Agenda for Membership Council Meeting
To be held on 04 May 2011 at 14:00 to 16:00 in the Lecture Theatre 1, UH Bristol Education Centre, Upper Maudlin Street, Bristol, BS2 8AE
Item Title and Purpose Sponsor Paper(s) No. 1. Welcome and Apologies Chairman 2. Declaration of Interest Chairman All members of the Membership Council present are required to declare any conflicts of interest with items on the meeting agenda 3. Minutes of Meetings Chairman Paper To receive minutes of the following meeting of the Membership Council dated 03 February 2011 for approval. 4. Matters Arising Chairman Paper To review the status of matters arising from previous meetings 5. Chairman’s report Chairman Verbal To receive this briefing by the Chairman to note 6. Governors’ Report Liz Corrigan Paper To receive this briefing by the Governor Representative to note 7. Chief Executive’s report Robert Woolley Verbal To receive this briefing by the Chief Executive to note 8. Quarter 4 Self-certification to Monitor Robert Woolley Paper To note the Trust Board of Directors’ Quarter 4 Self- certification of compliance to Monitor 9. Quarterly review of progress against the Annual Plan Deborah Lee Paper To note this report by the Director of Strategic Development 10. Draft Annual Plan 2011/2012 – Update Deborah Lee/ Paper To note the progress Ben Hume 11. Histopathology Inquiry- Request by a Foundation Trust Liz Corrigan Paper Member to establish a Public Forum – for discussion and to vote 12. Preparation of the Annual Report 2010/2011 – Update Charlie Helps Paper To note the progress 13. Draft Quality Account 2010/11 Chris Swonnell Paper For comment and to agree arrangements 14. Care Quality Commission Registration Update Alison Paper To note Moon/Chris Swonnell
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Item Title and Purpose Sponsor Paper(s) No. TEA BREAK
15. Governor Representative for 2011/2012 Chairman Paper To approve appointment of Governor Representative 16. Review of Foundation Trust Constitution Chris Swonnell Paper To approve suggested amendments 17. Report from Governors Nominations and Jeanette Jones Paper Appointments Committee To receive this report on the activities of the Governors Nominations and Appointments Committee to note 18. Reports from working groups: To receive the following reports to note: a) Membership Working Group Suzanne Green Paper b) Quality Working Group Pam Yabsley Paper c) Strategy Working Group Anne Ford Paper 19. Outcomes of Governors Outpatient Constituency Mo Schiller Paper Meetings To note feedback from questionnaires 20. Any Other Business Chairman To consider any other relevant business not on the agenda 21. Questions from Foundation Trust Members Chairman To consider any question from the Trust Membership 22. Date and time of next meeting: Chairman Membership Council on Friday 27 May 2011 at 1pm, Lecture Theatre 1, Education Centre
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Item 3 Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Trust Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Membership Council Members Present • John Savage – Chair • Florene Jordan – Staff Governor (Nursing and • Liz Corrigan – Governor Representative & Public Midwifery) Governor (North Somerset) • Chris Swonnell – Staff Governor (Non-Clinical • Anne Ford – Public Governor (North Somerset) Healthcare Professionals) • Heather England – Public Governor (Bristol) • Jan Dykes – Staff Governor (Non-Clinical Healthcare Professionals) • Jade Scott-Blagrove – Public Governor (Bristol) • Chris Payne – Appointed Governor (NHS South • Mo Schiller – Public Governor (Bristol) Gloucestershire) • Mary Hodges – Public Governor (Bristol) • James White – Appointed Governor (NHS North • Anne Skinner – Patient Governor (Bristol) Somerset) • Jacob Butterly – Patient Governor (Bristol) • Helen Langton – Appointed Governor (University • David Aldington – Patient Governor (Bristol) of the West of England) • John Steeds – Patient Governor (Bristol) • Sylvia Townsend – Appointed Governor (Bristol City Council) • Pam Yabsley – Patient Governor (Bristol) • Jeanette Jones – Partnership Governor (Joint Union • Neil Auty – Patient Governor (Tertiary) Wendy Committee) Gregory – Patient Governor (Carers of Patients 16 years and over) • Frank Palma – Partnership Governor (Voluntary Group) • Garry Williams – Patient Governor (Carers of Patients 16 years and over) • Joan Bayliss – Partnership Governor (Community Group)
In Attendance • Robert Woolley– Chief Executive • Sue Cotterell – Schools Liaison Co-ordinator • Alison Moon– Chief Nurse • Sarah Pinch – Head of Communications • Deborah Lee– Director of Corporate Development • Paul Tanner – Head of Finance • Jane Luker– Acting Medical Director • Charlie Helps – Trust Secretary • Deborah Tunnell – Resourcing Manager • Maria Fox– Membership Manager • Vicki Goodwin – Notes
Item Action By 1. Welcome and Apologies
The Chairman welcomed Joan Bayliss as the new Partnership Governor representing Community Groups.
The Membership Council noted apologies for absence from the following governors: Mohsin Sajid, Sian Evans, Pauline Beddoes, Ken Cockrell, Suzanne Green, Lorna Watson, Philip Mackie, Belinda Cox, Jim Catterall, David Tappin, Massimo Pignatelli, Sharon Hinsley, and Jane Britton.
It was confirmed that those present made up a quorum of the Membership Council. Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By 2. Declaration of Interests In accordance with the Trust’s Constitution, all members present are required to declare any conflicts of interest with items on the Membership Council Meeting Agenda.
No declarations of interest were made.
3. Minutes of Meetings The Membership Council considered the minutes of the previous two meetings and resolved to approve them as an accurate record of matters transacted.
4. Matters Arising The Membership Council considered the Schedule of Matters Arising. The status of each item for action arising from previous meetings was confirmed. Chris Swonnell noted an inaccuracy in Item 1 referring to the Governors’ request to arrange a meeting with themselves and the patient representative from the Histopathology Inquiry. This action had been incorrectly recorded as ‘completed’. Robert Woolley agreed to explore the option of a meeting. R Woolley The Council resolved to update the Membership Council Meeting Schedule of Matters Arising accordingly.
5. Chairman’s Report The Membership Council received and considered a verbal report by the Chairman to note. John Savage briefed the Governors on the status of the current Governor elections. 13 seats are up for election this year. There will be three election information events in March and nomination packs will be sent out towards the end of March. Voting will commence in April and the results will be announced in early June. He reported that Paul Burstow MP, Health Minister, had visited the Trust as part of the Government’s campaign around spotting the early signs and symptoms of bowel cancer. He stated that the visit had been very successful and following his visit the Health Minister released the following statement to the media: “It has been good to meet clinicians and patients at University Hospitals Bristol and see the fantastic work already being done here to diagnose and treat bowel cancer.” There being no further questions, the Membership Council resolved to note the Chairman’s report.
6. Governors’ Report The Membership Council received and considered the Governors’ report presented by Liz Corrigan, on behalf of the Governors. Liz highlighted the following items of interest: a) Liz Corrigan thanked the Appointed & Partnership Governors who had attended today and expressed how invaluable their expertise is to the Council. James White added that unfortunately he is not always able to attend Membership Council meetings due to a clash with NHS North Somerset’s Board Meeting. b) A representation of Governors would meet a member regarding the outcomes of the Histopathology Inquiry. Notes of the meeting will be distributed to all governors.
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By
There being no further questions, the Membership Council resolved to note the Governor’s report.
7. Chief Executive’s Report The Membership Council received and considered a verbal report by the Chief Executive. He reported on four items of interest as follows: a) Executive Director Recruitment Robert Woolley announced the appointment of three Executive Directors to the Trust Board, as follows:
• Deborah Lee has been appointed as Director of Strategic Development. Deborah has been seconded to the Trust since May 2010 from NHS Bristol, where she was Director of Commissioning. She will take up the post with immediate effect. • James Rimmer has been appointed Chief Operating Officer, coming to University Hospitals Bristol NHS Foundation Trust from the Royal United Hospital Bath, where he
is currently Director of Operations. He is expected to take up his role at the end of June 2011. • Dr Sean O'Kelly has been appointed as Medical Director to start mid-April 2011. Dr O'Kelly comes to us from Salisbury NHS Foundation Trust. Appropriate interim arrangements will remain in place until the final two appointees join the Trust. b) Performance
Robert Woolley briefed the Governors on the performance of the Trust over the Christmas and New Year period. Robert stated that over Christmas and New Year there had been an exceptionally high level of demand from patients visiting the Trust hospitals. The Trust recorded an 11% increase in emergency admissions compared to the Christmas of 2009. Robert added that in light of the demand for services over the Christmas period the Trust performed a ‘lessons-learned’ activity. Areas of interest were: • The need for extra planning to cover the two four-day Bank Holiday periods in April. • Support from the healthcare community. Robert praised all staff in the Trust for their hard work over this difficult period. c) Great Western Ambulance Service - Strike Withdrawn The Avon branch of Unison had given notice to Great Western Ambulance Service (GWAS) NHS Trust of their intention to strike, but have since withdrawn this notice. Robert reassured the Membership Council that the Trust had established emergency plans to deal with the potential influx of additional emergency cases to the Emergency Department. These provisions would be invoked again should a second notice be given. d) Strategic Plans The Trust has submitted a loan application for £70 million to help fund the extension to the Queens building. This extension would allow for the proposed Centralisation of Specialist
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By Paediatrics and the transfer of wards from the Old Building to the Queens building. e) Histopathology Inquiry The outcomes of the Inquiry were announced in December. The Trust has agreed an action plan in conjunction with North Bristol NHS Trust to meet the recommendations made by the Inquiry panel. This has been agreed by the Trust Board and will be submitted to its regulators. The Trust has also informed the Royal College of Medicine and the Bristol City Council Scrutiny Committee, who can question the progress at any time. The Trust has also set a date to appoint a joint Clinical Director of Histopathology. This role will be fundamental to ensure unity across both Trusts. Question from the Governors to Robert Woolley included: 1. Mo Schiller questioned Robert on the cultural and managerial lessons the Trust had learnt from the Histopathology inquiry. Robert recognised the inquiry findings on culture and the Trust is committed to providing a single service with North Bristol NHS Trust (NBT). The appointment of a Joint Clinical Director of Histopathology will ensure the cohesiveness of both Trusts. Many managerial lessons have been learnt. It is now a formal requirement for Executive Directors to report concerns which will be centrally logged and formally managed. 2. Frank Palma asked Robert about the progress of the patient partnership with NBT. Robert stated that it was too early to note the progress of the patient partnership with NBT but commented that it is designed to explore greater opportunities for partnership working. A formal Board will be established with Terms of Reference. It was agreed that a regular report would be presented to the Membership Council. 3. Chris Payne was concerned that the perception of healthcare in Bristol. Chris asked Robert how, as Governors, they can really know that improvements have been made. A baseline survey of staff on Trust values is currently being undertaken across the Trust. This is to assess the effectiveness of the values and also to request suggestions for ways of incorporating them into the workplace. The Trust values will be used as the basis of all recruitment, training and to manage performance. The Histopathology Partnership Agreement and the new appointment of a Joint Clinical Director of Histopathology are important steps for the future. Robert is pleased that the Partnership Agreement has received a positive response and it sends a strong signal to clinical staff. John Savage added that it is essential that the Governors are convinced that progress has been made on this issue. He implored that Governors should first satisfy themselves and then spread the message in the community. 4. John Steeds asked for further clarification on the Medical Division is recording a deficit month-on-month since September/October 2010. Robert explained that the plan for the year was based on the closure of beds, which would have resulted in savings but that these closures did not happen. At present there are currently 46 unfunded beds. The deficit could be due to control issues over nursing spends and drugs. Peaks have been identified on spending and a plan is currently being escalated to agree recovery plans. 5. Garry Williams asked whether the Trust is working on strengthening its relationships with 4
Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By General Practitioners and Primary Care Trusts in light of the Government’s move to GP consortia. They should realise common interests. Robert replied that so far he has had a good response from the Programme Board but more needs to be done in the future to the general imbalance in emergency care in Bristol, North Somerset and South Gloucestershire. The Trust is accepting increasing numbers of emergency patients from areas that would previously have used other services. James White, Appointed Governor NHS North Somerset, commented that everyone has a wider responsibility. The Trust needs to ensure only the urgent cases are seen by emergency staff. This message needs to be spread that the NHS has limitations due to decreased resources. 6. Mo Schiller asked Robert his opinion on the Watchdog Report and if an estimated £5 billion could be saved across the NHS if they combined procurement. Robert responded by saying that this report was very timely. The Trust has recently reviewed procurement and will be working with North Bristol NHS Trust on combining this, which will no doubt reap benefits. There being no further questions, the Membership Council resolved to note the Chief Executive’s report.
8. Quarter 3 Self-certification to Monitor The Membership Council received this report by the Chief Executive to note. Robert Woolley highlighted that the Trust has a Finance Risk Rating Assessment of 4, which is rated ‘very good’ by Monitor. The score for Governance has been assessed as 0, which is a ‘green’ rating under the amended 2010/11 Compliance Framework. Robert Woolley presented his recommendation to the Trust Board that Declaration One of the Monitor self-certification based on the evidenced performance of the Trust for Governance and Finance (as evidenced in the Summary Quality and Performance Report and in the Finance Report presented to the 21 January 2011 meeting of the Trust Board of Directors). There being no further questions, the Membership Council noted the Trust Board of Directors Quarter 3 Self-Certification to Monitor.
9. Quarterly Review of Progress against the Annual Plan Deborah Lee, Director of Strategic Development, presented a report to the Membership Council on the progress against the Trust’s Annual Plan Objectives 2010/2011. All objectives have been reviewed and generally good progress is reported against the objectives set at the beginning of the year. 70% of these objectives are currently rated as ‘green’. Two of these objectives are showing as ‘red’ issues; these are both within the ‘Becoming the Local Employer of Choice’ category. The two objectives are: • The Trust’s website. However, improvements to the website will be launched by June. • Ensuring all Trust policies and functions have an Equality Impact Assessment. A compliance reporting process has now been agreed with the Trust Secretary. This target will shortly be turning ‘green’. Wendy Gregory asked when the Trust thought the ten objectives showing as ‘amber’ relating to improving care for patients and overall patient experience would turn to ‘green’. Robert Woolley advised that this is the plan for 2010/2011.
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By There being no further questions or discussion, the Membership Council resolved to note the progress to date against the plan.
10. Self-Assessment of Membership Council Effectiveness The Chairman briefed the Membership Council on the progress of the self-assessment exercise. All governors have been sent a copy of the proforma to complete. Replies will be collated into a single document and the findings will be discussed at the next governors pre-agenda meeting on 21 March 2011, 2.00 – 4.00pm in Lecture Theatre 3. A combined response will be presented to the Membership Council on 4 May. The Membership Council noted the progress of the Membership Council self- assessment.
11. Report for the Governors Nomination and Appointments Committee The Membership Council received this report to note. This was presented by Phil Quirk on behalf of the Committee members. Phil highlighted the following activity: • Revision of the Committees Terms of Reference, to be presented for ratification at the next Membership Council meeting; • Planning for the 2011 Trust Board Appraisal exercise; • Planning for 2011 Non-executive Director reappointments. There being no further questions, the Membership Council resolved to note the Report for Governor Nomination and Appointments Committee.
12. Reappointment of Lisa Gardner as Non-executive Director The Chairman presented a paper for approval on behalf of the Nominations and Appointments Committee. This makes recommendations for the reappointment of Lisa Gardner as Non-executive Director and Chair of the Finance Committee for a further term of three years commencing 1 June 2011 to 31 May 2014. Lisa met with the Nominations and Appointments Committee on 9 December and they reached the unanimous decision to recommend Lisa for re-appointment for a further term of three years. John Savage personally added how valuable Lisa has been to the Trust, and how tuned in she is to the work of the Trust. The Membership Council approved the re-appointment of Lisa Gardner as Non-executive Director and Chair of the Finance Committee for a further three year term of office commencing 1 June 2011 to 31 May 2014.
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By 13. Reports from the Governor Working Groups The Membership Council received the following reports to note on the activity of the governor working groups. These were presented by the respective group Chairs. 13.1 Membership Working Group Liz Corrigan presented the Membership Working Group Report in the absence of the Membership Working Group Chair, Suzanne Green.
She highlighted the following activity to the governors:
• Revision of the groups terms of reference.
• Identify the aims and objectives of the group.
• Exploring routes to meet with the membership.
• The arrangement of three ‘Medicine for Members’ events, focusing on diabetes, healthy eyes and infection control.
• Involvement of governors in the Trust’s programme of events, including open days and health awareness events. • Liz is particularly keen for governors to volunteer for National Heart Month from 21-25 February, in the Bristol Heart Institute (BHI) Atrium and at the Bristol Haematology and Oncology Centre (BHOC) Open Day on Saturday 5 March, 11:00-15:00.
There were no further comments from the Governors. The Membership Council resolved to note the report. 13.2 Quality Working Group Pam Yabsley, Quality Working Group Chair, presented the report. Pam highlighted the following areas to the Governors: a) Cancelled Appointments - Tony Ranzetta, Acting Chief Operating Officer, attended the December meeting and said the Trust proposed to undertake a two-phase review of outpatient services due to start in January. The Governors requested an update on this. b) Patients experiencing problems with patient transport – Pam suggested that it would be helpful if Governors knew more about how the public transport system worked. The group are in the process of a arranging a meeting with Great Western Ambulance Trust to discuss.
Chris Payne, Appointed Governor representing NHS South Gloucestershire, said that the patient transport system was put out for tender last year. The services were divided into acute and patient transport. Chris suggested that in order to get the full picture the Governors should be talking to the Commissioners in conjunction with the Great Western Ambulance Trust.
Chris also explained that the eligibility criteria for patient transport had been reissued in
September/October 2010. The Governors requested a copy of the revised guidelines.
Deborah Lee to distribute the Patient Transport Eligibility Criteria to the Governors. D Lee c) Pharmacy – Patients are experiencing long waiting times. Steve Brown, Director of
Pharmacy, has been invited to attend the February meeting. d) Food – In a recent postal survey a third of patients said that they did not get enough
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By help from staff to eat their meals. Chris Swonnell said that this has been noted as part of the Patient Experience Action Plan, and that the Trust now has a protected meal time policy in place. e) Chair and Chief Executive Quality Walk Rounds – The Governors stated they valued the opportunity to be included in the walk rounds, and urged Governors to volunteer for the walk rounds. Robert Woolley briefed the Governors on the new style of walk round being trialled. It includes a presentation from the Divisional Board to give an overview of the area, followed by a visit to the area giving the opportunity for interaction between staff and patients. There were no further comments from the Governors. The Membership Council resolved to note the report. 13.3 Strategy Working Group Anne Ford, Strategy Working Group Chair, presented the Report. She highlighted the following activity to the Governors: • Mary Perkins had attended the last meeting and gave an overview of the Research and Innovation Strategy. • The group are reviewing their Terms of Reference and have discussed the streamlining of agenda items. • The group will be looking at the Trust’s Carbon Management Strategy in a future meeting. There were no further comments from the Governors. The Membership Council resolved to note the report.
14. Youth Council Update Report The Membership Council received and considered a verbal report by Jade Scott-Blagrove on behalf of the Youth Council. Jade reported on two items of interest as follows: • Website – At their meeting on 29 January the Youth Council discussed improvements to the Trust’s website. Suggestions included incorporating an interactive map, library and sections for younger children. Their comments would be passed back to the Web Development Team and a test website should be available for review at the next Youth Council Meeting. • Planning Future Activities – The group discussed fundraising and in particular, raising money to improve the hospital service and environment (24 February). They also discussed ‘Mystery Shopping’ which tests the hospital facilities (18 April) and tours around the hospital and talks from staff. There being no further questions, the Membership Council resolved to note the Youth Council’s Update Report.
15. Work Experience Policy The Membership Council received and considered an update report on the Work Experience Policy by Jade Scott-Blagrove. Jade reported that two members of the Youth Council had reported concerns that there had been a reduction in work experiences place at the Trust. At the last Membership Council
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By meeting Jade and Jacob Butterly highlighted this concern and requested Governor and Youth Council involvement in the review of the policy.
The review had taken place from September to December 2010. Jade received two letters from Steve Aumayer, Director of Workforce and Organisational Development, outlining the findings of the Trust’s Review. Jade had questions arising from the review. Deborah Tunnell, Resourcing Manager and Sue Cotterall, Work Liaison Co-ordinator addressed the concerns in the absence of Steve Aumayer.
Deborah advised that the Trust offered other opportunities such as school liaison ambassadors, mock interviews and school events. Specific fit for purpose placements will be carried out and offers made for 252 placements, in addition to school activity. The Trust has limited resources, which dictates the number of available places on offer to schools. At present the Trust receives about 700 or 800 requests for work experience placements a year and currently offers two places per school. Sue Cotterall added that the Trust follows a very strict vetting process, including relevant checks, and it is fairly time consuming procedure. The Trust conducted 34 school visits and tours last year. John Savage stated that he was very impressed by the work of such a small team, especially at a time when we need new doctors. Robert Woolley added that Steve Aumayer is revising the teaching and learning strategy at the moment. He will ensure work experience is included in this strategy and adequate resources are allocated. Questions from the governors: • Helen Langton, Appointed Governor representing the University of the West of England (UWE) asked if the team had explored working with other universities in town? Jade was encouraged to feed-back to young people that universities look for experience within community care, in addition to experience within acute care.
• Garry Williams asked how the two places per school were allocated and Sue explained that places are allocated by the school, to ensure fairness and to save the time of Trust staff interviewing pupils to ensure a good match.
• Jade added that she is worried that the revised policy has not been communicated to
young people via their schools. J Scott-Blagrove Jade Scott-Blagrove to report back to the Youth Council and ask if they would like Debbie Tunnell to attend. The Membership Council approved an Update Report on the Work Experience Policy by Jade Scott-Blagrove.
16. Any Other Business There was no other business.
17. Questions from Members There were no questions from the members.
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Minutes of a Membership Council Meeting of University Hospitals Bristol NHS Foundation Held on 03 February 2011 at 13:00pm in the Dental Hospital Lecture Theatre, Bristol Item 3
Item Action By 18. Date of Next Meetings The dates of the next meetings were confirmed as: 4 May 2011 and 27 May 2011, Lecture Theatre 1, Education Centre, University Hospitals Bristol NHS Trust, Upper Maudlin Street, Bristol.
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Item 4 Membership Council Schedule of Matters Arising 2011
Ref Date of Minute Description Action by Date to come Date Action Comments meeting number back to completed originating Membership action Council
5 03/02/2011 4 Histopathology Inquiry - Robert Woolley to explore the option of a R Woolley 04/05/2011 meeting between the governors and the patient representative.
7 03/02/2011 15 Work Experience Policy – Jade to report back to the Youth Council J Scott- 04/05/2011 and ask if they would like Debbie Tunnell to attend. Blagrove
27 April 2011
Item 6
MEMBERSHIP 4th May 2011 COUNCIL MEETING TITLE Governors’ Report
PURPOSE To inform the Council of the outcomes of recent Governors’ discussions THE COUNCIL IS To receive this briefing by the Governor Representative to note ASKED TO:
1. Context
We have been a Foundation Trust for three years and it is timely that we reflect on our achievements and at the same time look forward to the things we would like to do better. Throughout this report, where appropriate, I am using the word “constituents” to ensure the whole membership, in particular staff, is included. When talking to Governors from other Foundation Trusts we find that University Hospitals Bristol is far more progressive than other Foundation Trusts particularly in the Governors relationship with the Trust Board and Members of the Trust.
2. Summary
The Pre-agenda Governor’s Meeting was held on 21st March 2011 with 16 Governors attending. All topics covered at the meeting can be seen in the notes attached (see Appendix A).
3. The membership Council is asked to:
To receive this briefing by the Governor Representative to note
Prepared by: Liz Corrigan, Governor Representative, Public Governor North Somerset
Presented by: Liz Corrigan, Governor Representative, Public Governor North Somerset
4th May 2011
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Item 6 Governors Report
1. Introduction
We are pleased that the Appointed and Partnership Governors are now getting more involved as the knowledge of their particular speciality enables us all to have a better understanding of how things work, what works and what does not work well. We use the skills and background knowledge that we bring to the Council to help us work together as a team to benefit our constituents. Good communication is crucial to the success of The Trust and more work need to be done here. The formal complaints and the comment cards highlight that when things go wrong it is usually due to poor communication.
2. Achievements over the last three years
We now have: • A good understanding of our role, statutory duties, our boundaries and working together • The opportunity to attend education and training events to improve our effectiveness • A good working relationship with the Trust Board and other members of the Trust and secured their respect • Identified different ways of meeting our constituents and through real time feedback we have influenced change • Found ways of supporting the Trust in their achievements and have responded with the Trust to Consultation documents
2.1 Meeting our Constituents: A new initiative
Education is a vital part of communication to inform the general public of what is happening within the Trust and how to keep healthy. A new initiative organised by the Membership Office are the “Medicine for Members” Events and the first one was held in March. The topic was “Healthy Eyes” and the two speakers held our attention with excellent presentations and Members were very eager to ask questions. This also gave the Governors an opportunity to improve their clinical knowledge and an understanding the high quality of work going on within the Trust and identifying areas of clinical excellence. We also took this opportunity to talk to Members before the event on an informal basis. We would like to congratulate Maria Fox, Vicki Goodwin and Debbie Marks for their hard work in making this worthwhile evening so successful.
2.2 Working as a team
We were delighted to see more of our Appointed/Partnership Governor’s at our last Pre- Agenda Meetings and at other events. They add to our knowledge answering our questions relating to their speciality helping us to put things into perspective. Their presence is invaluable as they add to the skill mix enabling us to work better as a team.
2.3 Histopathology Inquiry
This is addressed as a separate agenda item and the paper accompanying it sets out how we and our constituents can have confidence in the way the Trust is carrying out the recommendations 2
Item 6 from the Inquiry and how we can be reassured on the safety and quality of the service that is being provided.
3. What we can do better
We should always strive to improve our service and learn from mistakes.
3.1 Governor Involvement
We are still concerned that a small number of Elected and Appointed/Partnership Governors have not met the minimum attendance requirement at Council Meetings, have not worked with us in any way and have not responded to our e-mails so delaying progress. This has not been formally addressed in the past but will be in the future. However, there are other ways of being involved and where it is not possible to be physically present perhaps in the future technology could be used for virtual meetings, taking the concept of communication to another level.
3.2 Communication
Our main concern now is communication both within and outside the Trust. Until we get this right patients, carers and staff will continue to be disappointed. In particular: • Staff need to be fully informed of what Governors do and what is happening with in the Trust. • We and our Executive and Non-executive colleagues need to be more visible to enable staff to ask questions and see that we are interested in what they have achieved and what their concerns are. This is starting to happen with Quality Walk Rounds but more work still needs to be done. • We need to make the general public aware of how the hospital works to help us to be more efficient: for example what and who our Emergency Department is for and who should attend. The Trust’s Calendar of Events should be available earlier in the year • All patient information should be in plain English without acronyms and duplication. The better we communicate and are proactive the happier our constituents will be.
4. Conclusion
There are still very few Foundation Trust Boards who allow Governors to be present and even fewer who allow them to ask questions. By doing this we are in the unique position to see how the Board Functions and what is happening. We see the Board in action as they challenge each other and ask questions that we would otherwise need to do.
As a Governing body we are ambassadors for the Trust, work well as a team and bringing invaluable background knowledge and skills to the Council. Governors must continue to be active on Working Groups and Committees and attend Trust Board Meetings to maintain the good work that we do. However, we must be sure not to over or under commit ourselves but share the workload to make the role interesting, enjoyable and above all feel that we have and are able to influence change and make a difference.
On a personal basis as I come to the end of our third year I believe that although there is always room for improvement that this hospital is “the best in the West” and we all want it to be the hospital of choice for the residents of Bristol and beyond. I would like to thank everyone 3
Item 6 for their help and support over the last three years and wish you continuing success for the future as we go through this period of major change. However, we must be sure that the changes made are in the best interest of our patients, our staff and UH Bristol as a whole.
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Item 6 Item 6 Appendix A
Governor’s Pre Agenda Meeting
Held on Monday 21st March 2011
1. NOTES OF THE MEETING
Present: Liz Corrigan (Chair) Public Governor - North Somerset & Governor rep Suzanne Green Patient Governor – Tertiary David Aldington Patient Governor – Local Anne Skinner Patient Governor – Local Jade Blagrove-Scott Public Governor – Bristol Mo Schiller Public Governor – Bristol Heather England Public Governor – Bristol Philip Mackie Patient Governor – Carers of under 16 years Wendy Gregory Patient Governor – Carers of 16 years and over Garry Williams Patient Governor – Carers of 16 years and over Florene Jordan Staff Governor - Nursing & Midwifery Jan Dykes Staff Governor - Non Clinical Healthcare Jane Britton Partnership - Avon & Wiltshire Mental Health Trust Sharon Hinsley Partnership - Great Western Ambulance Trust Jeanette Jones Partnership - Joint Union Committee Joan Bayliss Partnership - Community Group Governor
In attendance: Debbie Marks Membership Administrator (minute taker)
Item Action 1. Apologies
Apologies were received from - Mary Hodges, Pauline Beddoes, Neil Auty, John Steeds, Pam Yabsley, Jacob Butterly, Jim Catterall, Belinda Cox, Chris Swonnell, Chris Payne and Frank Palma.
2. Notes of the Last Meeting held on 10th January 2011
The notes of the last meeting were agreed as an accurate record subject to the following queries:
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Item 6 Item Action a) Suzanne hasn’t heard from Robert Woolley regarding Dr Foster and the National Audit of Theatre Equipment.
Action – Liz will speak to Robert on Suzanne’s behalf. Chair
b) Heather flagged Item 7c, Bullying and harassment, and Item 7d, Uniform. Heather would like an update of these 2 items at the next Alison Moon and Steve Aumayer meeting on 11th April. Jeanette informed the group that uniforms won’t be changing and the Trust will continue using Alexandra’s for uniforms. These 2 items are on the agenda for the meeting on 11th April.
3. Annual Work Plan – confirmation:
This was discussed at the previous meeting. Changes have been made and the group are happy to go ahead.
4. Governor Representative – Election Timetable:
Liz reminded the group that Governor’s have received nomination forms. Governor’s can nominate themselves or someone else. Forms need to be returned by 4th April 2011. Any forms received after this date will be disqualified. If more than one candidate is nominated then voting forms will be sent out and these will need to be returned by Wednesday 20th April.
5. Appointed/Partnership - Governor’s Involvement
Liz has looked at the Appointed/Partnership Governor’s attendance. There are 4 out of 11 Governor’s who are very active. 9 out of 11 are committed to the Membership Council meetings and 2 rarely attend. There is a new University of Bristol Governor (Professor Tim Peters) who will replace Massimo Pignatelli. Liz informed the group that after Governor elections Charlie Helps will be meeting with the new appointed/partnership Governor’s to explain the Governor role and what is expected from them. Phil Mackie inquired if a Governor’s term was terminated if they failed to attend more than twice. Liz confirmed that a Governor’s non-attendance should have a reasonable excuse, for example, one Governor has previously informed Liz that his Board dates clash with Governor meetings. We now have his meeting dates and only one date clashes. Joan informed the group that, previously, she has been involved with a Links representative who was on long term sick leave. It took one and a half years to get a replacement and Joan wanted the group to be aware of what a long, democratic process this could be.
Action – the group agreed for Liz to speak to Charlie Helps regarding poor Chair attendance.
Garry mentioned the Family Health Service (primary care) and that everyone there had a deputy – this solved diary problems and worked well. Liz replied that this idea has been previously been mentioned and believes that there is no provision in the Constitution for this. Liz also stated that if someone is not
6
Item 6 Item Action attending meetings at all then there is a problem that needs solving.
Action – Liz will mention Garry’s idea to Charlie Helps. Chair
6. Membership Council Self Assessment
a) Individual – 10 forms out of 38 were returned. b) Group – Liz suggested to the group that the consensus could be presented at the Membership Council Meeting on 4th May as it is currently written, or Governor’s can have a re-look at the forms and write it as a group. Joan flagged that there were gaps in the Membership Council’s background and Liz agreed - an example Liz gave was that at one point the group were heavily weighted with nurses but as new Governor’s are elected these gaps change. Anne Skinner questioned a comment on page 6 that mentioned payment for Governor’s in money terms. Liz reminded the group that these comments are individual Governor’s responses (and are made anonymously), they perhaps shows gaps in their knowledge, for example the Constitution etc, and where misunderstandings have been identified - this can be an action point for the coming year. There was a suggestion that the responses should be edited. Wendy pointed out that if individuals are asked to make comments and then they are re- edited, it won’t represent Governor’s feedback and therefore won’t reflect the consensus. Jeanette stressed that this is a working document and there is work to be done. Wendy suggested having workshops in the future where everyone has a say and agree on options. Joan stressed that this document represents individual Governor view’s (not representative of all Governor’s) and not the consensus of the group.
Action – Liz agreed to ensure that the above point is made on the completed Chair form.
It was decided to annotate the form alphabetically.
Action – Debbie to mark each section of the self assessment form D. Marks alphabetically so Governor’s can identify comments easier.
Joan asked if the Trust had suitable insurance cover for Governor’s.
Action - Liz will check the Trust’s insurance details for Governor’s. Chair
Garry disputed the fact that Governor’s are not employed by the Trust and yet Human Resources ask for intrusive forms to be filled in. Jeanette confirmed that Governor’s do need to fill in certain forms for CRB checking and for the Safeguarding Authority. Any Governor’s that are re-elected will have to fill in more in-depth forms for the Safeguarding Authority and will need references. Garry suggested that new Governor’s are made aware of this.
Action – Liz will speak to Charlie regarding these forms.
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Item 6 Item Action
c) Achievement – Liz has e-mailed all Governor’s asking what they felt had been achieved and only one response has been received. Liz went round the room asking each Governor present to state one achievement they felt had been made and these are the responses:
• Governor’s are a group of people involved with the Trust’s work and who challenge this work therefore making better outcomes for patients. • Governor’s have added another element, conscience, to the Trust Board. The Board are aware of big achievements made in the last year by the Governor’s and it is fantastic that Governor’s get recognition from John Savage at these meetings. • It is great that Governor’s are a group of individuals who are committed and who independently view problems/issues. • As a fairly new Governor I haven’t achieved much, so far. The group disagreed and felt that she has contributed a huge amount since joining. I recently attended the South West Forum meeting where a fellow Governor didn’t have permission to attend their Board meetings and pointed out that UBH Governor’s, as a group, are far more progressive than in other Foundation Trusts. • No comments yet • It’s brilliant that I can channel views from the Youth Council to the Trust Board.
• The profile has been raised for disabled children and their
carers. They are now better represented and in one area hours
for staff have been increased.
• I think that Governor’s have helped to develop consciousness
and the importance of it. Governor’s have a close relation to
the Chief Executive and Chairman and he also mentioned the
advocacy role this body brings especially on behalf of carers
and others who may not be aware of Trust issues – a good
opportunity to educate others.
• As an outsider (i.e. not having an NHS background) I have seen opportunities to make changes which have not been taken
up. He mentioned that he finds the Trust’s bureaucracy very
frustrating with the idea that the Health Service can’t be
changed. Several group members agreed with him but voiced
the opinion that things CAN be changed. He also stressed the
importance of looking at ways to improve, and therefore
provide, a better Health Service.
• Changes are being, and have been, made. Alison moon has been involved with several changes and has made sure these changes have happened. She raised the issue of PALS (Patient Advice Liaison Service) and said that patients don’t always want to make an official complaint especially after a traumatic event. She feels very proud to be involved with identifying 8
Item 6 Item Action and making changes. • I feel positive that, from a patient’s perspective, Governor’s are an extra route in. Governors have helped to increase and improve the quality of communication. The issue of communication is vital in any company or business but ten times more important within a hospital. • The Governor’s have to push forward but are getting there. The Governor meetings with John Savage help and said that John has acted on past queries very promptly. • I am still a new Governor and am finding my way. • I have observed, as a patient and a Governor, how much visibility there is of Governor’s for patients and pointed out how important this is. • Governor’s have got to know each other’s strengths and they all have the same aim – Patients.
7. Histopathology Inquiry –
a) Daphne Havercroft (DH) – implications of the proposal for a public forum and the Governor’s response to her – Liz presented the letter from Daphne Havercroft to the group and briefly mentioned that DH has been involved with the Trust’s Histopathology Inquiry for a long time. DH has written to the Governor’s asking for their support in putting together a public forum – see point 14 in DH’s letter (this letter and attachments have been circulated to all Governor’s). Four Governor’s met with DH in February 2011: Liz Corrigan, Neil Auty, Mo Schiller and Anne Skinner with Maria Fox and Charlie Helps in attendance. There were several comments from the Governors today: • Anne Skinner agreed that DH has a point and Governor’s should be challenging the Trust. • Mo pointed out that Governor’s shouldn’t get involved. • Phil Mackie drew attention to the fact that DH has raised very important issues which should be dealt with and not dismissed. • Jeanette commended some of DH’s actions but has concerns that Governor’s may lose the respect and credibility that has been earned – Governor’s should help to resolve problems and not join battles. • Joan wouldn’t support joining a forum. The inquiry has ended and a report has been issued. Governor’s should look to the future and not the past. • Florene is unsure about DH forming a public forum but emphasised the importance of ensuring the Trust deliver and implement what it says in the report.
• Garry proposed that Governor’s show an active interest but not
to get involved at present.
b) Robert Woolley’s progress proposal – Liz has met with Robert
Woolley who has proposed a Governors Quality Sub group. Liz has met with 9
Item 6 Item Action Alison Moon to discuss heading up the Quality Sub Group. This will allow Governor’s to question the progress of the inquiry’s recommendations. This group will be meeting the month before Alison reports to the Trust Board. Members of this sub group will be: Chief Nurse (Alison Moon), Medical Director, Head of Histopathology, Pam Yabsley (Chair of Quality Working Group) and the Governor Representative. Pam has suggested that Wendy and Mo join the group. The first meeting of the Sub group will be held in May and after that meeting the final make-up of the group will be decided. The purpose of this group will be to provide assurance from the Trust of the delivery of the action plan. Jane illustrated that the Quality Sub Group will need to put markers in place so Governor’s will know how and when things have changed. The Trust will also need to prove that processes have changed and prove the outcomes. Wendy had concerns as to where Daphne should go for support other than Governor’s and stressed the importance that the Governor’s give Daphne a very specific response. Jeanette raised concerns over point 16 of Daphne’s letter and the group agreed with Wendy that Governor’s should be very careful how the reply is worded.
Action – Liz will respond to Daphne Havercroft with the following points: • Inform Daphne Havercroft that her request will be put to Governor’s on the 4th May • To inform Daphne Havercroft the outcome of the vote on 4th May. Chair
Other supporting information covering public scrutiny and patient involvement – Liz informed the group the ways in which the public can be reassured that the inquiry recommendations can give confidence in the histopathology service. Other ways include: 1) The histopathology report is published and on the website 2) Progress is discussed at open Trust Board Meetings 3) CQC and Monitor – updated 4) Local Authority Scrutiny Commission (NHS, The Trust and PCT presented a paper 16th March 2011) – updated and pose questions 5) We heard from Tony Watkin (Public Involvement Project Lead) at the Membership Working Group meeting that he has set up four focus groups, two of these are cancer patients and the other two are benign (non cancer) patients. These focus groups will explore: • What a patient’s understanding of histopathology is. • What assurance patients look for when considering the quality of care offered by the histopathology service? • And how patients want to be involved in the ongoing development of histopathology at UH Bristol.
The group debated whether to have an open vote at the next Membership Council Meeting on 4th May or have a closed meeting beforehand. Florene stated that it would be good for members to see that Governor’s do what they say and members need to see actions. Liz clarified that all Governor’s had the chance to give their opinions and has had no responses. It was decided to have an open vote on 4th May. Joan requested that all Governors are made 10
Item 6 Item Action aware that they will have to vote.
Actions – a) The request for Governor’s to support the forum proposed by Daphne Havercroft to be an agenda item at the Membership Council meeting on 4th V. Goodwin May and will be voted on in the open Council meeting.
b) Liz to prepare paper for Vicki in time for the Membership Council Meeting and will inform all Governor’s regarding the open vote. Chair
8. Transport update –
Sharon reported to the group that each ambulance has a qualified staff member and an ECA (Emergency Care Assistant) onboard. Solo response vehicles have either one qualified person (paramedic or technician) or an ECP (Emergency Care Practitioner). Sharon also stated that out of the whole of Great Western Ambulance Service only 3 technicians didn’t wish to pursue further training.
9. Agenda Items For Council –
a) Request by a Foundation Trust Member (Daphne Havercroft) to establish a Public Forum (see Agenda Item 7 above – action points a and b). b) Quality report on the results of Constituency questionnaires P. Yabsley c) Work Plan M. Schiller d) Self Assessment of Membership Council Effectiveness E. Corrigan e) Constitutional changes C. Swonnell
10. Governor Involvement: Written reports or minutes of last meetings:
a) Quality Working Group – no comments from the report. b) Strategy Working Group – no comments c) Membership Working Group – no comments d) Nominations and Appointments Committee – Liz informed the group that a meeting was held on 17th March. The Constitution has been changed slightly and will be taken to the Membership Council Meeting on 4th May. The Work Plan is on target and there are 3 Non- Executives up for re-appointment in the near future and all 3 wish to be re-appointed. As with previous re-appointments they will meet with the Nominations and Appointments Committee in advance of their re- appointed date. e) Quality Walk Rounds Review – i) Governor’s attendance to date – no comments ii) Walks for 2011 - Mo needs one more volunteer for June 22nd, Level 4 Gastroenterology clinic, 11 – 1pm. All other dates are filled – thank you. Phil Mackie suggested the possibility of Governor’s doing walk rounds unannounced and stated that if staff know Governor’s are coming they may make an extra effort. Anne Skinner and David agreed with Phil and Mo
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Item 6 Item Action mentioned that she has previously asked about this and flagged that if this were to happen then Governor’s ID badges would need activating for access. Action – Liz will speak to Charlie Helps regarding access with ID badges. Chair f) Foundation Trust Governors Association (FTGA) – There was no report available for FTGA. Liz informed the group that she won’t be standing for re-election this year. Wendy confirmed that she was very interested in taking over from Liz.
Action- Liz/Maria to e-mail all Governor’s to remind them that one FTGA voting delegate place will become available from 1st June and for Governor’s Chair/ to register their interest. M. Fox
g) Alison Moon & Steve Aumayer meetings – Mo informed the group that these meetings will now be held every 2 months. Future meeting dates have been set and the next meeting will be held on 11th April. h) Constituency meetings in outpatients clinics – i) Results – Suzanne has completed a brief overview of findings from patient’s questionnaires. These findings were: • In the large majority of cases the patient experience is satisfactory and there are examples of praise for the staff and general treatment received. • One area of concern was the parking and transport system. Some patients had no knowledge of the shuttle bus. • Another cause for complaint was the long waits in pharmacy – one patient waited 6 hours for their prescription. • Communication on length of waiting time often does not seem to be happening. • A minority of questionnaires have not been completed following seeing the consultant. • It would be helpful for the Governor handing out the questionnaires to complete the back of the form please.
ii) Calendar – Mo told the group that all dates are covered up until 22nd June. Vicki will organise July to December nearer the time. V. Goodwin i) Communications Trust Wide Programme of Events – update – Liz highlighted Ovarian cancer week and mentioned that more volunteers are needed please.
j) Constitution update – (papers distributed at last meeting) – Liz and Chris Swonnell had met with Charlie Helps and Liz pointed out the recommended changes that are now to be made to the Constitution:
• typo on page 5
• Page 24 – noting that constitution will need updating when
PCT’s disappear
• Page 26 - correct name for AGW. • Page 26 – Charlie needed to make further enquiries about the status of the LINK and Joan’s position 12
Item 6 Item Action • Page 59 - paragraph 3.1.3 – agreed to re-write. • Page 85 – We then discussed raising the age of voting from 4 years to 7 years (which was one of the recommendations of the Youth Council, ) and it was agreed that the age of voting should be raised to 7 years but only if the young people between the age of 4 years and 6 years can still be members (e-mail dated 13th March says that Charlie will write to them telling them that they will remain members but will not be able to vote until they reach the age of 7 years). If this is confirmed again by Charlie to be correct we will recommend it at the same time as the other changes. If it is not confirmed as correct and there is any doubt to the membership of the ones under 7 years this will not be a recommendation this year and will need to go back to the Youth Council.
Action – Liz to confirm the last point with Charlie Helps.
k) PEAT 2011 – Jan explained that this went well but no results are Chair available from the national input as yet. The Patients environment group (patient safety) would like to change the timing of PEAT visits and is currently being discussed. l) Newsletter Progress – Wendy reported that the newsletter is progressing but has slipped slightly due to meeting frequency. The next meeting should be next month – Wendy will confirm with Maria. The newsletter team are currently testing colours etc. m) Website Progress – Wendy informed the group that Aardman has W. Gregory done a presentation which was excellent. The Website team are looking at illustrative links but the slippage of timelines is huge – the feedback hasn’t been great and the progress is nowhere near going live for 28th March. Wendy emphasised that the team are positively moving forward. n) Hand Held Surveys – Liz stated that all Governor’s have received a list of dates and can phone Tony Watkin (Tel 0117 3423729) with availability. Liz is doing her induction on 31st March.
11. Any Other Business –
a) PICU (Paediatric Intensive Care Unit) update – Florene told the group that she has met with Sarah Tanner who is the new Staff Nurse for PICU. Sarah currently works 25 hours per week over 5 days (9 – 2pm) which may be increased and is based in the community nurses office. Sarah has lots of ideas of how the current system can be improved in the future but is aware of limitations. Sarah has suggested coming to a Pre-agenda meeting and speaking to the Governor’s about her role. Jeanette suggested that Sarah attend a meeting in the future – Sarah has been in post for a short time, the remit is large and opinions have already been voiced about increasing her hours. Action – Jeanette will liase with Sarah. J. Jones
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Item 6 Item Action b) Joan mentioned that Links are doing a follow-up re acute stroke and recovery. If anyone has any comments regarding this then please inform Joan. 12. Next Meeting – Tuesday 14th June 2011 at 2-4pm in the Board Room, THQ
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Item 8
MEMBERSHIP COUNCIL 4th May 2011 MEETING PAPER Quarter 4 Governance and Financial Self Certification to Monitor PURPOSE For Information and Questions THE MEMBERSHIP Note the Trust Board’s Quarter 4 Governance and COUNCIL IS ASKED TO: Financial Self Certification
1. Context
NHS Foundation Trusts must confirm compliance with their Authorisation in relation to all healthcare targets and indicators listed in Appendix B of Monitor’s ‘Compliance Framework 2010-11’ issued in March 2010.
This item comprises the Board paper of 28th April 2011 and is provided to the Membership Council for information and questions.
2. Summary
The Trust Board submitted a Governance Risk Rating of 1.5 – “Amber-green”, and anticipates that the Trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.
The Trust’s Quarter 4 declaration is due for submission to Monitor by 30 April 2011.
3. The Membership Council is asked to:
Note the Trust Board’s Quarter 4 Governance and Financial Self Certification.
Prepared by Charlie Helps, Trust Secretary
Presented by Robert Woolley, Chief Executive
4th May 2011
Page 1
Cover Sheet for Report for a Trust Board Meeting, to be held on 28 April 2011 at 10:30 in Tutorial Room 4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE
Title of Report & Q4 Compliance Framework Monitoring Report Agenda Item Number Item 17
Purpose To consider the Quarterly Governance and Financial self- Certification to Monitor for Quarter 4 of 2010/11 Abstract NHS Foundation Trusts must confirm compliance with their Authorisation in relation to all healthcare targets and indicators listed in Appendix B of Monitor’s ‘Compliance Framework 2010-11’ issued in March 2010. The Trust’s Quarter 4 declaration is due for submission to Monitor by 30 April 2011.
Recommendations Once satisfied as to the current position, the Board is recommended to: Approve Declaration 2 and a Governance Risk Rating of 1.5 – “Amber-green”, and, to Approve a declaration to Monitor that the Board anticipates that the Trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.
Report Sponsor Chief Executive
Other Author Trust Secretary
Appendices The following Appendices are included in this report: • Appendix A – Quarter 4 Financial Performance Commentary for Monitor Return • Appendix B – Quarter 4 Governance Targets and Indicators
Previous Meetings The matters discussed in this report were considered in the following Trust corporate fora:
Executive Trust Finance Quality and Audit Other Management Executive Committee Outcomes Committee Team Group Committee 21 April 2011 26 April 2011 27 April 2011
2 Page 2 of 2 of Item 17 - Q4 Compliance Framework Monitoring Report for a Trust Board Meeting, to be held on 28 April 2011 at 10:30 in Tutorial Room4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE
Purpose The purpose of this report is to present the Quarter 4 position against the Monitor Compliance Framework and recommend that the Trust Board approves Declaration 21.
Background The Trust Executive will have considered the Trust’s current and future position at its Executive’s meeting on 20 April. The Finance Committee will have considered the Report of the Finance Director and the Quarter 4 Performance Commentary for Monitor Return on behalf of the Board on 26 April. The Quality and Outcomes Committee will have considered the Quality and Performance Report on behalf of the Board on 26 April. The Trust Board of Directors will have considered the Corporate Risk Register in the course of the meeting of the Board on 28 April. There are no adverse governance risk implications associated with the personnel changes to the Membership Council and the Trust Board of Directors in the period.
Previous Declaration and Indicated Position The Trust’s Quarter 3 declared position and indicated Quarter 4 position are set out below:
Q3 Declared Position Indicated Q4 Position Finance Risk Rating 4 (in accordance with plan) 4 (in accordance with plan) Governance Risk Rating Green Amber-green Mandatory Services Green Green
Other Non-Financial Submission The information set out below is also required to be submitted to Monitor:
a) Any change to NHS Litigation Authority CNST rating (General or Maternity) – No change b) Any change to auditors – No change c) Any planned or unplanned Care Quality Commission inspections – None d) Any Health and Safety Improvement notices issued – None e) Any adverse Coroner’s report – None
1 For one or more targets the Board cannot make Declaration 1 and has provided relevant details on worksheet “Targets and Indicators” in this return. The Board confirms that all other healthcare targets and indicators have been met over the period (after the application of thresholds) and that sufficient plans are in place to ensure that all known targets and national core standards that will come into force will also be met.
3
For consideration and approval by Finance Committee 26th April 2011 – Agenda Item 6 Trust Board 28th April 2011 – Agenda Item 18 To be Received by Membership Council 4th May 2011 – Agenda Item 8
QUARTER 4 PERFORMANCE COMMENTARY FOR MONITOR RETURN
Director of Finance April 2011
4 1. EXECUTIVE SUMMARY
This commentary covers the results for the year ended 31st March 2011..
The Trust reports an EBITDA1 surplus for the year of £40.443m. This is £4.746m higher than the Annual Plan for the year of £35.697m. EBITDA is at 113% of Plan. The summary income and expenditure statement shows a surplus of £12.186m (EBITDA and financing costs).
The financial risk rating is 4, which is in line with the Annual Plan.
31st March Weighting 5 4 3 2 1 2011 EBITDA Margin % 25 8.01 11 9 5 1 <1 Achievement of Plan 10 113% 100 85 70 50 <50
Return on Assets 20 7.44 6 5 3 -2 <-2
I&E surplus margin 20 2.77% 3 2 1 -2 <-2
Liquid ratio (days) 25 40.7 60 25 15 10 <-10
Overall rating 4 (actual weighted score = 4.05)
1 Earnings Before Interest Taxation Depreciation and Amortisation 1
5 2. NHS CLINICAL INCOME iii. Non-Elective
NHS Clinical income is £4.628m higher than the Monitor Annual Plan, Non-Elective, Emergency Short Stay and Emergency Long Stay are standing at £389.334m for the year. Clinical income includes income £5.7m over plan for the year. The over-performance is across a number from NHS commissioners and also income from territorial bodies, of areas, particularly Obstetrics, Cardiology, General Medicine and mainly Health Commission Wales. Paediatric Surgery.
The variance for the year is explained in table 1 below: iv. Planned Same Day
Table 1 – Clinical Income – Quarter 4 Year to Date Variance from Plan Day Cases are £1.3m over plan for the year to date, the key areas of
over-performance are Ophthalmology, Clinical Oncology and Medical £m Oncology. Monitor Plan 384.706 Other Changes To The Plan 0.225 v. Outpatients Current Plan 384.931 Over Performance (See Table 2 Below) 4.403 Outpatient activity is over-performing by £1.8m; the key areas of over- Year To Date Income 389.334 performance are Sleep Studies, Cardiology and Genitourinary Medicine. Activity and Income by Worktype vi. Accident and Emergency Performance against Service Level Agreement income budgets for the year is summarised below by worktype. A&E is over-performing by £0.4m.
i. Elective – Long stay vii. Other Activity Overall Elective Long stay is £3.3m behind plan. The under- performance is across a number of specialties, particularly Cardiac Other activity includes Direct Access, Radiotherapy, Critical Care, PbR Surgery, Cardiology, Medical Oncology, and Urology. Excluded Drugs & Devices and specialised services such as Bone Marrow Transplants. ii. Elective – Short stay
Elective Short Stay activity is £0.5m ahead of plan. The two main areas of over-performance are Trauma and Orthopaedics and Thoracic Surgery.
2
6 Table 2 – Clinical Income by Worktype commissioner and how the Variable Estimates income target then adjusts this for the overall position. Plan Actual Variance Worktype £m £m £m Table 3 Over Performance by Commissioner
Elective revenue, long stay 38.734 35.456 -3.278 Variance Variance Commissioner Elective revenue, short stay 8.709 9.221 0.512 £’m % Non-Elective revenue 97.823 103.531 5.708 NHS Bristol 5.102 4% Planned Same day (Day cases) 36.166 37.504 1.338 NHS North Somerset 3.961 14% Outpatient 59.400 61.215 1.815 NHS South Gloucestershire 2.786 13% A&E 10.852 11.240 0.388 NHS Wiltshire 0.194 4% Direct Access 4.886 4.659 -0.227 South West Specialised Commissioning 1.249 2% NHS Somerset 0.219 2% Critical Care 33.424 32.762 -0.662 NHS Gloucestershire 1.354 27% PbR Exclusion 13.108 11.862 -1.247 Prior Year Income 1.596 N/A 19.915 20.405 0.490 NICE College Variable Estimates -10.613 N/A 4.037 3.374 -0.662 At Cost Contracts Other (including Exceptional Funding) -1.444 N/A Radiotherapy Courses 7.789 8.061 0.273 Total
Excess Bed days 9.477 9.832 0.355 Bone Marrow Transplants 9.607 8.208 -1.399 3. NON-NHS CLINICAL INCOME Prior Year Income - 1.596 1.596
Other NHS 31.004 30.407 -0.597 Overall Non NHS clinical income is £0.043m lower than planned for Grand Total 384.931 389.334 4.403 the year to date.
Over Performance by Commissioner 4. OTHER OPERATING INCOME
During the Local Delivery Plan process the Trust agreed to reduce Overall other income is £6.251m higher than planned for the year. The Service Level Agreement values for demand management schemes put main reasons are: forward by Primary Care Trusts that the Trust believed were over optimistic. Because the Trust did not expect these activity reductions to Higher than planned levels of Education and Training income of materialise the clinical income budgets were not reduced, and an £1.840m due to changes in the contracts for SIFT and MADEL. income budget was created for a dummy commissioner -Variable Estimates. Table 3 below shows the cumulative income variances by
3
7 Lower than planned income received to date with regards to 5.3 Clinical supplies and services Skills for Health £2.168m due to income being deferred to the next financial year. Clinical supplies and services costs for the year were £3.836m greater Higher than planned income from charitable sources £0.567m than plan. This is mainly driven by lower than planned delivery of CIP Non recurring bowel cancer screening income £0.335m savings and higher than planned activity. Other non recurring income not in the original plan £3.135m Changes to original planned income £2.059m 5.4 Other Costs
Lower than planned income for research and development Other costs for the year were £9.297m lower than plan. This is due £0.146m mainly to. Higher than planned Patient Transport Service Income £0.629m
Higher than planned spend on premises and fixed plant and 5. EXPENDITURE establishment expenses £1.418m;
Lower than planned spend on Skills for Health £4.578m; This is Overall operating costs of £464.704m for the year were £6.089m higher due to work being deferred to the next financial year. than plan. Trust pay costs are £5.240.m greater than plan and non pay costs are £0.849m higher than plan. Greater than expected CRES achievement £3.040m Lower than planned spend on other expenditure £4.371m; 5.1 Pay Costs Higher than planned spend on non clinical supplies £1.274m.
Pay costs for the year were £5.240m, higher than plan. The main 5.5 Non Operating Expenses reasons for this are an underachievement against the planned CIP savings target and higher than planned spend within Skills for Health Minor financial variances are shown against PDC dividend expense and offset by underspending on various staff groups including scientific and bank interest. Lower depreciation charges reflect slippage on the capital technical staff and other clinical staff. programme and a lower level of indexation on asset values. Impairment charges are £563k greater than planned mainly because of the review 5.2 Drugs taken on the economic loss associated with the planned disposal of the Bristol General Hospital in 2012. Drug costs for the year were £6.310m greater than plan. This is due to higher than planned activity.
4
8 6. CAPITAL 7. STATEMENT OF FINANCIAL POSITION (Balance Sheet)
Actual expenditure for the year totals £25.415m. This represents net The significant balance movements and variances are explained below. expenditure performance of 81% when compared with the Annual Plan assumption of £31.377m. The slippage on schemes this year will be 7.1 Non Current Assets funded in 2011/12 by the use of the carry forward of cash balances at the year end. The balance of £295.289m at the end of March is broadly in line with the plan of £292.934m.
Financial Year 2010/11 7.2 Inventories (formerly referred to as Stock) Approved Variance Outturn Plan Fav/ (Adv) At the end of March the value of inventories held totalled £7.168m. The £’000 £’000 £’000 increase above the forecast given in the Annual Plan (£5.898m) relates Sources of Funding primarily to cardiac services. Donations 3,581 2,155 1,426 Asset Disposals - - - 7.3 Receivables (formerly Debtors) and Accrued Income Retained Depreciation 16,905 16,090 815 Cash balances 15,981 7,170 8,811 The Trade and Other Receivables balance at the end of March is Total Funding 36,467 25,415 11,052 £17.580m, which is £4.168m below plan of £21.748m. This is mainly due to NHS Trade Receivables being £5.674m lower than plan offset Expenditure and an increase in Non NHS Trade Receivables and Other Receivables Strategic Schemes (16,277) (9,712) 6,565 Medical Equipment (5,651) (4,380) 1,271 of £1.506m. Information Technology (5,432) (3,841) 1,591 Roll Over Schemes (2,016) (1,601) 415 The reduction in debtor balances reflects the concerted efforts made by Refurbishments (4,928) (2,274) 2,654 the Trust to improve its management of debtor balances. Operational / Other (8,869) (3,607) 5,262 Anticipated Slippage 6,706 - (6,706) 7.4 Accrued Income Total Expenditure (36,467) (25,415) 11,052 At the end of March the value of Accrued Income was £4.760m against a plan of £1.652m. Within this total £3.728m related to Skills for Health balances.
5
9 7.5 Prepayment Creditor Payment Performance The prepayment balance at the end of March is £1.579m. This is mainly Non NHS Creditors NHS Creditors due to payments for maintenance contracts for servicing of equipment. 100 This is broadly in line with the plan of £1.203m. 80 7.6 Deferred Income 60 Deferred income of £12.240 m is £4.832m higher than plan of £7.408m. £6.811m of this balance relates to Skills for Health. 40
of Creditor Number % 20 7.7 Trade Creditors / Other Creditors / Capital Creditors days 30 within paid invoices
Trade Creditors and Other Creditors are £2.470m higher than the - planned position of £21.321m. The creditor balance at the start of the 09- Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 10 year was particularly low as part of the Trust’s plans to prepare for the move to a new suite of core financial systems. This has now been fully implemented and payment performance for the year has been in line The improvement in payment performance in recent months reflects the with that achieved in previous years. The new system and the review of benefits of making better use of information and functionality offered processes planned for 2011/12 should see further improvements in by the new accounts payable system. payment performance and forecasting. 7.8 Accruals The Trust aims to pay at least 90% of undisputed invoices within 30 days. In December, the Trust achieved 96% and 93% compliance The accruals balance of £23.257m is £12.396m higher than the planned against the Better Payment Practice Code for NHS and Non NHS value of £10.861m. The variance is due to £10.540m for Skills for creditors. The cumulative position is 90% and 89% respectively. Health transactions. Timing differences can account for the classification of liabilities as either Creditors or Accruals.
7.9 Summary Statement of Financial Position
A summary statement is given below showing the balances as at 31st March together with comparative information taken from the Trust’s Annual Plan.
6
10 Summary Statement of Financial Position (Balance Sheet)
Position as at 31st March 2011 Position as at 31st March 2011 Variance Variance Plan Actual Plan Actual Fav/ (Adv) Fav/ (Adv) £’000 £’000 £’000 £’000 £’000 £’000 Non Current Assets Liabilities Non Current Intangible 1,791 3,084 1,293 Provisions (292) (256) 36 Property, Plant and Finance Leases (6,142) (6,142) - 291,143 292,205 1,062 Equipment Liabilities Non Current (6,434) (6,398) 36 292,934 295,289 2,355 Totals Current Assets Inventories 5,898 7,178 1,280 TOTAL ASSETS 296,235 311,050 14,815 Current Tax Receivables 683 542 (141) EMPLOYED Trade and Other 21,748 17,580 (4,168) Receivables Taxpayers’ and Others’ Other Financial Assets 1,810 509 (1,301) Equity Prepayments 1,203 1,579 376 Public Dividend Capital 191,011 191,011 - Cash and Cash 30,807 53,014 22,207 Retained Earnings 26,420 35,554 9,134 Equivalents Donated Asset Reserve 11,827 12,984 1,157 Non Current Assets held - 1,470 1,470 Revaluation Reserve 66,892 71,416 4,524 for sale Other Reserves 85 85 - Assets Current Totals 62,149 81,872 19,723 TAXPAYERS’ 296,235 311,050 14,815 ASSETS TOTALS 355,083 377,161 22,078 EQUITY TOTALS Current Liabilities Deferred Income (7,408) (12,270) (4,862) Provisions (638) (784) (146) Current Tax Payables (6,561) (6,948) (387) Trade and Other Payables (21,321) (23,791) (2,470) Other Financial Liabilities (11,078) (10,497) 581 Other Liabilities (5,408) (5,423) (15) Liabilities Current (52,414) (59,713) (7,299) Totals NET CURRENT 9,735 22,159 12,424 ASSETS/(LIABILITIES)
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11 8. Cash and Cash Flow 9. Potential Financial Risk Indicators
The Trust held cash balances at the end of March of £53.014m. This is Monitor has identified 10 potential financial risk indicators. The Trust’s £22.207m greater than the plan of £30.807m. The graph shown below position against each of these is summarised below. provides a comparison of actual compared with planned month-end cash balances throughout 2010/11. The year-end cash balance is higher 9.1 Unplanned decrease in quarterly EBITDA margin in two than plan reflecting the slippage on the Trust’s capital programme, a consecutive quarters. higher than planned income and expenditure surplus for the year and improvements made in managing debtor and creditor balances.. UH Bristol reports an EBITDA margin of 9.0% compared with the Plan for the fourth quarter of 7.1%. The Trust has also Monthly Closing Cash Balance 2010-11 (£'m) achieved a cumulative better than Plan EBITDA performance 70 for the yea. 65 9.2 Quarterly self-certification by the Trust that the Financial Risk 60 Rating may be less than 3 in the next 12 months. 55 50 UH Bristol = The Board anticipates that the Trust will continue to maintain a financial risk rating of at least 3 over the 45 next 12 months. 40 35 9.3 Financial Risk Rating 2 (or less) for any one quarter.
30 UH Bristol = Not applicable. 25 Plan Actual 20 9.4 Working capital facility agreement includes default clause.
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar UH Bristol = The following default events are specified: failure to pay on the due date any amount payable pursuant to the The Trust has a working capital facility of £37.5m. This has been facility; any representation made that proves to be misleading agreed with Barclays Bank for an initial period of 2 years from 1st in any material respect; the borrower is unable to pay its debts; September 2010. The facility was not used in 2010/11. value of assets is less than its liabilities; the borrower ceases or threatens to cease operations or its operations become
8
12 unlawful; any legislation or regulation or official directive that 9.10 Capital expenditure outside the range 75 – 125% of Plan for the materially affect the Bank’s ability to recover the Loan. year to date.
9.5 Debtors over 90 days past due account for more than 5% of total UH Bristol = The Trust’s capital expenditure of £25.4m is debtor balances. equivalent to 81% of the Annual Plan forecast for the year. The Trust held a correspondingly higher cash balance at the year UH Bristol = 17% of the Trust’s total debtor balances exceed end to fund slippage on the 2010/11 capital programme where 90 days. A provision has been made for all potential bad or costs will be incurred in 2011/12. doubtful debts as at 31st March. The Trust has made good progress in resolving a number of long standing debtor issues over the second half of 2010/11. Further progress is anticipated 10. Other in the coming months to minimise debtor balances over 90 days. 10.1 Submission of Annual Accounts 9.6 Creditors greater than 90 days past due account for more than 5% of total creditor balances. The Trust submitted its Draft Annual Accounts and the Foundation Trust Consolidated Schedules (FTCs) by the designated deadline of UH Bristol =Not applicable. 5pm Thursday 21st April.
9.7 Two or more changes in Finance Director in a twelve month The Trust will submit its Audited Accounts, Audited FTCs, final text of period. the Annual Report and a copy of the Auditor’s final ISA 260 report by 5pm Tuesday 7th June. UH Bristol = Not applicable. 10.2 Foundation Trust Financing Facility Loan 9.8 Interim Finance Director in place over more than one quarter end. University Hospitals Bristol has secured an offer of a loan in the sum of £70m from the Foundation Trust Financing Facility to partially fund the UH Bristol = Not applicable. capital costs of the scheme to facilitate the centralisation of specialist paediatric services and the Redevelopment of the BRI. Take up of the 9.9 Quarter end cash balance less than 10 days of annualised loan is subject to approval by the Trust Board of the Full Business Case operating expenses. for the BRI Redevelopment project and completion of the Monitor due diligence process. The Full Business Case for the Centralisation of UH Bristol = Not applicable. Specialist Paediatrics was approved by the Board in March 2011. The loan is available for staged drawdown in 2012/13 and 2013/14.
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13 University Hospitals Bristol Extract of Targets and Indicators for Quarter 4 2010/11 NHS Foundation Trust Declaration of performance against healthcare targets and indicators for Q4 for BRISTOL
These targets and indicators are set out in Appendix B on page 45 of the 2010-11 Compliance Framework Key: input always required. input MAY BE required if relevant to your FT
Q4 Service 2010/11 CF Annual Plan Threshold Performance Targets as per Compliance Framework 2010/11 as amended June 2010 Weighting 2010/11 Q4 2010/11 Performance Score
Result Details (if required) Performance C.difficile year on year reduction enter your Board approved YTD target here> 180 1.0 No risk Achieved Trajectory: Q1 45, Q2 42, Q3 45, Q4 48 94 0.0
MRSA - meeting the MRSA objective enter your Board approved YTD target here> 9 1.0 No risk Achieved Trajectory: Q1 2, Q2 2, Q3 3, Q4 2 5 0.0
Anti Cancer Drug Treatments 98% 1.0 No risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 100.0%
All cancers: 31-Day Wait For Second Or Subsequent Treatme 94% 1.0 No risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 94.9% Surgery 0.0 Radiotherapy (from 1 January 2011) 94% 1.0 No risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 99.6%
From Consultant Screening Service Referral 90% 1.0 Declared risk Failed to Meet 2.5 breaches more than 90% standard for the quarter. 84.4% 1.0 All cancers: 62-Day Wait For First Treatment Urgent GP Referral To Treatment 85% 1.0 Declared risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 85.5%
Significant outbreak of norovirus put significant pressure on bed availability in 4 hours A&E wait from arrival to admission, transfer, or discharge 95% 0.5 No risk Failed to Meet January and February; 95% standard met in March. 94.2% 0.5
31-Day (Diagnosis To Treatment) Wait For First Treatment All cancers 96% 0.5 No risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 97.1% 0.0
All cancers 93% 0.5 No risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 95.6% Two week wait from referral to date first seen 0.0 For symptomatic breast patients (cancer not initially suspec 93% 0.5 Declared risk Achieved Cancer performance figures: Jan/Feb confirmed and draft for March 100.0%
Thrombolysis within 60 minutes (where this is the preferred local treatment) 68% 0.5 No risk Achieved No thrombolysis cases 100.0% 0.0
Elective screening performance shown. Performance for emergency Screening all elective in-patients for MRSA 100% 0.5 No risk Achieved admissions above the commssioned threshold of 90%. 100.0% 0.0 Follow up contact within 7 days of discharge 95% 0.5 No risk Not relevant 0.0% 0.0 Care Programme Approach (CPA) patients Having formal review within 12 months 95% 0.5 No risk Not relevant 0.0% 0.0
Minimising delayed transfer of care <=7.5% 1.0 No risk Not relevant 0.0% 0.0
Admissions had access to crisis resolution home treatment teams 90% 1.0 No risk Not relevant 0.0% 0.0
Meeting commitment to serve new psychosis cases by early intervention teams 95% 0.5 No risk Not relevant 0.0% 0.0
Data completeness: identifiers 99% 0.5 No risk Not relevant 0.0% 0.0
Data completeness: outcomes 50% 0.5 No risk Not relevant 0.0% 0.0
Ambulance FTs - Category A call – emergency response within 8 minutes 75% 1.0 No Risk Not relevant 0.0% 0.0
Ambulance FTs - Category A call – ambulance vehicle arrives within 19 minutes 95% 1.0 No Risk Not relevant 0.0% 0.0
Ambulance FTs - Category B call – a response within 19 minutes 95% 1.0 No Risk Not relevant 0.0% 0.0
Self certification against compliance with requirements regarding access to healthcare for people with a learning disability N/A 0.5 No risk Achieved Standards continue to be met. n/a 0.0
Moderate CQC concerns regarding the safety of healthcare provision N/A 1.0 No risk No n/a 0.0 Major CQC concerns regarding the safety of healthcare provision N/A 2.0 No risk No n/a Failure to rectify a compliance or restrictive condition(s) by the date set by CQC within the condition(s) (or as N/A 4.0 No risk No n/a 0.0 subsequently amended with the CQC’s agreement)
Does the Trust have outstanding compliance actions applied by the CQC ? No No 1.5
Does the Trust have outstanding enforcement actions applied by the CQC No No
Registration conditions imposed by Care Quality Commission No risk No conditions 0
Restrictive registration conditions imposed by Care Quality Commission No risk No conditions 0 1.5
1.5 0 Results left to complete Total Score 1.5
Overide Overide Overide Non- scoring rated override if overridden please explain why here Rating Reason Rating
10/11 Plan Governance risk rating AMBER-GREEN Indicative Governance risk rating AMBER-GREEN
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Item 9
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Quarterly Review of Progress against the Annual Plan
PURPOSE To inform the Membership Council of the progress against the Trust’s Annual Plan Objectives 2010/2011.
THE MEMBERSHIP To note the overall progress to date against the plan COUNCIL IS ASKED TO:
All objectives have been reviewed and generally good progress is reported against the objectives set at the beginning of the year. This report highlights those objective actions where a “red” rating has been made and outlines action plans to make progress with these.
Prepared by Amy Rich PA to Director of Corporate Development
Presented by Deborah Lee, Director of Strategic Development
4th May 2011
ANNUAL PLAN 2010/11
PROGRESS AGAINST CORPORATE OBJECTIVES – QUARTER 4 2011
INTRODUCTION
This covering paper and the attached action plan outlines the progress against the Trust’s Annual Plan Objectives for 2010/2011.
All Objective Action Plans have been reviewed and generally good progress is reported against the Corporate Objectives set at the beginning of the year. The report highlights those Objective Actions where a red rating has been made and outlines action plans to make progress with these.
UPDATE
The summary position is attached as Annex 1. The complete Action Plan with progress shown is attached as Annex 2. There are seventy-five individual performance measures within the plan. Three of these are currently rated by those responsible for implementation of the actions as “Red” issues – two within Improving Care for Patients and the Overall Patient Experience and the second within Becoming the Local Employer of Choice, as follows:
Improve Care for Patients and the Overall Patient Experience
Target To deliver at least upper quartile service efficiency across the Trust through the Making Our Hospitals Better programme
Progress Medical length of stay reduced during the first half of the year and by October 2010 was on trajectory to deliver the levels set within the Trust’s 5 year bed strategy which underpins the BRI development business case. However, from November onwards, length of stay has been adversely affected by norovirus and emergency pressures. Viewed across the year as a whole, there was a small (0.1 day) reduction in length of stay for both emergency and elective patients during 2010/11 compared with the previous year.
Target All staff are aware of their child protection responsibilities and are appropriately trained
Progress Improvement in safeguarding children training compliance remains too slow to improve, resulting in a declaration of non compliance with CQC Outcome 7 (this also includes safeguarding adults training)
A new 8 week safeguarding children training recovery plan has been developed and approved, to achieve the target that 80% of staff are compliant with their required level of training.
Compliance figures, including lists of staff non compliant, are now monitored weekly, reviewed through TOG and within Divisions.
Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 1 of 30
To become the local employer of choice
Target Enhance the Trust’s internet and intranet sites ensuring it is an effective and accessible recruitment tool.
Progress Mentor Digital is working on this project and work is progressing well. The new and improved website will be launched by June 2011
CONCLUSIONS AND RECOMMENDATIONS
The Trust Board is asked:
• To note the overall progress to date against the plan • To review in detail all objectives shown as Red or Amber on the plan and confirm that remedial plans are considered adequate or request further action.
Prepared by:
Amy Rich, PA to Director of Strategic Development
Presented to the Trust Board by: Presented to the Membership Council by: Deborah Lee Xanthe Whittaker Director of Strategic Development Deputy Director of Strategic Development
Annual Plan Objectives 2010/11 – Review of Actions January 2011 Page 2 of 30
ANNEX 1 - Annual Plan Overview
Red Amber Green Total Improve Care for Patients and the Overall Patient Experience 2 5 13 20 To work with Partners to Deliver Better Patient Care 0 2 4 6 To use our resources as efficiently as possible 0 1 3 4 To increase the capacity and impact of Research and Development 0 0 7 7 To provide high quality teaching and training 0 2 9 11 To become the local employer of choice 1 4 14 19 To improve functions that support patient care 0 0 8 8 3 14 58 75
To improve functions that support patient care
To become the local employer of choice
To provide high quality teaching and training Red
To increase the capacity and impact of Research and Development Amber
To use our resources as efficiently as possible Green
To work with Partners to Deliver Better Patient Care
Improve Care for Patients and the Overall Patient Experience
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
ANNEX 1 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 3 of 30
ANNEX 2 Annual Plan Objectives 2010/11 Review of Actions April 2011
Section 1: To improve care for patients and the overall patient experience Section 2: To work with partners to deliver better patient care Section 3: To use our resources as efficiently as possible Section 4: To increase the capacity and impact of research and development Section 5: To provide high quality teaching and training Section 6: To become the local employer of choice Section 7: To improve functions that support patient care
1. To improve care for patients and the overall patient experience
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PE01 Implement robust accountability framework March 2011 COO Accountability framework Meet the service standards designed and implemented from mandated in national May 2010. Responsibility frameworks and agreed in local transferred to Director of Strategic contracts at a minimum Development in October 2010 and framework will be reviewed as part of Governance and Assurance review led by Trust Secretary.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 4 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Deliver agreed action plans March COO Action plans implemented for 4 2011 hours, cancer and 18 weeks. Trajectories submitted to Monitor in January achieved in full at the end of the first quarter. 4-hours 98% standard achieved in quarters 1 and 2. The national standard has now been reduced to 95%. The new standard was met for Q3 but failed for Q4 Cancer standards All standards with the exception of breast 2-week wait achieved in the first quarter. All standards forecast to be achieved in the second quarter. All standards met with the exception of 62 day GP screening
18-week Referral to Treatment Times targets achieved at an aggregated level in quarters 1 and 2. Although 18-week performance is no longer scored by Monitor, the Trust continues to meet the specialty level standards set by Monitor of two or fewer specialties, for each of the admitted and non-admitted standards, not achieving the 90 and 95% target for the quarter. 18 week Referral to Treatment targets continued to be achieved in Q3 & Q4
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 5 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Revise actions as required March COO As above 2011
1011/PE02 Implement action plan for reduction of length Phase one MD Medical length of stay reduced To deliver at least upper quartile of stay, Productive ward and theatre September during the first half of the year and service efficiency across the programmes 2010 by October 2010 was on trajectory Trust through the Making Our Phase 2 to deliver the levels set within the Hospitals Better programme March 2011 Trust’s 5 year bed strategy which underpins the BRI development business case. However, from November onwards, length of stay has been adversely affected by norovirus and emergency pressures. Viewed across the year as a whole, there was a small (0.1 day) reduction in length of stay for both emergency and elective patients during 2010/11 compared with the previous year.
Productive Theatres has already succeeded in bringing in an additional 42 sessions per month through eliminating cancelled sessions
Productive ward programme has been moved across to fall under the Quality strategy as it has no material productivity gain
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 6 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PE03 Implement Quality Committee and Deliver Committee MD 2009/10 Quality Account published To demonstrate the improving work programme of the committee April 2010 to stipulated timescales. Positive quality and effectiveness of external (Audit Commission) and clinical services across the Trust Work plan internal audits. and report this publicly in a Delivery Updated DH guidance published Quality Account March 2011 December 2010 – draft QA has been produced and will be reviewed by April Board. A new Quality and Outcomes sub- committee of the Board will meet for the first time on 27th April 2011. 1011/PE04 Implement planned programme to continue to Programme CN 5 cases recorded for year. Focus To reduce further the incidence reduce MRSA bacteraemias to within stretch approved by will continue in 2011/12 to of healthcare-acquired target ie no more than 6 hospital acquired Board April maintain the reduction. infections cases in year. 2010 with ongoing delivery.
Outcome of no more than 6 at the end of March 2010.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 7 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Implement planned programme to continue Programme CN 94 cases were reported in 2010/11. reduction in C Difficile infections. Hospital approved by All targets set nationally and acquired C difficile cases to below 0.28 per the Board by locally were achieved despite not 1000 bed days ie no more than 72 cases in achieving the challenging internal April 2010 year. target. A programme of work has with ongoing been developed with the aim of delivery. achieving no more than the national target (64) in 2011/12 Outcome of no more than 72 at end of March 2010. Implement planned programme to reduce all Programme CN There has been a reduction of all hospital acquired bacteraemias by 25% on approved by MSSA blood cultures (hospital cases from previous year (exact number to be Board by acquired and on admission) from confirmed). 105 in 2009/10 to 90 in 2010/11. April 2010 For MSSA bacteraemias that are with ongoing being used as a marker in line with delivery. the newly required national reporting there has been a reduction Outcome of from 86 in 2009/10 to 73 in no more than 2010/11 (a reduction of 15%). A previous year programme for a 20% reduction of at end of MSSA bacteraemias in 2011/12 has March 2011. been developed.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 8 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Maintain same sex accommodation standards Ongoing CN From January 1st to 31st March monthly 2011the number of breaches has monitoring been 64. The causal factors are the pressure on capacity to meet the demands of ED attendances and transfer into MAU and STAU. There has been further guidance from the DH to have totally eliminated mixed sex accommodation by March 31st 2011. The new standard to eliminate mixed sex accommodation was set from April 1st. The Board agreed non compliance and accepted an action plan to expand MAU. From August 1st it is anticipated that the only breaches recorded will be clinical exceptions agreed with commissioners.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 9 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Implement planned programme to reduce Programme CN As previously noted in updates the catheter associated urinary tract infection approved by Nursing and Midwifery Committee (High Impact Actions for Nursing and Board by agreed that monthly monitoring of Midwifery) to below 2 per 100 admissions. catheter infections would not be April 2010 introduced as surveillance had with ongoing shown a low rate of infection. delivery. Practice in insertion and management of urinary catheters continues to be monitored monthly and compliance remains at 96% Outcome of and 95% respectively. There have no more than been no MRSA bacteraemias previous associated with urinary catheters in years at end 2010/11. of March 2010.
Implement programme of planned educational Ongoing CN Compliance in training from activities to ensure compliance to statutory monthly February 2011 has exceeded the infection control updating over 90% monthly. monitoring 90% standard. This will be maintained in 2011/12 through continued delivery of training sessions and focus on identification of non-attendees.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 10 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PE05 To participate in the South West Quality and Deliver key MD Recent regional review scored 2 in To improve patient safety in Patient safety improvement Programme improvement line with required progress for this hospital targets as set stage of the project. Improvement has been made in at least 3 out of out in the the 5 pilot populations. Spread plan by plans for initial pilots are March 2011 identified. Next step achievement is to show improvement in all 5 pilot populations with sustained improvement in at least 1 pilot population.
A Trust objective for 2011 is to also raise awareness about the work streams with all trust staff and involve more staff in each individual work stream. This will be achieved by key individuals attending the Consultant Away Day, proposed Patient Safety Grand Rounds and also internal World Café Events within the work stream areas.
A separate Leading Improvement in Patient Safety (LIPS) programme has commenced in the Bristol Children’s Hospital using similar improvement methodology but with measurements targeted at this patient population.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 11 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PE06 All staff are aware of their child protection Ongoing - CN Improvement in safeguarding To ensure that every child in responsibilities and are appropriately trained. Training children training compliance hospital is protected from harm Strategy and remains too slow to improve, resulting in a declaration of non Matrix to be compliance with CQC Outcome 7 reviewed (this also includes safeguarding March 2010. adults training)
A new 8 week safeguarding children training recovery plan has Training been developed and approved, to compliance achieve the target that 80% of staff figures are compliant with their required monitored level of training. monthly/ quarterly Compliance figures, including lists of staff non compliant, are now monitored weekly, reviewed through TOG and within Divisions. National Vetting and Barring (including ISA) Ongoing - DW CRB fully implemented. guidance is fully implemented and audited Monitored as annually. part of ISA on hold. Confirmation from DH received, Recruitment awaiting further guidance. and Selection Policy, by Human Resources.
Robust child protection policies and Ongoing CN Safeguarding Children Policies and procedures are maintained. procedures available via intra net, updated regularly / as required.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 12 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Governance for child protection. Including Robust CN Safeguarding Review from Ofsted participation in Serious Case Review process system for the and Care Quality Commission and implementation of action plans, and child monitoring of report overall rated good. September 2010. 20010/11 Death Review process and including all Safeguarding annual report for monitoring of near misses. Safeguarding 2011 due June. Incidents to be developed Individual Management Review for (Nov 2010) Serious Case Review of Child M (Bristol) within specified time frame. Individual Management Review Serious Case for Serious Case Review of Child Review N (S Glos) due to be submitted mid action plans Feb 2011. reviewed Serious Case Review action plans quarterly. monitored quarterly by Women and Children’s Division Child
Protection operational Group, Child Death overseen by Safeguarding Children Steering Group. Review
Process fully Child Death Review process implemented, continues. Second Annual report reports to be published. sent to Child protection Team (March 2010)
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 13 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status NICE Maltreatment Guidance is fully Ongoing CN NICE guidance available on implemented across the Trust and incorporated intranet. Self audit completed. To into mandatory training. Some continue to be highlighted through specific training. Audit completed ‘one year targeted post implementation, (within the awareness CED), action plan formulated.
training to be New NICE Guidance for Looked completed After Children to be included in (Sept 2010) annual audit plan for 2011.
Make significant progress in reducing the Ongoing - CN Implementation of Contact Point risk of multiple sets of notes. Working has been suspended. Awaiting Group further information regarding national records system. continues to
work towards NHS Bristol Commissioners mitigating leading work in relation to the city risks and wide plan for the introduction of reviewing Care Plus. implementati on of Care Briefing/ Update paper on safeguarding issues and medical Plus and records to be submitted to the Contact Point Board May 2011. 2010/2011
Confirmed implementation of action plan Outstanding CN Quarterly activity reports produced recommendations from Healthcare actions for Commissioners and Local Commission ‘SWIFT REVIEW’. incorporated Safeguarding Children Boards
into Safeguarding Children 2011 / 2012 Safeguarding work plan monitored by Children Safeguarding Children Steering Work Plan Group and Care Quality Committee 2010/ 2011 quarterly.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 14 of 30
2. To work with partners to deliver better patient care
Objective Actions Delivery: Owner Risk RAG Progress/Next Steps Ref Status 1011/CQ01 To implement the Trust’s Patient & Public Ongoing CN Post-discharge inpatient survey, To increase the level of patient Involvement Strategy for 2010-12. throughout ward exit cards, and targeted hard- and public involvement in 2010-11 held surveys all implemented. service improvement Patient Experience Action Plans in place. Funding approved by Above and Beyond Appeal for Year 2 of strategy: continuation of inpatient methodologies and extension into Outpatients.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 15 of 30
Objective Actions Delivery: Owner Risk RAG Progress/Next Steps Ref Status 1011/CQ02 To successfully rollout e-discharge across the December COO Rolled-out to 90% of Trust wards To reduce delays in Trust and monitor performance via GP survey. 2010 at the end of September, ahead of communicating with referrers schedule. Roll out completed in about the care of their patients October 2010. Audit in December and to improve the quality of 2010 showed over 75% of information provided discharges were already on the e discharge system at that stage. Continue to promote and monitor.
1011/CQ03 Work with Primary Care Trust and Social Ongoing COO Trust is closely engaged with NHS To work with health and social Care to improve patient discharge and reduce Bristol urgent/emergency care care partners to redesign unnecessary attendances at Emergency demand management plan and services for patient benefit Department. Healthcare at Home plan through the project board. End of Life care coordination in place. Rapid Response service now in place and GPSU extended, to support early discharge, with full cover 24/7 except bank holidays. The Emergency Action Steering Group has been refocused with a comprehensive action plan to address front door issues/ patient flow and discharges.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 16 of 30
Objective Actions Delivery: Owner Risk RAG Progress/Next Steps Ref Status Ensure plans and management of transition to DSD Work streams established to ensure the South Bristol Community Hospital are safe and timely transfer of robust. rehabilitation services. Concerns regarding future model of care and impact on transferring workforce remain and work in train with Bristol Community Health and commissioners to address all outstanding issues.. Detailed workforce information due late April, impact assessment will be completed by end of June 2011. Governance oversight held by SBCH Steering Group 1011/CQ04 Co-ordinate responses to commissioner and March 2011 DSD Teenage and Young Adults To achieve designated provider network designation processes for relevant Principal Treatment centre status for key specialist services services, including paediatric cardiac surgery, designation awarded to UH Bristol. paediatric neurosurgery, and cancer services. Paediatric Cardiac Designation in public consultation. UH Bristol in all four options. Neurosurgery designation now commenced with culmination planned for Spring 2013. 1011/CQ05 Develop an engagement plan and establish September DSD GP Marketing and Engagement To engage primary care mutual priorities and key communication 2010 Plan approved at March TEG. GP practitioners in service channels. Education and Training pilot improvement and design approved for launch May 2011. GP Commissioning / Heads of Division engagement meetings established.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 17 of 30
3. To use our resources as efficiently as possible
Objective Actions Delivery: Owner Risk RAG Progress/Next Steps Ref Status 1011/OE01 To work closely with the divisions to support March 2011 COO Programme Steering Group To deliver the agreed cash and identify plans and co-ordinate corporate established in February 2010 to releasing efficiency savings programmes. replace the CRES Steering Group. plans Key work streams at Divisional and corporate level identified. Corporate work-streams have delivered targets with the exception of the Productive beds and Non pay work-streams. A total of £20m out of £22.8m CRES savings is currently forecast but with a forecast carry forward deficit (including new cost pressures) of £7m (still under review). 2011-2012 CRES programme is currently £7m short of a target of £25m and still under review. 1011/OE02 Agree Key Performance Indicators and create July 2010 COO Divisions now using standard To design a performance and roll out a dashboard to support the reporting template for reporting management and reporting accountability framework performance to their Boards and at framework aligned to the monthly review meetings with the objectives of the Trust that Director of Finance and Chief engages clinical staff in service Operating Officer. This includes all improvement key national and local performance indicators. 1011/OE03 / OE04 Develop service-line management reports June 2010 DF Continued improvement on To refine financial management, showing key financial and non-financial accuracy of patient level cost. income recovery and information Key Performance Indicators. Ongoing programme of procurement systems improvement. Develop ‘Manage Self-Service’ access to core March 2011 DF On hold pending agreement of financial systems. process in the Trust
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 18 of 30
4. To increase the capacity and impact of research and development
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/RD01 Implement e-discharges system to provide October 2010 DF In hand – completed before To improve information systems GPs with prompt patient discharge summary. Christmas 2010. in the Trust to enhance patient Refresh desktop for Trust with up to date October 2010 DF Completed care software. Continue implementation of EDS PAS October 2010 DF Completed improvements. 1011/RD02 To chair and co-ordinate the delivery of the March 2011 DSD Centre now operational. Formal To open a Clinical Research project plan. opening 14th February 2011. Imaging Centre at St Michael’s Hospital
1011/RD03 Continue progress towards delivery of March 2011 MD FSF funding call complete and 10 To collaborate with University integrated research programme across Bristol awards made. BRU renewal due partners in successful bids for summer 2011. Grants facilitation research programme funding manager commences employment 31st January 2011 1011/RD04 Participate and inform the BRIG-R October 2010 MD BRIG-H leadership groups have To develop a Bristol-wide approved continuation of work to research vision and Review as planned with NHS and Academic establish a Bristol AHSC. infrastructure partners 1011/RD05 Realise the benefits from the investment in March 2011 MD Review of SMART achievements To formalise academic SMART and investments by research partnerships committee May 2011.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 19 of 30
5. To provide high quality teaching and training
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/TT01 Scope out initial leadership programme for June 2010 DW Programme scoped and piloted To develop and deliver a ‘standards for managers’. November 2010. Top 150 leaders leadership programme across programme to roll out in 2011/12 the organisation Develop leadership competencies. May 2010 DW The KSF competencies have been further developed and mapped against the Leadership Qualities Framework for roll-out alongside the leadership programme. Leadership programme reflects competency and capability requirements for leaders. Further refinement of competencies taking place Q1 2011/12 following piloting Develop pilot leadership programmes which July 2010 DW Base programme scoped and underpin identified competencies. piloted November 2010. Competency paper going to Execs in April 2011 which will support the further development of additional programme elements and support the ‘standards for managers’ Rollout programme. September DW Pilot programme completed 2010 November 2010. Top 150 leaders programme to commence in 2011/12
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 20 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Continue with existing management Ongoing DW Management developed has been development programme for middle managers. signed off as mandatory in September 2010. 1232 managers attended our 10 People Management training modules in 2010. People Management courses being reviewed April to July, new and revised courses available in September
1011/TT02 To deliver a new Teaching and Learning Structure DW Structure identified and awaiting To enable colleagues to achieve structure and action plan which will include identified – review as a part of the Teaching to the best of their abilities training planning and a complete review of April 2010. and Learning strategy re-write. infrastructure in order to deliver Strategy principles have been presented to the Board and full development will be presented to TEG on 13th April, and to the Board on the 28th April.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 21 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Structure DW Structure identified and awaiting implemented review as a part of the Teaching July 2010. and Learning strategy re-write. Strategy principles have been presented to the Board and full development will be presented to TEG on 13th April, and to the Board on the 28th April. Spans and Layers methodology has commenced in the corporate function with a plan to deliver revised central structure by the end of June 2011.
In addition, a detailed finance review and project plan has been conducted as agreed with the Board; this will also help determine the future work streams for teaching and learning.
Training DW The training planning process Planning going forward is an integral part of process the Teaching and Learning Strategy. Strategy principles have agreed for been presented to the Board and 2011/2012 – full development will complete December March 2011. 2010. Training planning process for 2011/12 will remain unchanged but outcomes will be reassessed in light of the strategy review. 1011/TT03 Review training delivered in 2009 and existing Ongoing to DW Complete To enhance personal service packages. April 2010 skills, particularly in front line
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 22 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status staff Devise training package and ensure accredited April 2010 DW All NVQ packages include unit for NVQ, customer service-rollout. customer service units and accreditation - complete Roll-out to audiences agreed by Trust May 2010 – DW Programme rolling out to front line Executive Group. September staff. The programme has now 2010 been delivered to 179 staff in 2010/11. A review of customer service and the ‘offer’ is being conducted in April 2011.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 23 of 30
6. To become the local employer of choice
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/EC01 KSF promotion programme implemented July 2010 DW KSF has been further developed To ensure that all employees linking competencies more closely to job along with the appraisal policy. understand and maximise their expectations and performance management. Communication and roll out to contribution to the work of the continue throughout the year. Trust Performance Scorecard developed for use in September DW Board performance reporting talking to all employees about Trust 2010 updated and will be used to report performance. performance to staff – communications still need to be refined Cascade processes for future objectives May 2011 DW KSF has been further developed developed and integrated into performance along with the appraisal policy. management. Communication and roll out to continue throughout the year. Performance management roll out for 2011 to include objectives cascade from operating plan.
1011/EC02 Produce recruitment plans in line with Commence DW Recruitment plan for 2010/11 fully To attract and retain high calibre 2010/2011 workforce plans. 2010 resourced. Workforce plans for staff 2011/12 developed as part of operational plans, due for completion May 2011.
Plan open days and external recruitment Ongoing DW Delivered as required in response to events responsive to the workforce needs. recruitment needs. Complete
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 24 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Develop creative and innovative campaigns in Ongoing DW Ongoing as required. ITU response to specific recruitment needs such as expansion recruitment campaign to the existing work with Pharmacy and commence in Jan 2011. Theatres. Theatre recruitment campaign has completed and removed the need to use agency staff. Develop a strong recruitment brand in line June 2010 DW New Trust values have been with the new Visions and Values for the Trust. incorporated into all recruitment correspondence, Job descriptions and Contracts of employment. Advertising template to be designed for external professional press purposes New advertising template for all external press marketing is now live reflecting the Trust values, as do all adverts on NHS Jobs Enhance the Trust’s internet and intranet sites June 2010 DW Mentor Digital is working on this ensuring it is an effective and accessible project and work is progressing recruitment tool. well. The new and improved website will be launched by June 2011 Respond to the 2009 Staff Survey developing Commence DW Staff survey results presented to appropriate and meaningful plans with robust action TEG, HR, the Board and the Health action driven outcomes. planning and Wellbeing Group.
March 2010. Results linked to patient survey for Actions plans the first time. to be in progress with Trust level actions built into HR effect from review process. May 2010.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 25 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/EC03 Refresh the Trust’s Valuing Diversity Strategy April 2010 DW Single Equality Scheme will wrap To embed equality and diversity and other associated Equality and Diversity up all of these actions. Paper will into all aspects of Trust business documents and develop clear action plans. go to Trust Board March 2011. Scheme replaced by Equality Delivery System. Board approved moving to the new system. Equality and Diversity to form part of April 2010 DW Equality and diversity measured Divisional Performance Reviews and Division through staff survey and other Board reporting and Trust business planning. means. Equality and Diversity steering group set up to involve and assess performance across divisions in place of at Divisional Reviews Develop further actions for the Single Equality September DW Some aspects of the scheme have Scheme, which enhance patient care. Use 2010 already been extended and these new actions to consult with the public, developed using public and patient involvement. This will continue patients and key stakeholders. with the refresh of the scheme through to April 2011. Equality Delivery System implementation being led across local groups by the Trust. Ensure all Trust policies/functions and Ongoing DW Not all new policies have an EIA. services have an Equality Impact Assessment A compliance reporting process has (EIA). been agreed with the Company Secretary in February 2011 which will sort this issue over time. Conduct an Equality and Diversity training October 2010 DW Training needs analysis needs analysis to support all managers and commenced and initial paper staff. presented. Further work underway. Will link in with the Trust’s Learning and Development Strategy Appoint a full time, fixed term Respect for All April 2010 DW Complete Programme Manager.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 26 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/EC04 Develop leadership competencies. May 2010 DW The KSF competencies have been To develop a framework of further developed and mapped competencies that will support against the Leadership Qualities succession and career planning Framework for roll-out alongside the leadership programme. Further refinement of competencies to take place in Q1 2011/12 Develop career pathways. December DW The talent matrix for band 8a and 2010 above has been completed (December 2010). This will drive career pathways. Career pathways to be linked to refined competencies 2011/12 Create talent management pool. March 2011 DW The talent matrix for band 8a and above is being completed October 2010-December 2010. Band 7 and below to commence in the 2nd quarter of next year. Pool needs to be communicated and integrated into Trust development activity (see below). Develop talent centre for the Trust for all March 2011 DW The talent matrix for band 8a and succession and talent planning. above is being completed October 2010-December 2010. Band 7 and below to commence in the 2nd quarter of next year. This will now be used to proactively target people for development and as the focus for all Talent and succession planning.
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 27 of 30
7. To improve functions that support patient care
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PC01 To agree a plan to improve the environment March 2011 COO 1599 Range of capital projects To invest in the Trust’s estate, in patient and public areas. prioritised and being rolled out particularly in the patient under the scrutiny of the Capital environment, and to improve Prioritisation Group. physical access to services for Specific programmes of work in patients and visitors BHOC (Refresh), BDH (new lift). BRI programme includes ITU upgrade and refurbishment of wards 5abc, 12 and 15. These schemes are completed Continue to work closely with the Governors March 2011 COO 1461 Case for extending the Cabot and local transport services to improve Circus free bus service made and access to the Trust. funded by Above and Beyond. Service now implemented and extended to St Michael’s Hospital. Usage is increasing. Review has slipped to end of January 2011. 1011/PC02 Continue to support the development of ‘The March 2011 COO £300k capital programme of To reduce the carbon footprint Big Green Scheme’ in the Trust. improvements being progressed. of the Trust as part of the 5- Energy / Sustainability manager in year Carbon Management post. Green Champion training Programme continuing (over 200 volunteers), First quarterly energy performance report completed and reviewed by TOG and TEG. Trust registered for the Carbon Reduction Commitment Energy Efficiency Scheme (CRC). Continuing to deliver the requirements of the European Union Environmental Trading Scheme (EU-ETS).
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 28 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status 1011/PC03 Establish a consistent brand that reflects the July 2010 CE The ratio of positive : negative To enhance the positive life and work of the Trust through positive stories was 8 : 1 for Quarter One. reputation of the Trust and balanced media coverage. internally and externally, Highlights of coverage included: through proactive consultant ophthalmologist Phil communications, and celebrate Jaycock joining the BEH to set up the successes of staff a new unit – treating both NHS and private patients – offering laser surgery for the effects of diseases affecting the cornea. Health minister Paul Burstow visiting the BRI to meet patients and staff as part of a campaign to highlight the symptoms of bowel cancer. The BRHC cardiac unit chosen as one of the UK’s leading paediatric cardiac centres recommended in all four options of the Safe & Sustainable review, prior to consultation. The unveiling of the £1.6 million redesign and refurbishment of the BHOC, made possible by the fundraising of Above and Beyond and Friends of the BHOC. And Dr Andrew McIndoe featured on Sky News training medical students using role play and high tech dummies in the Trust’s Simulation Centre
ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 29 of 30
Objective Actions Delivery Owner Risk RAG Progress/Next Steps Ref Status Develop communication channels and May 2010 CE The Loud & Clear research has processes to embed the Trust’s vision and concluded and is in the process of values in the organisation. being evaluated. An action plan will be developed, which will be incorporated into the Communications Strategy and Plan 1011/PC04 Submit full Business Cases for Trust Board December DSD BRI redevelopment scheme on To take forward the approval for the: 2010 track, Full Business Case to Board redevelopment of the Bristol for approval in April 2011. Royal Infirmary and the • redevelopment of the Bristol Royal Scheme completion summer 2014. centralisation of specialist Infirmary Major risk relating to capital children’s services in Bristol funding now resolved, residual risk relates to underlying strength of LTFM.
Submit full Business Cases for Trust Board December DSD FBC approved in February 2011, approval for the: 2010 subject to loan funding being secured and BRI FBC being signed • Centralisation of specialist children’s off in April 2011. On track for services at the Bristol Royal Hospital Spring 2014 opening in line with plans for Frenchay. Revised for Children planning permission submitted with no anticipated problems. 1011/PC05 To conduct a strategic review for long term September DSD Strategic Framework for Clinical To review long term service service priorities 2010 Services approved at march Board. priorities Plenary event May 2011.
Key: CE Chief Executive CN Chief Nurse & Director of Governance COO Chief Operating Officer DSD Director of Strategic Development DF Director of Finance DW Director of Workforce & Organisational Development MD Medical Director ANNEX 2 Annual Plan Objectives 2010/11 – Review of Actions April 2011 Page 30 of 30
Item 10
MEMBERSHIP 4th May 2011 COUNCIL MEETING TITLE Draft Annual Plan 2011/12 - Update
PURPOSE Update report for information THE MEMBERSHIP The Membership Council is asked to note the current status of COUNCIL IS ASKED the annual planning round and the timetable for completion TO:
1. Context
This paper summarises the status of the 2011/12 annual planning round, next steps and key dates for delivery. The focus of this report is on the requirements for a published Annual Plan, which must be submitted by 31st May 2010 to Monitor.
2. The Membership Council is asked to:
To note the current status of the annual planning round and the timetable for completion.
Prepared by: Ben Hume, Head of Strategy & Business Planning
Presented by: Deborah Lee, Director of Strategic Development
Item 10
Annual Planning 2011/12 Trust Board Briefing Paper
1. INTRODUCTION
This paper summarises the status of the 2011/12 annual planning round, next steps and key dates for delivery. The focus of this report is on the requirements for a published Annual Plan, which must be submitted by 31st May 2010.
The 2010 Coalition Agreement states that the overall NHS budget will be protected, although it is expected that acute hospitals will be a focal point for spending constraint in the coming years. In October 2010, annual planning guidance was issued to Divisions and corporate departments.
The focus of the planning round is to determine how recurrent internal savings (CRES) will be made to support reduced tariff income and balanced Operating Plans. The planning period will be 3 years, with a focus on the first (2011/12).
Monitor (the independent regulator of Foundation Trusts) has now made clear its requirements for the Trust’s Annual Plan.
2. ANNUAL PLAN REQUIREMENTS
2.1 Annual Plan requirements
The Monitor Compliance Framework was published on 31st March 2011. This document sets out the approach that Monitor will take to assess the compliance of NHS Foundation Trusts with their Terms of Authorisation in 2011/12. The document also states that the Trust must submit an Annual Plan for 2011/12, including the following items:
• Annual Plan commentary; • Membership Report; • Board statement on risk, service performance, clinical quality, compliance with Terms of Authorisation and Board roles, structures and capacity; • Financial projections; • Annual update to Schedule 2 (mandatory goods and services) and Schedule 3 (mandatory education and training).
2.2 Templates
The templates issued by Monitor are brief and place value on the succinct expression of future Trust plans. These are designed to ensure that the Board and Governors have properly considered requirements for good planning to underpin the provision of high quality patient care. 2
Item 10
The commentary will be contained in a “Strategic Plan” Word document and the financial and all other aspects of the Annual Plan (including Membership and Board declarations) in a “Financial Plan” set of Excel work sheets. Appendix 2 details the structure of these.
Monitor does not require Trusts to produce any other Annual Plan documentation, although the content of the Strategic Plan will later be used to produce an accessible summary of Trust plans.
2.2 Assessment and review
Monitor has made clear a two-stage process for the review of Annual Plans, similar to that of 2010/11:
• Stage 1: Applies to all Foundation Trusts and will comprise an assessment by Monitor of risks to Authorisation. Based on the outcome of Stage 1, Monitor will decide whether further review is required, by the end of July 2011. • Stage 2: For Trusts that are identified in Stage 1 as requiring further review, Monitor will engage in a more detailed analysis of risks from August 2011 onwards.
The aim is to produce an Annual Plan that does not warrant a second-stage review.
3. APPROACH TO THE ANNUAL PLAN
The Trust Board approved the organisation’s approach to 2011/12 annual planning on 27th October 2010. Annual planning guidance was subsequently issued to Divisions and corporate departments and the planning process was initiated. The Trust Board was briefed of progress at its meetings of 27th January 2011 and 28th March 2011.
Requirements of the Annual Plan include approval by the Trust Board and assurance that consultation with the Trust’s Membership has taken place, principally through the Membership Council and the Governors’ Strategy Group. The Annual Planning process has been discussed at each of the Governors’ Strategy Group meetings since September 2010 and at two Governor seminars held during winter 2010/11.
A timetable and responsibilities for the completion of the Annual Plan documentation have been agreed (see Appendix 1 and 2). Included within Appendix 1 are dates for future Trust Board approval and Membership Council consultation.
3.1 Current status and key dates
Progress towards Divisional Operating Plans has been led since autumn 2010 through key work streams, as outlined at previous Trust Board meetings. Operating Plans are a key contribution towards the overall Annual Plan, giving assurance that the Trust’s strategic objectives can be delivered through a devolved structure.
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Item 10
Key future dates are outlined in Appendix 1; including final submission of the Annual Plan on 31st May 2011. Responsibilities and the Annual Plan document structure are outlined in Appendix 2.
The current phase of work is focused on the completion of final draft Annual Plan documentation, for review by the Executive team in the week commencing 2nd May 2011 and by Non-Executive Directors in the week commencing 9th May 2011. A further briefing reports will be presented to the Membership Council of 4th May 2011 ahead of the Annual Plan’s presentation to the Trust Board at its meeting of 26th May 2011.
All Annual Plan work will draw from the Clinical Services, Teaching & Learning and Research & Innovation strategies, as approved by the Trust Board at its meetings of February and March 2011.
4. CONCLUSION
Within a new financial environment, this year’s Trust annual planning process takes account of known or predicted changes.
The Annual Planning process has been discussed at each of the Governors’ Strategy Working Group meetings since September 2010 and at two Governor seminars held during winter 2010/11.
These processes contribute to the Trust’s Annual Plan for 2011/12, which must conform to templates recently set by Monitor. The final Annual Plan will be presented to the Trust Board in late May 2011, in accordance with the attached timetable.
The Membership Council is asked to note the current status of the annual planning round and the timetable for completion.
Ben Hume Head of Strategy & Business Planning
4
Appendix 1: Annual Plan 2011/12 – Document Timetable
Month Deliverables Date Responsibility 1st Draft Strategy Templates complete 8th April Head of Business Planning Progress Review w/c 11th April Head of Business Planning nd st April 2 Draft Strategy Templates to Executive Team 21 April Executives Annual Plan Briefing to Governors' Strategy Group 26th April Head of Business Planning Review of Templates and Commentary 28th April Head of Business Planning Briefing to Trust Board 29th April Director of Strategic Development
May Briefing to Membership Council 4th May Head of Business Planning Progress review with Executive Team 5th May Executives Final Draft review w/c 9th May Executives, Non-Executive Directors Final Draft Annual Plan to Trust Board 26th May Director of Strategic Development Submit Annual Plan to Monitor 31st May Head of Business Planning
Page 6 of 7 of an Cover Sheet for Report for a Trust Board Meeting, to be held on 28 April 2011 at 10:30 in Tutorial Room4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE
Appendix 2
Project Responsibilities - Strategic Plan - Word template (Part 1 of 2)
Section Section Title Lead Exec Sub -heading Nominated Lead 1 Strategy Deborah Lee 1.1 Trust Current Position and Vision Ben Hume 1.2 Trust Strategy (3 years) Ben Hume 1.3 Key Priorties and Milestones Ben Hume
2 External envrionment Deborah Lee 2.1 Key External Impacts Ben Hume
3 Financial Commentary Paul Mapson 3.1 Summary of current financial state Paul Tanner
Trust Plans (financial 4.1 4 plans) Paul Mapson Financial plans - income Paul Tanner 4.2 Key Income Risks Paul Tanner 4.3 Service Development priorities Ben Hume 4.4 Key Operating Efficiency programmes (Table A) Dean Bodill 4.5 Other Savings / Efficiencies (Table B) Dean Bodill 4.6 Workforce (Key Priorities) Heather Toyne 4.7 Key Capital Expenditure priorities Andy Headdon 4.8 Quality issues and measures Chris Swonnell 4.9 Clinical Plans - commentary Chris Swonnell 4.10 Other Strategic Priorities Ben Hume
5 Regulatory requirements Alison Moon 5.1 Key regulatory risks Anne Reader
6
Page 7 of 7 of an Cover Sheet for Report for a Trust Board Meeting, to be held on 28 April 2011 at 10:30 in Tutorial Room4, Education Centre, Upper Maudlin Street, Bristol, BS2 8AE
Leadership and 6.1 6 Governance Steve Aumayer Key leadership and governance priorities Charlie Helps 6.2 Board of Governors (how they have been engaged) Charlie Helps
Project Responsibilities - Financial Plan and Schedules 2 & 3 (Part 2 of 2)
Tab Title Nominated Lead Notes 1 thru 17 Finance Paul Tanner 18 Workforce Heather Toyne 31 Membership Charlie Helps Single document 32 Governors Charlie Helps 33, 34 Finance Risks & Declarations Paul Tanner 35 Board Statements Charlie Helps Schedule 2 (Mandatory Services) Paul Tanner Separate sheet Schedule 3 (Education & Training) Paul Tanner Separate sheet
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Item 11
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Histopathology Inquiry PURPOSE For discussion and voting THE MEMBERSHIP Vote on whether UH Bristol Governors wish to support COUNCIL IS ASKED TO: this forum
1. Context
A Foundation Trust Member has requested that Governors support their intention to establish a public forum to challenge the Histopathology services at UH Bristol in light of the recent Histopathology Inquiry.
2. The Membership Council is asked to:
Discuss and vote on whether UH Bristol Governors wish to support this forum.
Prepared by: Liz Corrigan, Public Governor North Somerset and Governor Representative
Presented by: Liz Corrigan, Public Governor North Somerset and Governor Representative
Date 4th May 2011
1
Histopathology Inquiry
1. Background - Request by a Foundation Trust member to establish a public forum – vote on whether UH Bristol Governors wish to support this request
We have been corresponding with this member for some time now and at her request four Governors met with her in February this year (Liz Corrigan, Neil Auty, Mo Schiller and Anne Skinner with Maria Fox and Charlie Helps in attendance). The letter with its attachments from the member (following this meeting) asking the Governors to support a public forum (set out in point 14 of the letter) have been circulated to all Governors for comment and to date there have had none.
The request was taken to the Governors Informal Pre Agenda meeting on 21 March where 16 Governors were present. They all agreed that a lot of work had been put into the document and this should be commended. Although the Governors present made a decision it was decided to take it to this Council Meeting to give all Governors the opportunity to vote on the matter.
2. Supporting information showing where public scrutiny and patient involvement are already in place
a) The Histopathology Inquiry Report is published and on the website for all to see. b) The Local Authority Scrutiny Commission is updated and poses questions. The NHS, the Trust and PCT presented a paper at the meeting on 16 March 2011. c) The progress of the action plan is discussed at open Trust Board Meetings, where Governors and the public are present. d) The Care Quality Commission and Monitor are regularly updated e) The Trust’s Public Involvement Project team has set up focus groups (including cancer and non-cancer patients) to explore for example: • What a patient’s understanding of histopathology is • What assurance patients look for when considering the quality of care offered by a Histopathology Service • How patients want to be involved in the on-going development of Histopathology at UH Bristol f) A sub-group of the Governors’ Quality Working Group which will provide assurance from the Trust of the delivery of the action plan. This allows Governors to question the progress of the inquiry’s recommendations and they will know how and when things have changed. In this way the Governors will be satisfied of continuing improvement.
It should be noted that any Foundation Trust member can approach Governors with concerns which will be taken seriously by the Governor who will direct them through the appropriate channels. Also, it does not require the Governors support for a member to set up a public forum. The Trust also has a position on this matter and if the Governors wish this can be presented.
3. The Question is:
3.1 Taking all of the above into account, are the Governors satisfied that there is already sufficient public scrutiny and patient involvement to reassure them and their Constituents that the Inquiry recommendations are being followed through and to have confidence in the Histopathology Service?
3.2 Or, do you wish to further strengthen the assurances in place? If so, would a forum be appropriate, and, is it constitutionally supported? 2
Item 12
MEMBERSHIP 4 May 2011 COUNCIL MEETING TITLE Preparation of the Annual Report 2010/11 - Update
PURPOSE For information.
THE MEMBERSHIP • Receive the report on the preparation of the Annual Report COUNCIL IS ASKED 2010/11 TO: • Note the timescale of the process • Note the requirement to include statements of compliance with the Foundation Trust Code of Governance in the Annual Report for 2010/11 • Note the content of narrative on Membership and the Membership Council in the annual report.
1. Introduction
NHS Foundation Trusts are required to publish an Annual Report each year. This report is published in the public domain after first being assessed by the Trust’s Auditors, submitted to Monitor, and laid before Parliament.
The content of the Annual Report and Accounts is prescribed in the NHS Foundation Trust Annual Reporting Manual 2010-11 (28 February 2011) which sets out the financial reporting requirements for 2010-11. The non-financial reporting requirements were published as Chapter 7 on 31 March 2011 following the conclusion and evaluation of Monitor’s consultation exercise on these requirements.
The Accounts will include: • a statement of the Accounting Officer’s responsibilities • a statement on internal control • the auditors’ opinion • main statements; and • notes
As a minimum the Annual Report will include: • a directors’ report, including a management commentary • a remuneration report • disclosures set out in the Foundation Trust Code of Governance • other disclosures in the public interest.
More detail on the content of the Annual Report is provided at Appendix A.
2. Timetable
The timetable for preparation and submission of the Annual Report is as follows:
Page 1 of 5 • Thursday 21 April – Draft Annual Accounts and Draft FTC Schedules sent to Monitor and the External Auditor
• Tuesday 26 April – Final text of the Annual Report sent to External Audit (for comparison to Annual Accounts, as above)
• Friday 03 June – The annual report and accounts formally approved by the Trust Board of Directors
• Tuesday 07 June – Audited accounts, Audited FTCs, Final text of the annual report, A copy of the signed audit opinion on the accounts, A copy of the auditor’s report on the FTCs, A copy of the auditors’ final ISA (UK&I) 260 report, Original, signed Statement on Internal Control; and Original, signed Chief Executive’s and Finance Director’s certificate on the FTCs – all posted to Monitor
• Thursday 30 June – Lay Annual Reports and Accounts before Parliament: Full annual report and full statutory accounts (bound as one document), to be posted to the Parliamentary Clerk’s office for laying before Parliament and copied to the Department of Health
• Wednesday 20 July –Full annual report and full statutory accounts emailed to Monitor: a copy to be sent electronically for inclusion in the NHS Foundation Trust Directory on Monitor’s website.
3. Membership Council
The following documents will be presented to the Membership Council at a general meeting on 27th May 2011.
• the annual accounts • any report of the auditor on them; and • the annual report
Prepared by: Charlie Helps, Trust Secretary
Presented by: Charlie Helps, Trust Secretary
Page 2 of 5 Item 12 Appendix A
Content of UH Bristol Annual Report narrative to cover 2010/11 as set out in Monitor’s NHS Foundation Trust Annual Reporting Manual 2010-11 (28 February 2011, amended 31 March 2011)
Chairman’s statement Directors’ Report Business Review A fair review of Trust’s business including description of principal risks and uncertainties Balanced and comprehensive analysis of the development and performance of the Trust Position of the business at the end of the financial year Information about environmental matters and impact of Trust on the environment Information about Trust employees Information about social and community issues Information about commissioners and other partners essential to the Trust’s business Analysis of Key Performance Indicators (KPIs) - national targets, core standards, compliance framework, contractual, financial Analysis of KPIs in relation to environmental matters Analysis of KPIs in relation to employee matters Directors report on consolidated accounts Elements of FT Code of Governance Remuneration report Disclosure of Senior Employees (Directors and Non-executive Directors) remuneration and pension entitlements Remuneration report, referencing relevant notes to the accounts, signed by CEO Remuneration Committee details: members, number of meetings and attendance, name of any advisors whether directors or others Statement of policy on remuneration of Directors and explanation of methods to assess performance, explanation and breakdown of performance related elements of remunerations. Summary and explanation of policy of duration of contracts and notice periods and termination payments Details of service contracts for each director including date of contract, unexpired term and notice period, provision for compensation and other details for early termination. Explanation of significant awards made to past directors Table of remuneration for directors to include: Salaries and allowances If a payment under an approved Compensation Scheme has been made Estimation of other benefits in kind Total remuneration package for current and previous years
Page 3 of 5 Any non-financial remuneration Pension disclosures (requested from the NHS Business Services Authority) FT Code of Governance specifics Statement of how the Trust applies the main supporting principles of the code Statement of “comply or explain” in relation to the code Membership Council Disclosures Statement of how the Board of Directors and Membership Council operate including high level decision making Composition of the Membership Council, list of governors, how appointed/elected, term of office, any election details Statement of number of meetings of Membership Council and individual attendance Register of interests of held by governors Statement of steps taken by the Board, to understand the views of governors and members Board of Directors Names of Chair, Deputy Chair, and Senior Independent Non-Executive Director dates of appointment and term of office. Name of Chief Executive and composition of Board of Directors Names of any independent Non-Executive Directors Number of Board and committee meetings and attendance Description of NED terms of office and how terminated. Board members profiles Statement about Board balance, completeness and appropriate membership Summary of how Board, committee and directors performance evaluation has been conducted Register of interests of held by directors Statement of other significant commitments of the Chairman Audit Committee Names of Chair and committee members Number of meetings and attendance Description of work of committees in discharging their responsibilities Confirmation that governors approved the appointment of the Audit Commission as external auditors for 2010/11 Narrative on Trust’s policy for ensuring external auditors independence has not been compromised Explanation from Directors of their responsibility for preparing the accounts Statement from the auditors about their reporting responsibilities Nominations Committee Names of Chair and members of Nominations Committee
Page 4 of 5 Number of meetings and individual attendance Description of work of the committee in including process for Board appointments Membership Description of eligibility, constituencies and boundaries for public membership Numbers of members and number of members per constituency Summary of membership strategy, membership profile and steps taken to achieve representative membership Contact procedure for members to communicate with governors and directors Other disclosures in public interest Action taken by Trust to maintain or develop the provision of information to and consultation with employees Trust policies in relation to disabled employees and equal opportunities Information on Health and Safety Information on Occupational Health Information on counter fraud policies and procedures Statement describing the better payment practice code or any other policy relating payment of suppliers Details of any consultations in previous year or planned for 2010/11 Consultation with local groups and Overview and Scrutiny Committees for Bristol, North Somerset and South Gloucestershire Local Authorities. Patient and Public Involvement activities Best practice other disclosures Performance against better payment practice code 30 day requirement Management costs Number of additional pension liabilities in relating to early ill health retirement Detailed disclosure of other income in notes to accounts where significant HM Treasury FREM requirements Sickness and absence Statement that the Trust has complied with the cost allocation and charging requirements in HM Treasury guidance Details of Serious Untoward Incidents involving data loss or confidentiality breach Statement of Accounting Officers responsibilities (model statement in FREM) Statement on Internal Control (model statement in FREM) Quality Objectives Details of quality objectives and performance against those in the annual plan
Page 5 of 5
Item 13
MEMBERSHIP 4th May 2011 COUNCIL MEETING TITLE Draft Quality Account 2010/11
PURPOSE For comment and to agree arrangements THE MEMBERSHIP Comment on the content of the Quality Account and agree COUNCIL IS ASKED arrangements for making a formal statement. TO:
1. Context
This is the third annual Quality Account produced by the Trust.
The purpose of the Quality Account is to report on progress against the Trust’s stated quality objectives for 2010/11 and to set out its ambitions for quality in 2011/12.
Members of the Governors Quality Working Group have been involved in determining both the structure and content of this year’s report.
The Membership Council is required to make a formal statement about quality, for inclusion in the final version of the document.
2. The Membership Council is asked to:
a) Comment on the content of the Quality Account.
b) Agree arrangements for making a formal statement.
Prepared by: Chris Swonnell, Staff Governor
Presented by: Chris Swonnell, Staff Governor
Item 14
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Care Quality Commission Registration Update
PURPOSE For Information
THE MEMBERSHIP Note the content of the report. COUNCIL IS ASKED TO:
1. Context
The Membership Council is asked to note that the Trust has formally declared non-compliance to the CQC in relation to Outcomes 7 (Safeguarding) and 11 (Equipment). This is in addition to Outcomes 5 (Nutrition), 14 (Supporting Staff) and 21 (Records), which have previously been declared as non-compliant and currently remain as such.
A declaration was made to the CQC on 13th April 2011 with the agreement of both Executive and Non-Executive Directors. The decision was confirmed at Trust Board on 28th April. The Trust has been given until 4th May to provide recovery plans explaining what action will be taken, and how patient safety will be ensured in the meantime.
2. The Membership Council is asked to:
Note the content of the report.
Prepared by: Chris Swonnell, Assistant Director for Audit and Assurance and Staff Governor
Presented by: Chris Swonnell, Assistant Director for Audit and Assurance and Staff Governor
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Care Quality Commission Registration update
Declaration of non-compliance with Outcomes 7 (Safeguarding) and 11 (Equipment)
In March 2011, the Trust Board received a quarterly report regarding compliance with Care Quality Commission key standards for safety and quality (‘CQC Outcomes’).
This report stated that the Trust would be giving further consideration to Outcomes 7 (Safeguarding) and 11 (Equipment) before reaching a definitive recommendation about compliance. In the case of Outcome 7, Quarter 4 data for safeguarding training was awaited, whilst for Outcome 11, the conclusions of a detailed review of compliance needed to be considered. This evidence has now been received and reviewed.
The Executive Directors held an extraordinary meeting on 22nd March 2011, at which compliance with all 16 Judgement Framework Outcomes was considered. The consequent recommendations of the Executive were discussed at the Audit and Assurance Committee on 12th April 2011.
In summary, the conclusion of Executive and Non-Executive Directors is that the Trust is non-compliant with five CQC Outcomes, as follows, for the reasons stated:
Outcome Primary reason for non-compliance 5 - Nutrition We need to confirm recent improvements in nutritional screening and observed protected mealtimes. 7 – Safeguarding We need to meet our 80% target for safeguarding training compliance. 11 - Equipment We require assurances that staff training needs for the use of medical equipment are routinely identified, and that training takes place. We need better records of the equipment managed by Divisions (i.e. non-MEMO equipment) 14 – Supporting Staff We need to confirm recent improvements in appraisal compliance, and ensure safeguarding training compliance as per above. 21 – Records We need to improve assurances about clinical records keeping. We also need to address the Trust’s current red rating for Information Quality and Records Management (Information Governance Toolkit)
This position was formally advised to the CQC on 13th April 2011. Outcomes 5, 14 and 21 were already declared as non-compliant and subject to actions plans. Outcomes 7 and 11 are newly declared as non-compliant.
The Trust has agreed to provide the CQC with detailed action plans by 4th May 2011.
Author: Chris Swonnell, Assistant Director for Audit and Assurance
Date: 13th April 2011
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Item 15
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Appointment of Governor Representative PURPOSE For approval THE MEMBERSHIP Approve the appointment of the Governor COUNCIL IS ASKED TO: Representative
1. Context
In July 2009, the Membership Council approved the process to select their Governor Representative and the role profile (appendix 1). The profile has been updated to reflect the shortened title to ‘Governor Representative’ and the ‘Trust Secretary’.
Elizabeth Corrigan has carried out this role from 1 June 2010 and is not seeking re-election as a governor when her term of office ends on 31st May 2011.
Therefore the agreed process for the governors to select their Governor Representative has been instigated during March and April 2011.
2. Nomination Process
Nomination papers were sent to all governors on 14 March 2011 and the deadline for receipt of nomination forms was 04 April 2011.
The outcome of the nomination process for the role of Governor Representative is one nominee, Neil Auty.
3. Election Process
Under the rules outlined in the paper submitted to the Membership Council in July 2009, only one nominee has been put forward, therefore no voting is required.
4. Ratification
As the only nominee, Neil Auty will be put forward as Governor Representative for ratification at the Membership Council on 4th May 2011.
5. The Membership Council is asked to:
a. Approve the appointment of Neil Auty as Governor Representative for a term of 12 months from 1 June 2011 to 31 May 2012. b. Note that Monitor will be informed of the Trust’s “Lead Governor” .
Prepared and presented by: Charlie Helps, Trust Secretary
4th May 2011
Page 1 of 3 Item 15 Appendix 1 GOVERNOR REPRESENTATIVE
1. Introduction The Governor Representative for University Hospitals Bristol NHS Foundation Trust (“the Trust”) will be a Governor elected by the Membership Council to act as a spokesperson on behalf of all Governors.
2. Role, Purpose and Duties a. The Governor Representative will act as the spokesperson for the whole of the Governor group or an individual Governor if appropriate. This would also apply where there was contact with external organisations such as Monitor. Contact with external bodies and individuals shall be conducted in accordance with the Governor Code of Conduct. The role of the Governor Representative is intended to be an additional resource to all of the members of the Membership Council. b. The generality of the stated duty in “a.” above will not in any way invalidate the rights and responsibilities of any other Governor in the Trust. c. The Governor Representative may call for support from other Governors, the Chairman, the Trust Board of Directors, the Trust Secretary and the Membership Manager to enable the role to be carried out effectively. d. If the Trust Board Chair and Trust Board Deputy Chair are both unable to attend a formally convened Membership Council meeting, committee meeting or general meeting, the Governor Representative will chair the meeting. If none of the above is in attendance, Governors may invite another Governor present to the Chair. e. The Governor Representative will chair the meeting to review the appraisal process for the Trust’s Chairman at the relevant Nominations and Appointments Committee. If the Governor Representative is not a member of that committee, the committee will invite him/her to chair the appraisal meeting. f. Represent the views of Governors at the annual review of the Trusts Constitution. g. Present an overview of the work of the Governors at the Trust Members Annual Meeting. h. Help to co-ordinate Governors’ activities and facilitate the process of obtaining a Governor consensus on Trust matters after consultation. i. Working with the Trust’s Chairman and Trust Secretary to develop open communication between Governors and the Trust Board. j. Liaise with the Sub-group Chairs and, where possible, attend meetings of each Sub- group. k. Liaise with the Trust Secretary in setting of the Membership Council Agenda. l. Support the development of Governor skills, a strong Membership Council and a raised public awareness of the Governor role in conjunction with the Membership Manager, Trust Secretary and the Chair of the Trust.
3. Election Process and Appointment to Office Election shall be conducted using a formal written nomination process with nomination forms sent to every Governor followed by secret ballot if there is more than one nominee. Stages in the election process will be as follows: a. The Trust will send a nomination paper together with a copy of the purpose, duties and responsibilities description (as in Section 1) to each Governor.
Page 2 of 3 b. Governors may nominate themselves or one other Governor. In either case, they must obtain a seconder for their nomination and must return their nomination form to the Trust Secretary in accordance with the published timetable for election. c. If only one suitable Governor nomination is received the Governor nominated will be ratified at the next Membership Council meeting. d. If more than one nomination is received, the election will be determined by secret ballot of all Governors each having one vote. The elected Governor will be the one who receives the most votes. e. In the event of a tie, the Trust Chairman will have the casting vote. f. The election will be co-ordinated by the Trust Membership Office, scrutinised by the Trust Secretary and authorised by the Trust Chairman. g. After the election process the Trust Chairman will ask the next meeting of the Membership Council to ratify the election of the successful candidate. h. When a Governor Representative vacancy arises as a result of the end of a term of office, the Governor Representative resigning or not being able to continue before the end of the elected term, the Chairman will invite expressions of interest for nomination to the role from the Trusts Governors. The election process will then proceed as from “b.” above.
4. Term of Office a. The elected Governor will serve for a period of 12 months (unless terminated early as in 3.h. above). After this period, the election process as outlined in Section 3 above will be put in motion. It is possible for the same Governor to be re-elected for further terms if Governors elect to do so. b. The Governor Representative may step down from the role at any time by mutual agreement with the Trust Chairman. c. The Governor Representative will be required to step down in the event of a majority vote of no confidence at a Membership Council meeting.
Originally prepared by: Anne Skinner, Heather England, Andrew Yerbury and Clive Hamilton with the help of Liz Corrigan, Mo Schiller and Anne Reader, 16 July 2009
Updated by: Charlie Helps, Trust Secretary, March 2011
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Item 16
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Review of the Constitution of University Hospitals Bristol NHS Foundation Trust
PURPOSE For discussion and approval
THE MEMBERSHIP • Note the content of the report and discuss the COUNCIL IS ASKED TO: recommendations, giving particular consideration to the proposal to make a change to the minimum age at which members may vote.
• The Membership Council is asked to consider and approve these recommendations for approval by the Trust Board of Directors on 26th May 2011 (and subsequent notification to Monitor).
1. Context
The Constitution of the Foundation Trust is required to be reviewed annually and any changes are either to be agreed at a joint meeting of the Trust Board of Directors and the Membership Council or by the Trust Board of Directors on the basis of an approval by the Board of Directors which shall first have consulted the Membership Council on each such proposal.
2. The Membership Council is asked to:
2.1 Note the content of the report and discuss the recommendations, giving particular consideration to the proposal to make a change to the minimum age at which members may vote.
2.2 The Membership Council is asked to consider and approve these recommendations for approval by the Trust Board of Directors on 26th May 2011 (and subsequent notification to Monitor).
Prepared by: Chris Swonnell, Assistant Director for Audit and Assurance and Staff Governor
Presented by: Chris Swonnell, Assistant Director for Audit and Assurance and Staff Governor
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Review of the Constitution of University Hospitals Bristol NHS Foundation Trust
Introduction The Constitution of the Foundation Trust is required to be reviewed annually and any changes are either to be agreed at a joint meeting of the Trust Board of Directors and the Membership Council or by the Trust Board of Directors on the basis of an approval by the Board of Directors which shall first have consulted the Membership Council on each such proposal.
Meeting of Governor working party A short-term working party of Governors met on 10th December 2010 to review the wording of the current Constitution. Members of the working party were Neil Auty, Jeanette Jones, Mo Schiller and Chris Swonnell. Aside from a number of minor points relating to presentation and terminology, the major point of discussion was the current minimum age of membership. The view of the working party was that the current minimum membership age of four years is not appropriate. This view was supported by the Youth Council. The working party discussed whether it would be more appropriate to set a higher minimum age of membership, in line for example with the age of criminal responsibility. The Youth Council provided examples of minimum membership ages adopted by other FTs, e.g. Birmingham (10), Manchester (11), Sheffield (14).
Meeting with Trust Secretary Chris Swonnell and Liz Corrigan subsequently met with the Trust Secretary, Charlie Helps, on 10th March to discuss with Governors’ review. The Trust Secretary was able to provide assurances that various aspects of the Constitution were indeed correctly worded. Agreement was reached that the items listed below should be put to the Membership Council as proposed amendments to the Constitution.
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Recommendation to the Membership Council
Page reference Proposed amendment in Constitution p5 Amend typographical error to read “Health Service Body” p26 Insert correct name of “Avon and Wiltshire Mental Health Partnership NHS Trust” p57 Add new paragraph 3.1.3 to the Standing Orders of the Membership Council as follows*: “If the Chair fails to call a meeting of the Membership Council after a requisition for that purpose, signed by at least one-third of the whole number of the Membership Council has been presented to him at Trust Headquarters, such one third or more members of the Membership Council may forthwith call a meeting.” p79 Para 5.8 of the Standing Orders of the Board of Directors to be amended to read as follows: “The Trust Board of Directors shall establish an Audit Committee, Nomination and Appointments Committee, and a Remuneration Committee as standing Committees of the Trust Board of Directors. In addition, the Trust Board of Directors shall establish such other Committees as it deems necessary and appropriate from time to time.” p81 Para 1.1.9 of Annex 9, Further Provisions Following discussion with the Trust Secretary, and in line with the views of the Youth Council, the working group’s original recommendation had been to establish a new voting age of 7 years, whilst enabling those aged 4-6 years to continue as non-voting members. Unfortunately, upon further exploration of the matter, there is no concept of a non voting member within the Foundation Trust framework. There are therefore two recommendations to the Membership Council:
1. That the minimum age of membership be increased to 7 years 2. That further consultation takes place with the Youth Council and stakeholders on the question of how best to involve those aged under 7 years old outside of formal membership
The Membership Council is asked to consider and approve these recommendations for approval by the Trust Board of Directors on 26th May 2011 (and subsequent notification to Monitor).
* During the course of the review, it was noted that amendments to the Constitution agreed at the previous annual review have yet to be notified to Monitor. These changes will therefore be incorporated with any changes agreed here by the Membership Council. It should be noted that the wording on p57 referenced above is in fact a clarification of a new paragraph requested following the previous review of the Constitution.
Author: Chris Swonnell, Staff Governor Date: 15th April 2011
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Item 17 MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Report from Governors Nominations and Appointments Committee PURPOSE For the Membership Council to be informed of the work of the Nominations and Appointments Committee. THE MEMBERSHIP • Receive the report on the work of the Nominations COUNCIL IS ASKED TO: and Appointments Committee • Approve the recommendation that the Chair and Non-Executive Directors remuneration remains unchanged for 2011/12. • Note the plan to repeat a Board appraisal exercise in Summer 2011. • Note the updated Nominations Committee work plan for 2011/12. • Note the Preparations for Non-Executive Director Recruitment.
1. Context
The governor Nominations and Appointment Committee has delegated responsibility from the Membership Council to keep under review the balance of skills, knowledge and experience of the Non-Executive element of the Board and accordingly appoint and decide terms and conditions (including remuneration) of the Chair and the Non-Executive Directors. The Committee makes recommendations the full Council for approval.
2. Nominations and Appointments Committee Report
The Committee met on 17 March 2011. Key points discussed were:
• Revision of the committee’s Terms of Reference • Planning for Trust Board Appraisal Exercise to take place in Summer 2011 • Preparations for Non-Executive Director recruitment to replace Selby Knox, whose term of office ends on 31 January 2012. • Annual review of Non-Executive Directors remuneration • Finalising the committee work plan for 2011/2012 (appendix 1)
3. The Membership Council is asked to:
3.1 Receive the report on the work of the Nominations and Appointments Committee 3.2 Approve the recommendation that the Chair and Non-Executive Directors remuneration remains unchanged for 2011/12. 3.3 Note the plan to repeat a Board appraisal exercise in Summer 2011. 3.4 Note the updated Nominations Committee work plan for 2011/12. 3.5 Note the Preparations for Non-Executive Director Recruitment to replace Selby Knox, whose term of office ends on 31 January 2012.
Prepared and presented by: Jeannette Jones – Partnership Governor representing the Joint Union Committee Page 1 of 1
Item 18a
MEMBERSHIP COUNCIL 4th May 2011 MEETING TITLE Membership Working Group Report
PURPOSE For information
THE MEMBERSHIP Receive the report from the Membership Working Group COUNCIL IS ASKED TO:
1. Context
This report is to keep all governors informed of the work being undertaken by the Membership Working Group.
2. Membership Working Group Members
The membership currently consists of:
Suzanne Green Chair, Patient Governor Jade Scott-Blagrove Public Governor Jacob Butterly Patient Governor Liz Corrigan Public North Somerset & Governor Representative Florene Jordan Staff Governor Kelvin Blake Non Executive Director Charlie Helps Trust Secretary Cathy Gane Young Person’s Involvement Worker Tony Watkin Public Involvement Project Lead Maria Fox Membership Manager Hayley Porter Project Co-ordinator, Communications
We are also actively seeking representation from the Strategy and Quality Working Groups to ensure strong lines of communication between all three groups.
3. Meetings
The Membership Working Group meets bi-monthly.
The next meeting is on Tuesday 10 May at 10am in the Finance Room, THQ.
4. The Membership Council is asked to:
Receive the report from the Membership Working Group.
Prepared and presented by: Suzanne Green, Chair and Patient Governor
4th May 2011
Page 1 of 5
Governor’s Membership Working Group
Held on Tuesday 15th March 2011
1. NOTES OF THE MEETING
Present: Liz Corrigan (Acting Public North Somerset & Governor rep Chair) Jacob Butterly Patient Governor - Local Jade Scott-Blagrove Public Governor Pam Yabsley Patient Governor - Local Anne Ford Public North Somerset Florene Jordan Staff Governor Charlie Helps Trust Secretary Tony Watkin Public Involvement Project Lead Amy Holgate Publication Officer Maria Fox Membership Manager
In attendance: Debbie Marks Membership Administrator (minute taker)
Item Action 1. Apologies & Welcome -
Apologies were received from Suzanne Green (Chair). Liz welcomed to the group Pam Yabsley (Chair for Quality Working Group) and Anne Ford (Chair for Strategy Working Group).
2. Notes of the Last Meeting held on 18th January 2011 -
The notes of the last meeting were recorded as an accurate record subject to the following amendment:
5.2 Hand held Surveys – Tony wanted to clarify the sentence ‘Tony stated that structurally Membership and PPI don’t presently work together’. This sentence meant that opportunities are there to work together better. Anne questioned CRB checking and Tony confirmed that all volunteers need to be CRB checked unless they are staff members or Governors who are already CRB checked.
3. Members Newsletter update –
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Item Action Amy Holgate (Publication Officer) updated the group regarding the Members Newsletter. Distribution of the Newsletter is on schedule for 5th April. Jacob’s story will be included in the next issue. The newsletter has recently been reshaped to enable copies to be distributed with ‘Voices’. Anne commented on the newsletter being in colour and the cost of these changes. Amy assured the group that these changes involve no additional costs.
Amy informed the group that the next newsletter will include a piece on Governor’s and how they have been making a difference – this could also include Trust Members.
Florene asked about Hayley’s suggestion from the last meeting regarding holding seminars for Staff to promote the Governor role. Amy had no update A. Holgate but will follow it up with Hayley. Liz suggested that Staff Governor’s write a piece on how their day to day duties fit in with their Governor role. Amy agreed and informed the group that the planning for May’s issue will commence in 3 weeks.
4. Terms of Reference – update
Charlie will present the updated Terms of Reference at the next meeting in C. Helps May.
5. Work Plan for 2011:
5.1 – T. Watkin to identify work streams and leads – Tony has done a scan of the top work steams.
Action – Tony will put this information into a table for the Governor’s. T.Watkin/ Debbie will distribute to the Membership Working Group when completed D. Marks ready for discussion at the next meeting
5.2 – Re-draft of Work Plan – Charlie will present this at the next meeting C. Helps in May.
6. Governor Elections 2011 – update
Maria updated the group regarding Governor Elections. Maria reported that Elections are on schedule and nomination papers have gone out. So far 2 election events have been held and another is planned for this week. Few forms have been received as yet so members will be contacted over the next couple of weeks ensuring there are nominees for each constituency. The current vacancies are - Carers of 16 years and under (letters have been posted to all carers) and Staff, Medical and Dental (only one nominee so far). All other areas have received enough nominees.
Maria continued that the next step would be getting members to vote. Liz inquired what happens if any vacancies aren’t filled. Maria explained that another election would be held if this happens and it would involve extra costs.
Page 3 of 5
Item Action
In response to a question from Anne, Maria clarified that the terms of office for all Governor’s is 3 years. The initial set up was 2 and 3 years, this was to enable Governor terms to be staggered so the Trust wouldn’t lose all Governor’s and their experience at the same time.
Charlie informed the group that letters have been sent to all eligible staff members to encourage nominees to come forward. Several Staff Members have raised issues with the cost of these letters being sent because home addresses were used. Charlie assured the group that it was done this way for fairness - Public members were sent letters through the post so it was only fair to inform staff members the same way.
7. Communications Programme of Events Update
The finalised Events calendar has been distributed to all Governor’s. Hayley Porter leaves in April and as yet there is no replacement.
Maria reminded the group that the Medicine for Member’s Event (Healthy Eyes) takes place on March 30th 6 – 7:30pm. A Consultant will be giving their time free to talk to members about the relevant specialty. Members have to book their place and there are currently 54 members attending. Liz discussed how Governor’s could identify constituencies and mentioned using coloured stickers. Tony suggested using different shaped stickers which would be better for any members with colour blindness.
Maria informed the group that the next event will be about Diabetes and is being held in June – more information to follow.
Liz pointed out Ovarian Cancer week. This commences Monday 28th March to Friday 1st April. Hayley has previously spoken to Governor’s about attending this event – Pam has offered to attend Wednesday afternoon.
Liz asked Florene if the Chief Executive’s staff meetings were well attended and highlighted the importance of Staff attending these meetings. Florene stressed the importance of all staff members being aware who Governor’s are - a point previously raised at the last meeting. Liz suggested that present Staff Governor’s meet and discuss how each of them fulfils their Governor role whilst carrying out their day to day work duties. Following the elections Charlie will be meeting with the new Staff Governor’s to discuss how the Governor role works - this would be an ideal opportunity for present Staff Governor’s to raise any problems or issues that need resolving relating to this and the importance of all Staff Governor’s supporting each other.
8. Creating Links with PCT:
8.1 – Web team links – Amy will chase any update and report back. A. Holgate
8.2 – PCT involvement/Links – Liz read an e-mail from Suzanne which asked whether this is the appropriate time to link with PCT’s as they will be
Page 4 of 5
Item Action changing in the future. Liz stated that it was and Pam agreed. Tony emphasised the importance of keeping abreast of development and informed the group that a Regional meeting on how Links is becoming Health Watch is being held in Exeter on 7th April.
9. Revolving Chair –
A note from Suzanne suggested that interested Governor’s would be Chair for 3 months and then revolve. Liz questioned if 3 months was long enough given that Membership Working Group meetings are held bi-monthly. Jacob suggested 4 months whilst Liz suggested 6 months. Tony raised concerns about losing consistency with a revolving chair whilst Pam reminded the group that members attend meetings therefore are aware of what’s happening.
Action – To be carried forward to the next meeting in May.
10. Youth Council Update –
Jade reported that the Youth Council are currently raising funds to re-design a room in the Orthopaedic department which is used for children. Jade is hoping for help from the Grand Appeal or Above and Beyond. The next Youth Council meeting is in April.
11. Reimbursement update –
Tony explained that this was a review of an existing policy. Tony confirmed it is not a HR issue neither is it appropriate for the Membership Working Group. The group agreed to remove this item from the agenda.
12. Fundraising update –
Liz had no updated information available for today’s meeting.
Liz and Pam informed the group they are both participating in a tandem sky dive in September with Above and Beyond for charities of their choice.
13. Any Other Business –
Tony mentioned the next survey training event is being held on Thursday 31st March at 10am in the Conference Room, THQ.
14. Next Meeting –
Tuesday 10th May 2011 at 10am -12pm in the Finance Room, THQ.
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Item 18b
MEMBERSHIP 4th May 2011 COUNCIL MEETING TITLE Quality Working Group Report
PURPOSE For information
THE MEMBERSHIP Receive the report from the Quality Working Group COUNCIL IS ASKED TO:
1. Context
This report is to keep all governors informed of the work being undertaken by the Quality Working Group.
2. Quality Working Group Members
Pam Yabsley Chair: Local Patient Governor Alison Moon Chief Nurse Jane Luker Acting Medical Director Anne Skinner Local Patient Governor Mary Hodges Local Public Governor Mo Schiller Local Public Governor Sian Evans Local Public Governor Jade Scott Blagrove Local Public Governor Wendy Gregory Carer Governor Lorna Watson Carer Governor Chris Swonnell Staff Governor/Assistant Director for Audit & Assurance Florene Jordan Staff Governor Belinda Cox Staff Governor Frank Palma Partnership Governor Jeanette Jones Partnership Governor
3. Meetings
The Quality Working Group meets on a bi-monthly basis.
4. Key Points
a) Histopathology Inquiry Alison Moon has suggested forming a Quality sub-group as a follow up to the Histopathology Inquiry in May. With expertise from the Board it would allow Governors to be kept informed of further developments and challenge decisions made.
b) Outpatient Appointments/Patient Experience We are continuing to do Governor Constituency meetings within Outpatient departments. The appointment system and transport are still an area of concern for patients. Waiting one and a half or two hours for an appointment at the BHI surely speaks of inefficiency within the system. Receiving three letters for one appointment
Page 1 of 8 Item 18b
leads to unnecessary confusion for the patient. These are just two examples of what has been seen in the past two weeks.
How close is the Trust at addressing these issues? We are hoping to invite a member of GWAS to our next Quality meeting together with a Transport Manager to try and identify why there are problems with patient transport.
c) Pharmacy We realise much work has been undertaken to address problems surrounding patient medication both as an inpatient and as an outpatient. As Governors we welcome these changes and look forward to positive feedback from patients.
d) Hand Held Surveys - Based on issues raised by the Care Quality Commission (CQC) Committee. We are involved and welcome the opportunity to engage with patients to capture the “true” patient experience.
e) Quality Account 2010/2011 – Choice of Performance Indicators Chris Swonnell informed the Quality groups that Monitor usually mandate three indicators but this year there are only two – the third is to be chosen with Governor’s involvement. Chris is in the process of identifying what this should be.
f) Nutrition Helen Bishop presented to the group how by using a new assessment tool nutrition can be improved in all adult wards. The Children’s hospital has their own assessment tool.
g) Dementia Helen Morgan presented a paper to the group entitled ‘Improving Care for People with Dementia or Mild Cognitive Impairment while in Hospital’. There is a huge amount of work being undertaken.
The minutes of the last meeting are also attached for information.
5. The Membership Council is asked to:
Receive the report from the Quality Working Group.
Prepared and presented by Pam Yabsley, Local Patient Governor
4th May 2011
Page 2 of 8 Item 18b
Quality Working Group
Held on Tuesday 22nd February 2011
1. NOTES OF THE MEETING
Present: Pam Yabsley (Chair) Local Patients Governor Anne Skinner Local Patients Governor Mo Schiller Public Governor Frank Palma Partnership : Voluntary Group Governor Wendy Gregory Carers of patients 16 years and over Governor Florene Jordan Staff Governor Chris Swonnell Staff Governor Mary Hodges Public Governor Jade Scott- Blagrove Public Governor Jeanette Jones Joint Union Committee Governor Alison Moon Chief Nurse
In attendance: Liz Corrigan Public North Somerset & Governor Rep Debbie Marks Membership Administrator (minute taker)
Item Action 1. Apologies
Apologies were received from Jane Luker and Lorna Watson.
2. Notes of the Last Meeting – 10th December 2010
The notes of the last meeting were agreed as an accurate record.
Outpatients - Pam updated the group re Outpatients and the Transformation team. Lots of patient information has been gathered from visits. This information will be collated and presented at the next Membership Council Meeting on 4th May.
Quality Walk Rounds - Pam informed the group that these were very good and exactly what the Governors were after. This information was relayed to Robert Woolley.
Events calendar – Mo is meeting with Hayley Porter today. The Walk Round dates for the year will be included in the Events Calendar. V. Goodwin/ Action - Vicki/Debbie will distribute a copy to the Governors. D. Marks
Page 3 of 8 Item 18b
Item Action 3. Matters Arising:
3.1 – Transport – Frank reminded the group that this was an offer of someone from PCT to join a Quality meeting to speak to the group. Jeanette said that she was in contact with Sharon Hinsley (Partnership, Great Western Ambulance Trust) about speaking to the Quality group.
Action – Jeanette to contact Sharon Hinsley. J. Jones
3.2 – Hand Held Surveys - Pam informed the group that not many Governors are volunteering to do Hand held surveys. Mo stated that she has recently offered 4 dates but isn’t given enough notice of the confirmed date. Liz has offered just one date and has had no problems. Alison informed the group that non-clinical staff are now being trained by Tony Watkin to do hand held surveys. Wendy asked the length of time required and the answer was 2 hours.
The current theme for hand held surveys is ‘Compassion on the ward’.
Action – Chris will speak to Tony regarding prompt confirmation of dates. C. Swonnell Tony will be invited to the next Quality meeting on 5th April. D. Marks
4. Update and agree Terms of Reference – Chris will re-draft the Terms of C. Swonnell Reference and present at the next meeting.
5. Work Plan for 2011 – Pharmacy: Steve Brown, Director of Pharmacy, joined the group to discuss Pharmacy. Steve informed the group that: • Pharmacy consists of 5 different dispensaries, plus Callington road, and 3 technical services. • £36 million of public money is spent on medicines and approximately 350 prescriptions are dealt with daily. • The ‘Lean Programme’ is underway and is helping to improve efficiency and wastage. • The Bristol Royal Infirmary (BRI) dispensary deals with BRI, Bristol Haematology & Oncology Centre and discharge prescriptions for Bristol Children’s Hospital. • The focus is to achieve a 2 hour turn-around – this is 2 hours from when the discharge prescription enters pharmacy to when it is delivered to the ward. Pharmacy’s aim is to achieve 90% in the 2 hour target – this has proved beneficial. • Wards are now using the Electronic Discharge Letter (EDL) system. This includes the discharge letter as well as a list of medications needed on discharge. The GP receives a copy in less than 48 hours. Pharmacy found increased pressure during the roll out of this new system. An extra 5-7 minutes was required for each prescription with no extra staff. The performance prior to the introduction of EDL was 70%. This dipped to 40-50% after the roll-out which was partly due to robotic problems and the EDL system. Since the summer 2010 the performance percentage has increased, it was 74% in January 2011
Page 4 of 8 Item 18b
Item Action and for February is just above 90%. Performance has increased due to several reasons: the EDL system, a co-ordinator post being implemented in pharmacy and screening of all prescriptions. Also, Dosette boxes have been outsourced to Lloyds pharmacy because they are time consuming to prepare. These are turned around in 24 hours and Lloyds pharmacy currently prepares 8 a day for the BRI. • Future changes include: a) having a community pharmacy onsite. The Trust would save 1.2 – 1.6 million on VAT if this happened because the community pharmacy wouldn’t have to pay VAT. It would also benefit the patient because they would be able to collect their prescriptions from their local pharmacy. BRI pharmacy would still deal with inpatient prescriptions, the community pharmacy would deal with all outpatient ones. b) Working towards patient self administration. c) patient/pharmacist relationship needs to improve. Pharmacy technicians need to introduce themselves to patients and answer any questions where possible and also informing patients of any changes to their medicines.
Pam agreed that having a community pharmacy onsite would be very beneficial and will take a lot of pressure off pharmacy.
In response to a query from Frank, Steve assured the group that pharmacy technology works well. Discharge planning should start when a patient is admitted to a ward and Steve has provided each ward with discharge planning guidance sheets. A new web track system is also currently being used and helps to track every step through pharmacy to when a porter delivers the drugs to the ward. The web track system will feed into a big screen on a wall in pharmacy. The screen will be put up in a couple of weeks and Steve welcomed any Governor’s who wished to visit pharmacy and have a look. Alison agreed that it would be a very useful visit for Governors.
Liz drew attention to the fact that patients don’t know the system and asked when it is a pharmacy problem. Steve replied that it is pharmacy’s fault when- a script isn’t turned around in 2 hours, if a script is lost, if someone signs off the wrong script, computer or robotic problems and staff shortages/sickness.
Steve receives approximately one written letter of complaint per month which he investigates. Liz asked how many of these written complaints were pharmacy’s fault to which the answer was 50%. Alison agreed that although patients wait a long time for their medication it’s not always pharmacy’s fault – as discovered when comment cards are investigated. Steve has asked all heads of nursing, and Patient Involvement Committee, to send any relevant comment cards to him and he will investigate them.
Wendy agreed that there has been increased improvement but reminded the group that sometimes the last thing a patient (who’s been ill and possibly frightened) wants to do is write a letter of complaint. Wendy also stressed the importance of junior Doctors giving patients all the facts regarding the discharge process and wait times.
Both Wendy and Mo raised concerns of oncology patients waiting for Page 5 of 8 Item 18b
Item Action extreme lengths of time for their drugs. Steve agreed that in the past a few were missed and ensured the group that day patients in oncology now go through a different stream through pharmacy which has improved these problems.
Jeanette stressed her support for Steve and his team. Pharmacy has been very pro-active and it’s been the investigation element that has identified not all complaints is actually pharmacy’s fault.
Anne raised the issue of drugs being left on the wards’ reception desk and not being dealt with straight away. Steve worked with dispensary last Friday and identified a potential issue which the new computer system should help with.
Action - Steve will speak to the pharmacy porters regarding this matter. S. Brown
6. New Admission Policy/ High Impact Actions – Jeanette ran through the High Impact Action document which was distributed at the last meeting (copies will be sent to those who didn’t receive it). The key pointers are: keeping skin in good condition, staying safe – preventing falls, keeping nourished, promoting normal births, important choices – where to die when the time comes, fit and well to care, ready to go – discharge and protection from infection. This document is being used as a teaching tool for staff to improve delivery of care and encourages patient independence.
Pam raised an issue with nutrition. The result of a postal survey showed that one third of patients didn’t receive the help they needed at meal times. Pam has been informed that this issue is being addressed.
Mo drew attention to a dispatches programme on television regarding nutrition in hospitals and that a patient’s relative was allowed to visit at meal times to help feed the patient. Alison agreed with this idea. Protective meal times has been ruled out across all wards within the BRI so patients have uninterrupted time to eat but this should also be flexible to allow carers in to help feed relatives that need it.
Alison mentioned a report that has been published this month called ‘Care and Compassion’ by the Parliament and Health Service Ombudsman. The website address for this report is www.ombudsman.org.uk . This report will be discussed in more length at the next meeting and Alison will provide latest A. Moon statistics for the group.
Alison also informed the group about the Care Quality Commission and said that in March/April there will unannounced nurse-led inspections in over 100 Trusts in England. They will be looking at compassion, dignity and nutrition.
7. Quality Accounts – update from steering group meeting on 24th January 2011 – Chris presented the minutes from the meeting on 24th January. Other Trusts approached Quality accounts differently last year which Chris is looking into. Chris met with the Quality lead for NHS Bristol and mentioned the National King’s Fund document.
Page 6 of 8 Item 18b
Item Action Action - Debbie will attach the document to the minutes. Anyone who wishes a hard copy to be sent through the post please let Debbie know. D. Marks
Chris explained that the document includes what needs to be reported but also what governor’s would like to be included. Item include: safety (histopathology report), Care Quality Commission Standards, South West Patient Safety Programme, Falls, Infection Control, Antibiotic prescribing appliance, increased risk – patient harm (? Include adverse events), patient experience, privacy and dignity, complaints, staff and patient feedback and outcomes – mortality, implementation of NICE standards for Dementia, PROMS, Cardiac surgery. Possible other outcomes to be included are: cataract surgery, adult intensive care, oesophageal cancer, sequins and commissioning targets.
Frank questioned the expansion of how we use PROMS and possibly using a pre admission/discharge type questionnaire. Chris stated that these are before and after measures and queried that patient’s expectations are high. Alison informed the group that the NHS Outcomes Framework has 2 areas: a) intention to map framework to accounts. Work is being done in specialised areas that we aren’t aware of and this will scope it. 2011/2012 is about building on outcomes. b) To get to the bottom of patient recorded outcomes. The Head and Neck Division are working on pre op counselling.
8. “Treating people well” Training - Chris contacted Emma Whetter who mentioned that she is unable to get people to attend this training session. Managers need to identify staff for training. Liz pointed out that in private medicine this type of training would be mandatory. Alison has discussed this training with Robert Woolley – it’s not just reception staff that needs to attend but also senior staff members. It was also suggested that training groups were mixed i.e. porters/receptionist mixed with nurses/doctors etc. Alison and Steve Aumayer will be visiting Yeovil Hospital. Yeovil have done a lot of work with their staff and they asked them ‘how do you want to be treated as staff?’ and ‘how do you treat your patients?’ This has proved to be very effective and staff from Yeovil will be coming to Bristol to help with the existing training programme.
9. Any Other Business –
Neil Auty – an issue was raised by Neil at last week’s Strategy Working Group meeting. Neil Auty has taken over dealing with Claims & Settlements on behalf of the Governor’s. Neil raised concerns of there being no formal process in place from learning from mistakes. The information that is learned is reported back to Divisions but not the Governors, therefore Governors are unaware of any outcomes. Deborah Lee informed the Strategy group that Jane Luker and Alison Moon were the best people to talk with and suggested that this item was on the agenda for the Quality Working Group.
Action – Alison agreed to discuss this at the next Quality meeting. The group A.Moon/ agreed to add this as an agenda item for the meeting on 2nd June as April’s J. Luker agenda is busy. Neil Auty will be invited to attend.
Page 7 of 8 Item 18b
Item Action Dementia – Alison is part of the South West Dementia Partnership Board. Alison mentioned that a programme regarding people with dementia will be going out on ITV west country on March 11th. The programme will cover diagnosis, use of drugs and care in hospitals. There is currently a lot of work happening with dementia and Alison agreed to speak about this at April’s A. Moon meeting. Alison will invite Helen Morgan (Head of Nursing for Specialised Services) to attend the meeting.
Study days – Jeanette informed the group of a HCA study day being held on Friday 8th April. It will include privacy & dignity and record keeping. Also, Thursday 12th May will be Nurse’s day. For any further information please contact Jeanette.
Meeting times – Chris mentioned that not all meeting dates had a 2 hour time slot. Debbie has rectified this. Please see dates below regarding extended D. Marks times.
10. Meeting Dates/times –
• Tuesday 5th April at 2 – 4pm in Lecture Theatre 3, Education Centre. • Tuesday 2nd June at 2 – 4pm in the Board Room, THQ • Monday 22nd August at 11:15 – 13:15 in the Conference Room, THQ • Tuesday 18th October at 10 – 12 in Tutorial Room 4, Education centre • Wednesday 30th November at 1 – 3pm in the Conference Room, THQ
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Item 18c
MEMBERSHIP 4th May 2011 COUNCIL MEETING TITLE Strategy Working Group Report
PURPOSE For information
THE MEMBERSHIP Receive the report from the Strategy Working Group COUNCIL IS ASKED TO:
1. Context
This report is to keep all governors informed of the work being undertaken by the Strategy Working Group.
2. Strategy Working Group Members
Anne Ford Chair: Public North Somerset Wendy Gregory Carers of patients 16 years and over Jan Dykes Staff: Non clinical Healthcare Professional Heather England Public Bristol Anne Skinner Patients: Local John Steeds Patients: Local Ken Cockrell Patients: Local Neil Auty Patients: Tertiary Deborah Lee Director of Corporate Development Ben Hume Head of Strategy & Business Planning Paul Tanner Head of Finance Paul May Non-Executive Director
3. Meetings
The Strategy Working Group meets bi-monthly.
The next meeting is due to be held on 26th April 2011.
The minutes of the last meeting are attached for information.
4. Key Points
In April Ben Hume presented a seminar on the Clinical Services Strategy. It was well received by the governors who attended and provided a clearer overview of the Trusts forward planning for health care in the wider Bristol.
5. The Membership Council is asked to:
Receive the report from the Strategy Working Group.
Prepared and Presented by: Anne Ford, Public Governor for North Somerset
4th May 2011 Page 1 of 6
Item 18c
Governors Strategy Working Group
Held on Monday 14th February 2011
Notes of the Meeting
Present: Anne Ford (Chair) Public North Somerset Jan Dykes Staff : Non clinical Healthcare Professional Wendy Gregory Carers of patients 16 years and over Heather England Public Bristol Anne Skinner Patients: Local John Steeds Patients: Local Neil Auty Patients: Tertiary Deborah Lee Director of Strategic Development Ben Hume Head of Business Planning, Trust Lead Paul Tanner Head of Finance Paul May Non-executive Director Sarah Pinch Head of Communication
In attendance: Debbie Marks Membership Administrator (minute taker)
Item Action 1. Apologies:
Apologies were received from Ken Cockrell and Steve Aumayer.
2. Notes of the Last Meeting:
The notes of the last meeting were agreed as an accurate record subject to the following amendment:
John Steeds corrected an error on page 3, third paragraph. The sentence should read ‘JSt commented on the figures noted in section 1.8.’
Anne Ford requested an update regarding the Long Term Financial Plan. Deborah reported that it is near the final draft and will be available for the next Strategy meeting being held on 26th April.
3. Matters Arising:
3.1: Centralisation of Specialist Paediatrics update – Deborah informed the group that the business case will be presented to the Board on 28th February. It has been endorsed by the Specialist Commission Group and should be agreed at Trust Board without challenge.
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Item 18c
Item Action John asked for clarity on this development. Deborah explained that the Bristol Children’s Hospital is being physically extended to accommodate Specialist Paediatrics including burns and neuro due to Frenchay Hospital’s closure in 2014. Wendy asked for a projected timeline to which Deborah replied late spring/early summer 2014.
Deborah confirmed that the Burden Centre will remain at Frenchay.
Paul May asked about Specialist Commissioners. Deborah stated that there is no shadow-body in place yet. A memorandum agreement has been prepared and has been signed by the Department of Health and Robert Woolley.
3.2: BRI Re-development Update - Deborah pointed out that this is a more complex business plan and therefore will be presented to the Trust Board in March. John asked if planning approval was required. Deborah reported that modifications have been made. The original plan was approved 2 weeks ago and the next step is to submit the amendments.
3.3: Air Ambulance Access Update - This is progressing with no issues and will be presented to the Trust Board in February. Jan drew attention to the possibility of the air ambulance not having permission to fly at night. Deborah reassured the group that this is an aviation restriction and is the air ambulances choice not to fly at night. The Trust are not responsible for running this service, they only provide the location.
4. Forward Work Plan – Ben presented to the group a draft Work Programme for April 2011 to April 2012.
Queries raised –
In response to John’s question about a joint board, Deborah informed the group about the ‘Partnership Programme Board’. The Terms of Reference has been agreed by both Trusts. Deborah can provide an update on this should the Governor’s wish. Sarah clarified that the Partnership Programme Board is a separate committee and not a joint Board. Anne Ford added that it is a way of looking at how to work together. Deborah agreed and added that it will make sure the Trust is on track and making progress.
Wendy suggested that there was an element of discomfort when people mentioned ‘merger’ and that Governor’s are speculating that a potential merger is happening. Sarah explained that the Partnership Programme Board is about looking at how the Trust can improve services which could then, possibly, result in a merger. Deborah verified that all Trusts should be Foundation Trusts by Spring 2014.
Anne Skinner emphasised that it’s a positive step to improving health all over Bristol. Deborah agreed and explained that having a combined rota and booking service would benefit the city.
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Item 18c
Item Action Paul May raised the issue of Non-executives not being made fully aware of ongoing plans. There are issues that need resolving and suggest that the Programme Board has greater transparency. There needs to be a degree of care and balance.
Ben suggested that the group discuss this topic in more detail at a later meeting when more information will be available.
Clustering of PCT’s – Anne Ford recalled that there are 3 Boards and one overall Board that will oversee all 3. Deborah continued that they will operate as a single organisation e.g. instead of having 3 different commissioning policies there will be one. Baines & Wiltshire and now a duo and likewise are Gloucester & Swindon. Somerset remains single.
NHS Operating Framework – Deborah informed the Governor’s that these documents have been condensed and will provide the Governor’s with the last 3 documents.
Action – Deborah to provide Governor’s with the last 3 documents D. Lee
The group agreed to the Work Programme Schedule.
5. Terms of Reference – Anne Ford suggested changing one sentence in the second paragraph. The updated sentence will now read ‘Its primary role will be to advise about the acceptability of the Trust’s strategic plans to service users and carers in partnership with the general public and associated delivery plans’.
The group agreed and the Terms of Reference is now finalised.
6. Clinical Services Strategy Review update: market analysis – Deborah informed the group that the next step is the Trust Board in March. The document describes the Strategy Framework. It won’t answer questions but includes context and structure.
Paul May raised the importance of having discussions rather than just the end report. Deborah suggested that the Strategy Group have a 2 hour meeting to discuss the Clinical Services Strategy Review. The documents will be distributed to the Governor’s beforehand. D. Lee/ Action – A two hour meeting to be arranged to discuss this agenda item. Chair/ D. Marks 7. Annual Business Planning Process – Ben presented two papers to the group - Integrated Business Plan and Planning Process Update (Feb 2011).
Planning Process Update (Feb 2011) – This document highlights where the Trust is within the planning process. The annual plan will be submitted to monitor, this will describe the next 3 years. Templates are currently being sent to Divisions.
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Item 18c
Item Action
Deborah highlighted item 4 - Emerging Risks. 70% of income comes from the 3 PCT’s. The CRES target is 27 million, 9 million brought forward from last year. The contract settlement is the end of March.
Paul Tanner confirmed that the Trust is not alone – this is replicated across the country.
Ben drew attention to Table 1 in this document. Wendy pointed out that the Trust is a centre of excellence which is what attracts patients and that money travels with these patients. Deborah agreed and stated that Trust must first attract revenue and have access to capital in the first instance. Ben mentioned that other business cases may be presented. If these business cases can provide their own capital then they can go ahead, the ones that can’t provide capital go for discussion.
Paul May questioned whether there is a policy regarding priority for patients and staff and also, that clear simple priorities need to be established for Governors. Ben replied that this is in the early stages and more information will be available to the Governors in April. Deborah pointed out that clear guidelines are laid out regarding priorities and waits.
Action – Deborah to send copy of agreement to Governors
Research - John raised the issue of research within the Trust and the D. Lee importance of retaining this research. Deborah clarified the 3 strategies – Research & Innovative, Teaching & Learning and Clinical Services Strategy and declared that no disconnections in the process have been recognised. David Wynick and Mary Perkins have both been involved with looking at these strategies and will put forward any proposals. Anne Ford reminded the group that Mary will be talking to the Governors in the future.
Anne Skinner suggested that John raise this issue at the Governors next meeting with John Savage. J. Steeds Paul May recalled that research within the Trust has been exceedingly high.
Action - Deborah agreed to speak with David Wynick when she meets with him next week and will update the group at the next meeting in April. D. Lee 8. Any Other Business – Neil was asked by Mo Schiller to take over from George Wynn Willson. George was a previous Governor who dealt with claims and settlements on behalf of all Governors. Neil has met with Peter Harrowing (legal team) who informed Neil of the Trusts in-house firm of solicitors.
Neil raised concerns of there being no formal process in place from learning from mistakes. The information that is learned is reported back to Divisions but not the Governors, therefore Governors are unaware of any outcomes.
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Item 18c
Item Action Deborah emphasised that there are very clear mechanisms in place for near misses and mistakes. Staff competencies are also measured in various ways. This could involve having staff supervised for certain lengths of time by senior staff members to staff having annual appraisals. There is a complex system in place.
Neil agreed this was assuring but there needs to be a mechanism in place for Governors to also be informed of outcomes. Wendy agreed with Neil and stated that staff do need to be careful not to become complacent in their roles.
Deborah agreed and suggested that this item be on the next agenda for the Quality Working Group.
Action – Debbie Marks has spoken with Chair for Quality Group. It has been agreed that this item will be added to the next Quality Working Group Chair/ meeting being held on 22nd February. D. Marks
9. Next Meeting – Tuesday 26th April at 10 – 11:30am in the Conference Room, THQ
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Item 19
MEMBERSHIP 04 May 2011 COUNCIL MEETING TITLE Outpatient Constituency Meetings
PURPOSE For Information
THE COUNCIL IS To receive this briefing by the Governor Representative to note ASKED TO:
1. Summary
Constituency meetings are held twice a month in outpatients departments with two to three governors involved each time. They cover a two hour session either am or pm with a questionnaire (attached in appendix A).
The questionnaire is completed by the patient and returned to the membership office. Suzanne Green collects the responses, collates them. The Membership Office then forwards the results onto the matrons of clinics and heads of divisions. Clinics covered to date have been Upper GI, Thoracic, Oncology, Ophthalmic, Dental, Orthopaedics, Dermatology, Gynaecology, Paediatrics, ENT, Lower GI and neurology, Gastro and BHI.
All meetings are pre arranged by the Membership Office. Governors are always made to feel welcome. Patients feel valued by their concerns being listened to and it helps them understand the role of the governor. Any concerns that require immediate action are resolved by governors liaising directly with the clinic sister.
These meetings are considered invaluable by the governors. We meet patients and carers and have the opportunity to listen to their experiences. These are regularly fed back to the board so that concerns can be addressed and patient experiences improved.
2. Outcomes
Please see below a summary of the outcomes to date for information.
1. Appointments
1.2 Did you receive enough information regarding the appointment? • Almost all patients had enough information where to come. • Almost all patients knew the time to arrive. • Almost all knew what to bring. • Almost all knew what would happen. 2. Referral
2.1 How long have you waited from referral by your GP/Medical practitioner to today’s appointment? • Occasionally under 1 month. • number 1-2 months, • 2-5 months, rarely longer, 1
• 1 over 6 months. 2.2 Were you given a choice of hospital at the start of your treatment? • Half of patients were not given choice of hospital. 2.3 Were you given a choice of time for today’s appointment? • Frequently no choice of time offered, more choice needed on time of day. • OPD clinics/appointments are currently being looked at by the Trust. 3. Transport
3.1 What method of transport did you use to get here? 3.2 If you used a car, where did you park? • Mixed methods, parking especially for disabled a problem. Most patients aware of Cabot concession. Need greater awareness of parking and hospital bus system. • UHB must provide transport to take wheelchairs and buggies; this is being addressed in new vehicles. • GWA/hospital transport criticised frequently, collected too early, returned too late, spend too long sitting without food and drink, and these patients tend to be old and sick. This service needs improving. 4. Service and Environment
4.1 Are you happy with the clinic efficiency? 4.2 Are you happy with the appearance of the clinic? • Most were seen within a reasonable time. They prefer time wait to be displayed or information given. Information was given on most occasions adequately. • A few complaints about inability to understand as Dr's English was poor. • The elderly require greater time spent with them as they cannot hurry. • Delight at the refurbishment of oncology, most were happy with the remaining clinics. • Pharmacy waiting times to collect meds, one patient waited 6 hours, improvement needed. This is being addressed by trust 5. Communication and Information
5.1 Were you told how long you would have to wait? • Waiting time not always displayed or info given 5.2 Did you understand the information given to you regarding tests? e.g. blood, x-ray • Most explanations clear 5.3 Did the clinician clearly explain any test results? • Most understood, again elderly need time 5.4 Did you understand the explanation given to you about your treatment? • Most understood 6. Is there anything else we can do to improve our services?
• The concerns that have been highlighted to the trust are being investigated to improve the service and patient experience.
Prepared and presented by: Mo Schiller, Public governor
4th May 2011
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Item 19 Appendix A Governors Outpatients Questionnaire
A) Prior to Clinic Visit 1. Appointments 1.1 Is this your first visit to this clinic? Yes No (if not go to question 3) 1.2 Did you receive enough information regarding the appointment? a) where to come for your appointment Yes No c) anything you needed to bring Yes No b) what time you should arrive Yes No d) what would happen during your visit Yes No Any further comments re your appointment:
2. Referral 2.1 How long have you waited from referral by your GP/Medical practitioner to today’s appointment? Under 1 month 1-2 months 2-5 months More than 6 months 2.2 Were you given a choice of hospital at the start of your treatment? Yes No 2.3 Were you given a choice of time for today’s appointment? Yes No Any further comments re your referral:
3. Transport 3.1 What method of transport did you use to get here? Own Car Hospital Transport Walk Taxi Bus Train Hospital Shuttle Bus Bicycle Other: 3.2 If you used a car, where did you park? Car Park Street Meter Park & Ride Disabled Space Cabot Circus Other: Any further comments re transport:
B) Following Clinic Visit 4. Service and Environment 4.1 Are you happy with the clinic efficiency? a) were you seen on time Yes No b) did the clinician have all the information they needed about you Yes No 4.2 Are you happy with the appearance of the clinic? Yes No Any further comments re the service or environment:
5. Communication and Information 5.1 Were you told how long you would have to wait? Yes No 5.2 Did you understand the information given to you regarding tests? e.g. blood, x-ray Yes No 5.3 Did the clinician clearly explain any test results? Yes No 5.4 Did you understand the explanation given to you about your treatment? Yes No
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Any further comments re communication or information:
6. Is there anything else we can do to improve our services?
Thank you for completing this form. It will help us to improve patient care
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