executive
Appendix 1
Acceptance Form
We hereby accept the below grant totaling £620,888.95 given by South Essex Partnership NHS Foundation Trust General Charitable Fund into the Barts and The London Charity for the benefit of the patients and staff of the Bedford and Luton services of the East London NHS Foundation Trust, i.e. the Luton and Bedfordshire mental health, learning disabilities, CAMHS, intermediate and community health services which transferred from South Essex Partnership NHS Foundation Trust to East London NHS Foundation Trust on the 1st of April, 2015. We agree to use the grant for the purposes for which it has been given and to adhere to the below restrictions.
Restricted to Cedar House/Bedfordshire Mental CEDAR HOUSE FUND £396,411.23 Health Services PROFESSOR BESAGS Restricted to Prof Besag's Bedford and Luton £19,236.53 LD SERVICE FUND Learning Disabilities Services
DR IQBALS LD SERVICE Restricted to Dr Iqbal's Bedford and Luton £242.33 FUND Learning Disabilities Services Unrestricted Designated and General Funds for BEDFORD AND LUTON the benefit of patients and staff of the relevant £204,998.86 UNRESTRICTED FUNDS Bedford & Luton services £620,888.95
We confirm that we agree to the administration of the grant as stated in the letter above.
______Sign ______Name Date On behalf of Barts and The London Charity
______Sign ______Name Date On behalf of East London NHS Foundation Trust
Please return original signed copy to: Finance Directorate, Thameside House, Thurrock Community Hospital, Long Lane, Grays, Essex RM16 2PX. And signed electronic copy to: [email protected] Agenda Item No: 8b
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: SFIs: Approval of High Value Invoice Executive/Non-Executive Lead: Mark Madden Report Author(s): Nikki Brown Report discussed previously at: Level of Assurance: n/a Level 1 2 3
Purpose of the Report To seek Board approval for a payment of £2m to NHS Property Approval Services Discussion Information
Recommendations / Action Required
The Board is asked to approve the payment of £2m to NHS Property Services
Summary of Key Issues
The Trust is in a long running dispute with NHS property services over the level of charging for properties occupied primarily for the delivery of community services. Whilst agreement has been reached on the payments due for 2015/16, no invoices have been paid relating to 16/17 as NHS Property Services proposes to change the basis for charging, and this has not yet been agreed by SEPT.
The expected charge for use of properties is in excess of £8m per annum. Our dispute with NHS Property Services means that we have paid no occupancy charge invoices this year. In December 2016, SEPT made a payment on account of £4m in respect of Q1 and Q2 to ease NHS Property Service’s cash flow issues, this was approved by the board in November 2016.
Whilst progress is being made on agreeing charges for 16/17 these have not yet been finalised. NHS Property services have asked the Trust to make a further payment on account of £2m in respect of Q3 whilst these negotiations are ongoing. The mechanism for doing this will be that NHS Property Services will raise an invoice for the payment on account and will raise a credit note to be used once the invoicing levels have been agreed. This is not a payment in advance, it is payment in towards the October- December 16 charges.
Trust SFIs require that the Board approves the payment of any invoice in excess of £1m.
The invoice is expected to be received by the end of the month, and authorisation is sought to enable this payment to be released.
Page 1 of 2 Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? No If yes, insert relevant risk Do you recommend a new entry to the BAF is made as a result of this report?
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Cash Revenue £ implication Non Recurrent £ only Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? Yes / No If yes, EIA Score
Acronyms / Terms used in the report
Supporting Documents &/or Further Reading
Executive Lead
Mark Madden Executive Chief Finance Officer
Page 2 of 2
Agenda Item No: 8c
SUMMARY REPORT BOARD OF DIRECTORS MEETING 22 February 2017 PART 1
Report title: Board of Directors Governance Update Executive Lead: Nigel Leonard, Executive Director Corporate Governance Report Author(s): Cathy Lilley, Trust Secretary Report discussed previously at: Level of Assurance: Level 2
Purpose of the Report The purpose of this report is provide an update on a range of Approval governance and procedural issues that require the Board’s attention Discussion since the last report in January 2017. Information
Recommendations / Action Required 1 To note the contents of the report 2 To request any further information or action.
Summary of Key Issues The Board of Directors Governance Update report includes a number updates to be brought to the Board’s attention including: Managing conflicts of interest in the NHS: the guidance comes into force from 1 June 2017 and is applicable to NHS FTs. The aim is to strengthen the management of conflicts of interest and ensure that the NHS is a world leader for transparent and accountable healthcare. NHS FTs must have regard to this guidance through its incorporation into the NHS Standard Contract pursuant to General Condition 27 Independent panel for advising Governors disbanded Adult social care – market shaping: guidance has been published that is aimed at people who buy social care services Carter review on operational productivity and performance: a review into community and mental health trusts is to take place mirroring the approach taken in the acute sector review PLICS standards: first ever costing standards have been published in draft format for mental health and ambulance providers Quality Reports 2016/17: details of requirements have been published Establishing food standards: an updated Hospital Food Standards Panel report recommends a set of food standards that should become routine practice across NHS hospitals Shake-up of health regulation: Ministers are considering a controversial shake-up of health regulation that could see nine bodies merged into one new super-watchdog IAPT – outcomes based payment approach: guidance has been published following NHSI’s publication of the 2017/19 National Tariff Payment System Local Growth Academy: is a pioneering new initiative to radically transform NHS organisations’ ability to tap into local economic opportunities Recovering the cost of NHS treatments given to overseas visitors: New regulations requiring all hospitals to check upfront whether patients are eligible for free NHS treatment will be in place under plans to recover the cost of health treatment provided to patients not ordinarily resident in the UK
1
Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness
Relationship to the Board Assurance Framework Are any existing risks in the Board Assurance Framework affected? No If yes, insert relevant risk n/a Do you recommend a new entry to the Board Assurance Framework is made as a result of No this report?
Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ N/A Non Recurrent £ Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? No If yes, EIA Score
Acronyms / Terms used in the Report CCGs Clinical Commissioning Groups NHSE NHS England DoH Department of Health FT Foundation Trusts CQC Care Quality Commission NHSI NHS Improvement PLICS Patient-level cost collection NTPS National Tariff Payment System HEFCE Higher Education Funding Council for England
Supporting Documents &/or Further Reading Main report Legal & Policy Updates
Non-Executive Lead
Nigel Leonard Executive Director Corporate Governance
2
SEPT Board of Directors
Agenda Item 8c Board of Directors Meeting Part 1 22 February 2017
BOARD OF DIRECTORS GOVERNANCE UPDATE
1 Purpose of Report
The purpose of this report is to provide an update on a range of governance and procedural issues that require the Board’s attention since the last report in January 2017.
2 Executive Summary
2.1 Managing conflicts of interest in the NHS On 9 February 2017 NHS England (NHSE) issued new guidance on managing conflicts of interest in the NHS. This guidance: Introduces common principles and rules for managing conflicts of interest Provide advice to staff and organisations about what to do in common situations Supports good judgement about how interests should be approached and managed.
The guidance comes into force from 1 June 2017 and is applicable to CCGs, NHS Trusts, NHS Foundation Trusts and NHSE. Although the guidance does not apply to independent and private sector organisations, general practices, social enterprises, community pharmacies, community dental practices, optical providers and local authorities. However these organisations are ‘invited’ to consider implementing the guidance as a means to effectively manage conflicts of interest and provide safeguards for their staff.
NHS Trusts and NHS Foundation Trusts must have regard to this guidance through its incorporation into the NHS Standard Contract pursuant to General Condition 27.
The aims of the guidance are to strengthen the management of conflicts of interest and ensure that the NHS is a world leader for transparent and accountable healthcare. The guidance permits staff, such as nurses, to receive a box of chocolates or other small tokens of gratitude from patients but will require them to decline anything that could be seen to affect their professional judgement. Gifts with a value over £50, accepted on behalf of organisations, will need to be declared. It will also be standard practice for NHS commitments to take precedence over private practice and for any member of staff, clinical or non-clinical, to declare outside employment and the details of where and when this takes place although not earnings at this stage.
To help organisations and staff implement the guidance a suite of tools and supporting materials are being developed by NHSE. The Trust’s current processes will be reviewed in March against the guidance with a view to amending them in preparation for 1 June 2017 and the establishment of the new Trust should the merger proceed. This timing aligns with a model policy being released from NHSE that will reflect the guidance.
NHSE are also planning to release some short guides for key staff groups to help them understand what they need to do and how the guidance applies to them. In addition in the run up to the launch on 1 June, NHSE will run a series of WebEx sessions for staff to help explain the content of the guidance, how it should be applied and deal with other common issues.
2.2 Independent panel for advising governors disbanded NHS Improvement have advised that as Governors are choosing not to make use of the Panel’s facility (including raising substantive questions) in accordance with the referral
Board of Directors Part 1 22 February 2017 Page 1 of 4 SEPT Board of Directors criteria laid out in legislation, the decision has been taken to disband it with the full support of the Panel Chair.
2.3 Adult social care: market shaping DoH has published guidance that is aimed at people who buy social care services, including local authority and CCG commissioners, as well as personal budget holders and people who fund their own care, care service providers and potential investors in the care sector. The adult social care market refers to independent care sector providers and support organisations, those that provide CQC regulated services, such as care and home care, as well as unregulated care, such as personal assistants, volunteers and communities and informal family carers, and wider support services.
2.4 Operational productivity: Carter review of community and mental health trusts Following on from the review into the operational productivity and performance in the acute sector a review into community and mental health trusts is to take place with findings expected to be published in late 2017. As part of the review process headed by a team under the auspices of NHSI, the Carter team will work with a cohort of 20 trusts to specific benchmarking criteria for an ‘optimal model’ NHS community or mental health care trust.
Mirroring the approach taken in the acute sector review, NHSI have set up a cohort of 23 trusts across both community and mental health with which more detailed engagement will be focused over the initial stages of the review process over the next six months. They are also looking at the scope to extend this review to all remaining providers including ambulance trusts and specialist acute trusts.
The review will look to understand: how organisations in mental health and community trusts operate what good looks like what approaches to improving productivity and efficiency are already in place and what opportunities there are to drive these further what metrics and indicators are required to support the development of the model for these sectors
2.5 PLICS standards developed for mental health and ambulance providers The first-ever costing standards for mental health and ambulance providers have been published in draft format by NHSI with mandated patient-level cost collection (PLICS) due in 2019-20 for these organisations.
As well as working with the 80+ acute providers, NHSI is working with three mental health providers as roadmap partners, who will undergo rigorous PLICS implementation, and five others as contributors. It is also working with three ambulance trusts (see full list below) to test the draft standards for these trusts.
The latest publication consists of a quick-start guide to the standards, plus policy and technical guidance. And although the new standards do not currently cover community providers, the regulator has asked that they too adopt the costing principles and the costing process.
As well as launching the standards, NHSI requires providers to map their general ledger to a new cost ledger.
2.6 Quality Reports 2016/17 requirements NHSI has published details of contents and assurance requirements for NHS FTs preparing their 2016/17 quality reports. At their meeting on 9 February 2017, Governors received a detail report on the Quality Report/Accounts that took account of the complexity of developing the report this year due to the impending merger. As in previous years a process is in place for the Council to select the local indicator for assurance by external auditors.
Board of Directors Part 1 22 February 2017 Page 2 of 4 SEPT Board of Directors
2.7 Establishing food standards for NHS hospitals DoH has issued an updated Hospital Food Standards Panel report that recommends a set of food standards that should become routine practice across NHS hospitals. The report looks at standards relating to patient nutrition and hydration, healthier eating across hospitals and sustainable food and catering services. NHS adoption of the recommended standards will be required through the NHS contract meaning that hospitals will have a legal duty to comply with the recommendations.
2.8 Shake-up of health regulation Ministers are considering a controversial shake-up of health regulation that could see nine bodies merged into one new super-watchdog covering around a million health professionals. Jeremy Hunt, the health secretary, is preparing to publish a consultation paper that could lead to the medical and nursing professions no longer having their own dedicated disciplinary bodies.
The thinking is that an overhaul would improve patient safety and also make health regulation more efficient by streamlining how complaints from patients are investigated. The Robert Francis’s 2013 report into the Mid Staffordshire hospital care scandal has been cited as it highlighted public uncertainty over which health regulatory body did what and the need for them to work more closely together.
The consultation paper will set out a range of options. They will include merging all nine bodies into one new overarching health regulator; bringing some of the nine together; and leaving the nine as separate entities but working more closely together.
2.9 New guidance published on developing an outcomes based payment approach for IAPT services NHSI and NHSE have published detailed guidance on the new outcomes based payment approach for IAPT services. This follows NHSI’s publication of the 2017/19 National Tariff Payment System (2017/19 NTPS). Within this, rule 8 mandates the use of an outcomes based payment model for IAPT services from 1 April 2018. An outcomes based payment approach consists of: A basic service price component reflecting activity: includes an amount for assessment and an amount for the mental health cluster-based package of care or episode of care. An outcomes payment component: based on the performance of the service against the 10 national quality and outcome measures.
2.10 Pioneering venture launched to help solve 'capital finance conundrum' A pioneering new initiative is set to radically transform NHS organisations’ ability to tap into local economic opportunities.
The Local Growth Academy, an exciting cross-sectoral venture, has been launched to help NHS organisations understand how to access the new and emerging finance mechanisms determining local infrastructure planning. With capital finance severely constrained yet critical to realising the ambitions of local plans, the Local Growth Academy aims to build NHS organisations’ capacity to maximise their contribution and involvement in local developments. Established by the NHS Confederation, Higher Education Funding Council for England (HEFCE), Universities UK and Local Government Association, the academy will support the NHS to address some of the complexities that come with place-based developments.
2.11 Recovering the cost of NHS treatments given to overseas visitors New regulations requiring all hospitals to check upfront whether patients are eligible for free NHS treatment will be in place under plans to recover the cost of health treatment provided to patients not ordinarily resident in the UK. Legal changes will require all hospitals to
Board of Directors Part 1 22 February 2017 Page 3 of 4 SEPT Board of Directors establish whether patients are eligible for free treatment and to charge upfront those who are not eligible, for any non-urgent, planned care. The law will change from April 2017 and this will play an important role in meeting the government’s ambition to recover up to £500 million a year from overseas visitors who are not eligible for free care.
The new measures will also require hospitals and NHS bodies to identify and flag a patient’s chargeable status so that other parts of the NHS can more easily recoup costs from overseas visitors wherever charges apply. The government will provide support and guidance to the NHS so it can identify those not eligible for free care and address any challenges ahead of the implementation of new legal regulations.
The government consulted on extending charging rules to areas of NHS care between December 2015 and March 2016. The consultation aimed to support the principle of fairness by making people who are not ordinarily resident in the UK pay for NHS care.
2.12 Legal & Policy Update This report is continued to be produced weekly and discussed at the Executive Operational Sub-Committee. Copies are available on request from the Trust Secretary.
3 Action Required
The Board of Directors is asked to: 1 Note the contents of this report 2 Identify any further action.
Report prepared by Cathy Lilley, Trust Secretary On behalf of:
Nigel Leonard Executive Director Corporate Governance 22 February 2017
Board of Directors Part 1 22 February 2017 Page 4 of 4