Board of Directors Meeting Thursday, 28 April 2016 at 1.00 pm Boardroom University Hospital of North Tees

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1 Board of Directors Meeting Thursday, 28 April 2016 at 1.00 pm Boardroom University Hospital of North Tees

2 Glossary of Terms Strategic Aims and Objectives Strategic Aims Putting Patients First to create a patient centred organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery. Integrated Care Pathways to develop and expand the portfolio of services to provide integrated care pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare. Service Transformation to improve and grow our healthcare services to continually review the needs of our healthcare community and transform services. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes. Manage our Relationships to ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working. Maintain Compliance and Performance to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business. Health and Wellbeing to embrace the health and well being of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the commissioning of services from the Trust. Strategic Objectives Maintain Compliance and Performance assurance around compliance with standards, performance indicators and requirements within the Terms of Authorisation. Requirement to provide Board regulation and self certification on a quarterly and annual basis in accordance with Monitors Terms of Authorisation. Seasonal Pressures requirement to ensure preparedness for seasonal winter pressures. Reduce Hospital Acquired Infections supports the Trust s key strategic theme of; Maintain Compliance and Performance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of the Trust business. Effective Board Governance corporate oversight and scrutiny will continue to be provided by key management structures; 1. Board of Directors, 2. Executive Team, 3. Trust Directors Group. Training ensuring the workforce is appropriately trained.

3 Workforce absence management, ensuring we have adequate staffing levels that provide safe and effective care to our patients. Momentum Pathways to Healthcare delivery of a new healthcare system for the people of Easington, Hartlepool, Sedgefield and Stockton. Putting Patients First / Patient Safety to create a patient-centred organisation by engaging and enabling staff to add value to the patient experience, demonstrated through patient safety, service quality and LEAN delivery. Finance to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

4 PG/SH 21 April 2016 Dear Colleague A meeting of the Board of Directors will be held on Thursday, 28 April 2016 at 1:00 pm in the Boardroom, University Hospital of North Tees. Yours sincerely Paul Garvin Chairman Agenda Led by 1. (1.00pm) Apologies for absence Chairman 2. (1.00pm) Declaration of Interest Chairman 3. (1.00pm) Minutes of the meeting held on, 28 January 2016 (enclosed) Chairman 4. (1.05pm) Minutes of the Extra Ordinary Board meeting held on, Chairman 4 April 2016 (enclosed) 5. (1.05pm) Matters Arising Chairman Items for Information 6. (1.10pm) Chairman s Report (enclosed) Chairman 7. (1.20pm) Chief Executive s Report (enclosed) A Foster

5 Quality 8. (1.30pm) Care Quality Commission Report Update (enclosed) J Lane 9. (1.40pm) Quality Report (enclosed) J Lane 10. (1.50pm) Infection Prevention and Control Report (enclosed) J Lane Strategic Management 11. (2.00pm) Strategy Development Progress Report (enclosed) J Gillon 12. (2.10pm) Transformation Programme Update (enclosed) A Burrell 13. (2.20pm) Capital Programme Performance 2015/16 (enclosed) L Hodgson Performance Management 14. (2.30pm) Compliance and Performance Report (enclosed) J Gillon 15. (2.40pm) Finance and Contract Performance Report, C Trevena as at 31 March 2016 (enclosed) 16. (2.50pm) Human Resources and Education Report /16, (enclosed) A Burrell 17. (3.00pm) Revenue and Capital Budgets 2016/17 (enclosed) C Trevena Governance 18. (3.10pm) Compliance Report to Monitor, Quarter /16 (enclosed) J Gillon 19. (3.20pm) Any Other Notified Business Chairman 20. Date of Next Meeting (Thursday, 26 May 2016, Boardroom, University Hospital of North Tees)

6 North Tees and Hartlepool NHS Foundation Trust Minutes of Board of Directors Meeting held on Thursday, 28 January 2016 at 1.00pm at the University Hospital of North Tees Present: Paul Garvin, Chairman* Brian Dinsdale, Non-executive Director* Rita Taylor, Non-executive Director* Steve Hall, Non-executive Director* Jonathan Erskine, Non-executive Director* Kevin Robinson, Non-executive Director* Alan Foster, Chief Executive* Julie Gillon, Chief Operating Officer/Deputy Chief Executive* Lynne Hodgson, Director of Finance, ICT and Support Services* Ann Burrell, Director of Human Resources and Education David Emerton, Medical Director* Julie Lane, Acting Director of Nursing, Patient Safety and Quality* Barbara Bright, Company Secretary In attendance Sarah Hutt, Assistant Company Secretary (Note taker) Bill Johnson, Healthcare User Group Representative (HUG) Posmyk Boleslaw, HAST CCG John Edwards, Elected Governor, Stockton George Lee, Elected Governor, Hartlepool Graham Popham, Smith and Nephew Mark Payne, Hartlepool Mail Aneesa Aziz, Student Nurse Debbie Wise, Student Nurse Amy Lambert, Student Nurse Louise Hislop, Student Nurse Kathleen Aquinu, Student Nurse BoD/3022 Apologies for Absence Chairman BD RT SH JE KR CE COO/DCE DoF,ICT&SS DoHR&E MD ADoN,PS&Q CS Apologies for absence were reported from Cath Siddle, Director of Nursing, Patient Safety and Quality. BoD/3023 Declaration of interest There were no declarations of interest on open agenda items. BoD/3024 Minutes of the meeting held on, 26 November 2015 Resolved: that, the minutes of the meeting held on Thursday, 26 November 2015 be confirmed as an accurate record. * voting member

7 BoD/3025 Matters Arising a. BoD/2047 Chief Executive s Report The CE provided a further update in respect of Neonatal Services. The issue was discussed at the regional Overview and Scrutiny Committee held in Hartlepool on 17 December. The meeting had good representation and was well attended. It was agreed no changes would be made to the current service provision recognising that changes to the transport service would be required first. Any future changes would be subject to further regional consultation. The Trust would continue to work closely with South Tees Hospitals NHS Foundation Trust. b. BoD/2058 Operational Resilience 2015/16 The COO/DCE reported that the Trust was continuing to see an increase in the acuity and complexity of patients evidenced through the admissions into hospital and high levels of bed occupancy. During the first week in January in support of the Kick Start to the Year initiative there were representatives from social care on site to assist with patient flow and discharges to care settings. Significant pressures were currently being seen system wide, with the majority of trusts across the region currently at NEEP level 4. The COO/DCE confirmed that the Trust had 47 additional beds open presently, to assist in managing patient flow, following a query by the Chairman. c. BoD/2093 Chief Executive s Report/Collaborative Working The CE provided an update regarding the streams of collaborative working being undertaken with South Tees Hospitals NHS Foundation Trust in respect of breast, urology and spinal services. The CE emphasised that the work was to enhance the services currently being provided and improve pathways for patients by the two trusts working together. Meetings to date between the trusts had been constructive. d. BoD/2093 Chief Executive s Report/Industrial Action The MD reported that the proposed industrial action involving junior doctors on 1, 8 & 16 December was cancelled; however, a day of action took place on 10 January with emergency cover only being provided for a 24 hour period. The Trust s contingency arrangements had worked well. e. BoD/2099 Finance and Contract Performance Report The Chairman reported that he had met with Dr Posmyk, Chair of Hartlepool and Stockton Clinical Commissioning Group (CCG) and it was agreed that a joint meeting of individual board members would be arranged to discuss winter funding. Resolved: (i) that, a joint meeting between the Trust and CCG board members would be arranged; and (ii) that, the information be noted. BoD/3026 Chairman s Report a. Consultant Appointments The Chairman reported that there had been no consultant appointments since the last meeting. 2

8 b. NHS Providers The Chairman reported that he had attended a dinner for Chairs and Chief Executives hosted by NHS Providers in London with Simon Stephens, Chief Executive, NHS England, who had outlined that trusts would be required to work together to transform local health economies and look at broader geographical areas, which complimented the work the Trust was currently initiating across the Tees Valley and County Durham. A more joined up approach was being developed nationally in respect of regulation as health economies rather than single entities. Finally, provider organisations were expected to deliver within the resources available during 2016/17. The Chairman also reported he had attended a Chairs and Chief Executives event where Lord Carter, Chair, NHS Procurement and Efficiency Board outlined the work being undertaken in respect of a board level dashboard for efficiency from his report. c. Meetings The Chairman outlined in more detail that he had met with Dr Posmyk, Chair, HAST CCG to discuss how the Better Health Programme could be effectively delivered jointly, and for the CCG to gain assurance in respect of the Trust s actions regarding mortality. The challenges faced by both organisations in respect of winter beds and the respiratory pathway were also discussed. d. Collaborative working The Chairman reported that he and the CE had met with the Chairs and Chief Executives of South Tees Hospitals NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust, along with Jim Mackie, Chief Executive, NHS Improvement, to move forward with collaborative working discussions, and to develop a 5 year plan for the Tees Valley and County Durham area. e. Linda Shields The Chairman reported the sad news that Linda Shields, former Governor and HUG member of the Trust had passed away. He placed on record recognition of Linda s long standing support and input to the work of the Trust. BoD/3027 Resolved: that, the information be noted. Chief Executives Report a. Care Quality Commission Report The Care Quality Commission (CQC) carried out an inspection at the Trust in July As part of the inspection process an unannounced visit took place which was to underpin the original findings, before a final report was produced, which had been presented as part of the Quality Summit at the Trust on 27 January The report was embargoed until 3 February when it would be published. The Trust had 28 days to produce an action plan based upon the 14 must do items. The CE placed on record his thanks to all staff for the hard work during the inspection process. 3

9 b. NHS Planning Guidance The NHS Planning Guidance which outlines delivery of the five year forward view was published in December It set out the requirements for 2016/17 and beyond, including sustainability and transformation plans to be produced during The CE outlined the top ten priorities included within the report. c. Urgent and Emergency Care Vanguard Project The CE reported that he had attended a regional Chief Executives meeting hosted by NHS England on 22 January, which included a briefing regarding the Urgent and Emergency Care Vanguard Project designed to improve access to urgent and emergency care in and out of hospital. A bid of 20m had been submitted to progress the work. The CE congratulated the COO/DCE on her appointment to the North East Board of the Urgent and Emergency Care Vanguard to oversee delivery of the project. d. Cancer Campaigns The CE reported that the recent cancer awareness campaigns had led to a large increase in the number of patients being referred, placing pressure on all cancer services. Work was commencing, led by the Cancer Network, to review how increased demand and capacity could be better managed and improve delivery against the cancer performance targets. JE, sought to understand what actions were being taken in respect of staff shortages and training issues with regards to primary care. The CE explained there was a need to increase training overall, and the DoHR&E reported that Health Education North East (HENE) were reviewing future models of care and looking how junior doctor rotations could be interlinked with the South of the Country. BoD/3028 Resolved: that, the information be noted. Board of Directors Declaration of Interests and Fit and Proper Persons Declaration The CS reported that the Board of Directors were required to declare annually any interests that may conflict with their position as a director or non-executive director of the Trust. The interests were required to be made at an open meeting of the Board and to be recorded in a register, which was referred to in the Trust s Annual Report and should be available for inspection by the public. Following the introduction of the fit and proper persons standard in November 2014 as part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations), an annual declaration was required for an executive director/non-executive director or equivalent, to demonstrate continued fitness to undertake the role and such declarations would be recorded as part of the register. It was noted a correction was required for the entry in the Declaration of Interest Register in respect of the DoF,ICT&SS. Resolved: (i) that, the information be noted; and (ii) that, a correction to the Declaration of Interest Register be made in respect of the entry for the DoF,ICT&SS. 4

10 BoD/3029 Quality Report The ADoN,PS&Q presented the Quality Report and drew members attention to the key points. The Staff, Patient Experience and Quality Standards (SPEQS) reviews were cancelled for October and November due to service pressures, however, during that period unannounced visits and independent scrutiny had continued to take place to provide assurance. The overall score for inspections in December was 96.87%, an increase of 1.15% from September. The highest score achieved was 100% by 23 wards/areas. First Impressions achieved 96.97% (98.33%); Patient Experience achieved 98.06% (98.43%); Nursing Evidence achieved 93.18% (90.83%) and Staff Involvement achieved 95.83% (89.58%). Areas achieving 100% continued to be recognised, and areas achieving low scores were revisited to ensure corrective action had been taken. The database used to compile the scores was being reviewed to provide more in-depth analysis. The Trust s HSMR value continued to decrease from (Sep 14 to Aug 15) to , and the crude mortality had decreased from 4.03 to Both were still out of the as expected range. The SHMI value had slightly improved at (Jul 14 to Jun 15) from (Apr 14 to Mar 15), which was also out of the as expected range. The Keogh Delivery Group continued to oversee actions being taken. Work with Advancing Quality Alliance (AQuA) commenced in January, following an earlier postponement due to proposed industrial action, to review the Trust s mortality position, particularly in respect of Sepsis and Acute Kidney Injury. There had been 551 complaints for the period 1 April January 2016, of which 21.59% were categorised as Stage 3. There were currently 69 complaints open. The compliance rate for responses for November 2015 was 91%. In December the Safety Thermometer results included: New pressure ulcers had increased to 1.06% from 0.27% in November; Falls with harm had increased to 0.47% from 0.27%; Catheter and New UTI had increased to 0.47% from 0.13%; New VTE (venous thromboembolism) had decreased to 0.12% from 0.13%, and Harm free care had decreased to 98% from 99.07%. Overall Falls with Fracture had decreased in quarter 3, however, the number of Falls with Harm remained a challenge due to the number of frail patients. As part of Safer Staffing, the number of planned and actual staffing levels, as well as registered and unregistered care staff fill rates during November and December 2015 was provided. The Trust had successfully recruited a number of registered nurses from Romania and the Philippines who would commence employment in February. The Friends and Family % of patients who would recommend the services was 96.39% for in-patients; 90.79% for A&E; 98% for maternity, and 88.68% for outpatients. The number of responses for the out-patient clinics had increased to 663 in December from 485 in November. The fall in the number of returns from A&E was recognised and ways to improve this were being explored. The Trust held its 2 nd annual Quality Accounts Marketplace event on 9 December, inviting members of staff and stakeholders to review work that had been undertaken in key areas and whose feedback would help to shape the key priorities for this year s accounts. The first draft of the 2016/17 Quality Account was being drafted. No further Never Events had occurred since the last report in November

11 RT, Chair of the Ps and Qs Committee sought clarification as to why AQuA were reviewing Sepsis and Acute Kidney Injury data specifically. The ADoN,PS&Q explained that these two areas had been identified as being of concern nationally. Resolved: (i) that, the content of the report be noted; and (ii) that, the current performance in respect of complaints, mortality; Friends and Family test; and the Safety Thermometer data be noted. BoD/3030 Infection Prevention and Control Report The ADoN,PS&Q presented the Infection, Prevention and Control Report to 31 December 2015, and drew members attention to key areas: There had been 2 cases of Clostridium Difficile in December; and 25 year to date exceeding the challenging annual trajectory of 13 cases. Full root cause analysis had been undertaken for all the cases and the only recurring theme was in relation to poor cleaning scores for patient equipment. Intensive work was being carried out in ward areas including fogging where possible, hand hygiene training and antimicrobial stewardship. A task and finish group continued to meet to explore any further actions to minimise the risk of infection; There had been no cases of Trust attributed MSSA bacteraemia cases for December, and 15 cases year to date against the internal trajectory of 18 cases for the year; There had been no cases of Trust attributed MRSA bacteraemia in December, and 2 cases year to date, which exceeded the zero tolerance trajectory. Learning had been identified from both cases; There had been 1 case of Trust attributed E coli bacteraemia in December, and 30 cases year to date against the internal trajectory of 27 cases for the year; Overall compliance for hand hygiene was 95.04%, slightly above the Trust target of 95%. Over 100 hand hygiene champions had been recruited to promote good hand hygiene in their area of work. Ward Matrons of areas with low compliance were invited to the Healthcare Associated Infection (HCAI) Operational Group to provide assurance that action was being taken to improve compliance. The Trust continued to work with the CCG regarding reducing the number of community acquired infections. KR, Chair of the Infection Control Committee reiterated the robustness of the Trust s screening processes, prompting discussion in respect of the varying degrees of screening amongst different organisations. Resolved: (i) that, the content of the report be noted; and (ii) that, the on-going work to improve performance regarding Clostridium Difficile be noted. BoD/3031 Transformation Programme Update The DoHR&E outlined progress to date in respect of the Transformation Programme. A detailed discussion had taken place at the Board Seminar on Thursday, 21 January regarding future plans following the transfer of the Transformation function to the DoHR&E. 6

12 Key projects were underway including the development of Integrated Pathways for: Respiratory; Frail Elderly and Dementia; End of Life Care, and Diabetes. Work was also underway to transform Outpatient Services to develop the right operational model including technology. A full appraisal of the Administration Review had been completed and it was agreed that the full impact of TrakCare s implementation and the IT Strategy needed to be understood before progressing further. The Transformation Programme was allocated a savings target of 4.271m, from the overall efficiency target of 10.9m for 2015/16. At Month 9, 819k of cash releasing savings had been identified, behind the plan of 1,172k. A full audit of the DQIP project which was reviewing clinical coding and data quality in respect of mortality had been completed. To date no savings had been realised, however, a business case had been submitted to Monitor requesting additional external support to continue with the project with the aim to improve processes and generate savings. SH, Chair of the Transformation Committee provided assurance regarding the Transformation Programme and the commitment of clinicians to take this work forward. The Chairman sought confirmation that the postponement of the Administration Review was only temporary and the review would continue in due course. The DoHR&E explained that administration reviews were undertaken when directorate reviews were carried out, however, this was a full scale review and the overarching changes that would be required with the implementation of phase 2 of TrakCare needed to be understood first, which was reiterated by the CE. Resolved: (i) that, the current position of the Transformation Programme be noted; and (ii) that, the remit for Transformation was now with the DoHR&E. BoD/3032 Capital Programme Performance Quarter 3: 2015/16 The DoF,ICT&SS presented the Capital Programme Performance Report for Quarter 3 and drew members attention to the key areas. The Capital Programme Expenditure Plan had significantly altered during Quarter 3. Monitor had encouraged the Trust to develop plans to transfer uncommitted capital to support the revenue position. The original capital allocation for 2015/16 was m including a loan facility of 2m, which would not now be utilised, and a further 2m had been identified to transfer to the revenue position, resetting the capital funding to 6.798m. Expenditure at the end of Quarter 3 was within the annual profile and projections of achieving a minimum expenditure of 85%, and less than 115% against the reset capital allocation of 6.789m. Monitor was now reviewing expenditure on a monthly basis. The Trust had secured 25m from the Department of Health to support the replacement of the primary engineering infrastructure at the University Hospital of North Tees, which would be available from April The TrakCare programme had been successfully implemented, with the first phase going live on 19 October 2015; a business case to set up a 32 bedded resilience ward had been approved, and a five year capital expenditure projection had been developed. At the end of Quarter 3, 7.497m, of the original 8.798m allocation had been committed, not all of which will be in place by the year end. The DoF,ICT&SS provided an updated in respect of the GS1 project, following a request by the Chairman. The Trust had been successfully accepted as a pilot site for the GS1 project, whose aim was to individually barcode all equipment, drugs and consumables used by NHS organisations, and would generate an electronic record for all patients to eliminate any errors 7

13 and to individually identify what equipment has been used where. BD, Chair of the Audit Committee had been appointed to its virtual board to oversee the project. RT, Chair of the Ps and Qs Committee queried what effect the 2m identified to help the Trust s revenue position would have on the Capital Programme, prompting discussion. The DoF,ICT&SS confirmed that it would not impact the normal programme of works, however, it would assist the NHS not to exceed its deficit. It was agreed that a further 5m would be requested to assist with the 5 year transformation sustainability work, given the number of additional capital projects the Trust would be required to undertake. BoD/3033 Resolved: (i) that, the progress of the capital schemes be noted; and (ii) that, the Trust had been successfully identified as a pilot site for GS1; and (iii) that, an additional 5m would be requested in respect of the 5 year transformation and sustainability work. Compliance and Performance Report The COO/DCE presented the Compliance and Performance Report for December 2015, and drew members attention to the key points. Following the implementation of the new Patient Administration System TrakCare, there had been some initial data recording and reporting issues which had impacted on obtaining a validated performance status for some indicators, including Referral to Treatment indicators and A&E standards. Performance against key operational standards and trajectories continued to be a challenge, with pressures in the wider health system, impacting the delivery of both elective and nonelective pathways. Non elective activity in December indicated a 9.74% decrease in comparison with the same period last year, and both attendances and admissions via A&E saw decreases of 5.17% and 6.88%, however, across the Trust there was an increase in the acuity of patients with complex needs being seen, which was evident in the increased number of bed days. The overall emergency activity included 541 patients who had been treated via Ambulatory Care, 16.26% of the total emergency admissions. Performance against the emergency care standard was above the national requirement of 95%, reporting at 96.47%, however, for quarter 3 the standard was underachieved at 94.13%, due to under performance in October and November, which was impacted by the early onset of winter pressures and patient flow issues. The Trust was looking at alternative methods of treatment and discharges especially during the peaks in activity. A successful initiative was run at the beginning of January Kick Start to the Year, to improve patient flow and timely discharge, having social care representation on site to provide immediate assessments. The Trust achieved against the RTT incomplete standard reporting 92.53% against the 92% standard and reporting 94.11% at quarter 3. The decrease in performance was evident following the introduction of the TrakCare system, with outstanding issues in relation to system and user performance. Work was on-going to rectify the situation to ensure the accuracy and completeness of the data was recovered. The Trust performed above the national average in November for incomplete pathways and had no over 52 week waits in quarter 3. It was refreshing its capacity and demand model to fully understand the demands within the system in respect of current and forecast pressures. The Trust achieved against a number of core cancer standards in November, however, under-achieved against the cancer 62 day referral to treatment standard due to significant system pressures, specifically in relation to referrals involving tertiary centres and complex pathways. The un-validated quarter 3 position reported achievement against all the cancer 8

14 standards with the exception of the 62 day consultant upgrade standard, reporting at 70.59% against a target of 85%, however, this was a supporting target and not part of the national reporting requirement. An increase in referrals as a result of cancer awareness campaigns had placed a significant amount of pressure on diagnostic services and achievement of the 2 week wait standard. Work was on-going with GPs in respect of the uptake of patient choice to be seen within the required timescales, and with CCG partners to review the system wide approach in managing cancer pathways. From November 2015 trusts were required to report weekly all patients who had breached beyond 104 days from referral to treatment. KR, Chair of the Infection Control Committee, sought to understand the position in respect of breaches against the 62 day referral to treatment standard. The COO/DCE explained that for complex cases patients were referred to tertiary centres, and when delays occurred it negatively impacted achievement of the standard. A robust governance process had been established between the Trusts to identify avoidable and unavoidable breaches, and identify which organisation or both were responsible and therefore share the breach. The number of cancer awareness campaigns placed further pressure on the pathway. A new national antismoking campaign would be commencing on 1 February. The Trust reported non-medical cancelled operations at 0.15%, against the CQC target of 0.8%. In quarter 3 no urgent procedures had been cancelled. New Outpatient DNA was above the stretch target of 5.40% at 10.26%, and Review DNA rates were 14.30% above the 9% target. Work was on-going to improve the position, which during quarter 3 was impacted by the automated reminder service being disabled throughout the implementation of TrakCare. In December the Trust reported outside the annual trajectory of 13 cases for clostridium difficile with 25 cases, and 2 cases of MRSA during quarter 3, against a zero tolerance. SH, Chair of the Transformation Committee, sought clarity regarding assistance from local authority partners in respect of admission avoidance, patient flow, and timely discharges. The COO/DCE explained that the Trust was working with primary care and local authority partners to develop integrated pathways, and establish a clinical triage facility within the Single Point of Access (SPA). The CE reiterated that he had had positive discussions with Gill Alexander, CE, Hartlepool Borough Council in respect of reducing bed blocking and expediting discharges through input from social care. Due to the limited number of care homes currently in Hartlepool patient choice arrangements were being reviewed. BoD/3034 Resolved: (i) that, the current position and risks to performance be noted; and (ii) that, the continued pressures, particularly in emergency care and cancer services be noted. Finance and Contract Performance Report The DoF,ICT&SS presented the Finance and Contract Performance Report as at 31 December and drew members attention to the key points. The Trust reported an operational deficit of 7.729m, which was 3.129m behind the planned deficit for the period of 4.600m. The deficit had stabilized for the second consecutive month. At month 7 the forecast outturn had been modeled for best, worst and most likely scenarios and the most likely forecast outturn was revised to 7.442m. The Trust had recently undertaken a self-assessment against the Monitor Grip and Control Checklist, and had invited Northumbria Healthcare NHS Foundation Trust, who was reporting a surplus position, to undertake a peer review of this assessment to provide external assurance and to highlight any areas requiring improvement. 9

15 There was an over recovery of income of 2,210k against plan, which was due to increased emergency activity and phasing in all of the winter resilience funding. An additional 1,000k of risk income was still reflected in the financial position, which was from the deferred government grant. Due to issues following the implementation of TrakCare in October 2015, only estimated data was available for month 7, 8 & 9, and an assumption of over performance in line with activity at month 6 had been applied. Pay budgets were over spent against plan by 1,550k, with the main area of risk being recourse to agency and locums to cover vacancies and maternity leave; however, this was reduced compared to previous months. The Trust had exceeded the 3% cap on agency nursing as a percentage of the in-month nursing pay bill; however, the cumulative quarter position was within target. Non pay budgets were underspent by 189K with a worsening trend for in month overspends as a result of increased activity. The gross Service Improvement & Efficiency Programme (SIEP) target for 2015/16 of m had been reduced to 6.235m as a result of recurrent and non-recurrent schemes actioned during the month. The Trust had delivered 5.188m of its in year SIEP, with 2.418m recurrent and 2.248m non-recurrent, and the balance of 0.522m being cash releasing avoidance. A target for directorate specific programmes had been set for the year of 6.630m and at month m savings had been made. The Transformation Programme was allocated a target of 4.271m, and at month 9 522k of cost avoidance schemes had been delivered and 297k had been delivered through VAT rebates. Further work on identifying and delivering recurrent SIEPs continued. The Trust expected to deliver the revised forecast outturn of 7.4m. Net cash flow for quarter 3 was an increase of 0.013m, resulting in an increase of cash from m to m, and net current assets had decreased by 4.874m to m. The original capital allocation for 2015/16 was m which included 2.0m of external financing, however, the Trust has decided not to go ahead with the financing and had adjusted the capital allocation accordingly. To date 5.556m had been spent on capital schemes and 1.941m of further commitments had been identified. It was noted that the analysis of performance against the new financial sustainability risk ratings demonstrated that the Trust continued to report a risk rating of 2, indicating a material risk of intervention from Monitor. Had the metrics not changed the risk rating would be 3. BD, Chair of the Audit Committee expressed concern in respect of the estimated position in relation to projected income from the CCGs including the insufficient winter funding allocated to the Trust, and the resulting impact on the cash position in having to fund the shortfall. The Chairman agreed and explained that a meeting was required with the CCG as a matter of urgency. Resolved: (i) that, the current financial position be noted; and (ii) that, the analysis of performance against the Financial Sustainability risk ratings be noted; and (iii) that, a meeting with HAST CCG be arranged in respect of winter funding. BoD/3035 Operational Efficiencies Report The COO/DCE presented the Operational Efficiencies Quarter 2 Report and drew members attention to key points. 10

16 The challenges faced by the Trust with the current and forecast economic climate continue, with the added challenge of maintaining quality and safety, whilst delivering operational efficiencies. In addition, Lord Carter s Report in respect of efficiencies outlined that all areas of productivity and expenditure required scrutiny, which placed further challenge on organisations to apply a stronger grip on the use of assets and resources. Radical changes were required system wide to ensure it remained fit for future delivery of health and social care. Progress, actions and achievements to date were provided. In summary, the Trust demonstrated a positive quarter 2 position against its operational efficiency performance indicators, which was attributed to the continued efforts of the clinical teams and service lines. The development of the Clinical Services Strategy (CSS) to develop a service fit for the future had presented additional challenges, along with slow progress of the integrated working requirements of the former Better Care Fund (BCF). KR, Chair of the Infection Control Committee, sought to understand the context of efficiencies and staffing in relation to the acuity of patients. The ADoN,PS&Q explained that following the high volumes of activity in October and November 2015 a review of the acuity of patients was required and validation of professional judgement. The Safer Nursing Tool catagorises patients into levels of acuity to ensure the right staff with the right skills were in the right place at the right time, which was reviewed regularly. JE, sought to understand work in relation to improving Average Lengths of Stay, although the Trust s performance amongst its peers was good, explaining that a piece of research from a trust in Manchester highlighted that the hour of admission was more important than the day of admission. The COO/DCE explained that work was ongoing to consider alternative staffing models during peak periods of activity to assist with patient flow, which prompted discussion. BoD/3036 Resolved: (i) that, the content of the report be noted; and (ii) that, the progress to date be noted; and (iii) that, the future challenges and risks to deliver be noted. Human Resources and Education Report The DoHR&E presented the Human Resources and Education 2015/16 Quarter 3 Report. The Trust headcount had increased by 48 from 5393 at year end 2014/15 to 5441 at quarter /16. The turnover rate was 12.92% in quarter 3, compared to 13.06% in quarter 2, which included the change-over of foundation doctors. The number of new starters had decreased by 70 to 172 compared to quarter 2, and there were fewer leavers at 130. Flexi retirement remained the top reason for leaving. To assist with the number of RGN vacancies, a recruitment campaign was held in the Philippines in July 2015, and in Romania in November 2015, in conjunction with NHSP. 39 applicants from the Philippines received an unconditional job offer, and 14 nurses were appointed from Romania, however for the first 12 months they would be employed by NHSP. Both cohorts of staff were expected to begin work in early Successful candidates for the Care Support Worker Development Programme commenced on the programme on 4 January The sickness absence rate was 4.66% and the number of sickness episodes had increased by 183 compared to quarter 2. The 3 main reasons for sickness absence remained the same: anxiety/stress/depression; musculoskeletal and gastrointestinal problems. Regional 11

17 sickness absence figures in quarter 1 and 2 illustrated that the Trust continues to be below the regional average. In quarter 3 the Trust s overall compliance level for training was 95% and despite winter pressures and escalated NEEP levels had achieved green status in the following areas: blood transfusion; acute kidney injury, and fire training. The quarter 3 Staff Friends and Family Test (SFFT) was undertaken as part of the 2015 Staff Survey. The results were expected in February. Simulation training continued to improve with the installation of new technology as well as the development of links with various specialities in the Trust, and continued to be delivered to nursing staff, midwives, doctors in training, and medical students. The Team has also developed links with allied health staff, increasing the potential to expand simulation training into those areas. A significant amount of work had been undertaken with Directorates in respect of the Clinical Service Strategy, including a series of staff workshops and workforce projections. BoD/3037 Resolved: (i) that, the content of the report and current position be noted; and (ii) that, the improvement to sickness rates be noted; and (iii) that, the recruitment of international nurses be noted. Quarter 3 Compliance Report to Monitor The COO/DCE presented the Quarter 3 Compliance Report to Monitor. Monitor s risk-based framework assigns 2 risk ratings: Continuity of Service and Governance conditions to each foundation trust on the basis of its forward plan and in-year performance against that plan, and consequently the risk of breach of Continuity of Service or Governance conditions of the licence. The Trust declared delivery of the clostridium difficile standard as a risk for 2015/16 with a declaration of non-compliance in the Operational Plan. In addition, the risk of underachievement against access and cancer standards was anticipated and acknowledged in the Annual Plan. In quarter 3 the Trust has under achieved against 2 of the key targets; clostridium difficile, and the A&E four hour wait standard and full analysis was provided. The Trust had raised concerns with regards to the unrealistic clostridium difficile annual trajectory with NHS England. The Trust had achieved an overall aggregate score of 2, and in line with the Risk Assessment Framework this could trigger Monitor intervention. The Trust had submitted a full update of the current position and on-going actions to improve the position, including inviting external organisations to provide independent assurance. Resolved: (i) that, the content of the report and current position be noted; and (ii) that, the underachievement against the clostridium difficile and A&E four hour wait standard be noted; and (iii) that, delegated responsibility be passed to the Chairman to sign the governance statement on behalf of the Board of Directors as noncompliant; and (iv) that, the declaration of at risk in the Annual Plan be noted. 12

18 BoD/3038 North Tees and Hartlepool NHS FT Charitable Funds Accounts 2014/15 The DoF,ICT&SS presented the North Tees and Hartlepool NHS Foundation Trust Charitable Funds Accounts 2014/15 and drew members attention to key points. The accounts were independently audited by the Trust s external auditors, Price Waterhouse Coopers, and since the time of writing had made some minor changes, which were outlined. Resolved: BoD/3039 a. HUG Visits that, the Board of Directors approve the Charitable Funds Accounts for 2014/15. Any Other Notified Business Bill Johnson, the Healthcare User Group (HUG) Representative reported that no visits had taken place since the last meeting, due to illness amongst the HUG members. b. HAST CCG The Chair of HAST CCG, noted the improvements in respect of mortality and acknowledged the Trust s successful acceptance as a GS1 project pilot site. In relation to the data recording and reporting issues following the implementation of TrakCare in October 2015 he reported that this had also impacted GP colleagues. BoD/3040 Date and Time of Next Meeting Resolved: that, the next meeting be held on Thursday, 28 April 2016, at 1.00pm in the Boardroom, University Hospital of Hartlepool. BoD/3041 Signed: Exclusion of Press and Public Resolved: that, representatives of the press and other members of the public be excluded for the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2), Public Bodies (Admission to Meetings) Act 1960). The meeting closed at 3.10pm. Date: 13

19 North Tees and Hartlepool NHS Foundation Trust Minutes of an Extra Ordinary meeting of the Board of Directors held on Monday 4 April 2016 at the University Hospital of North Tees Present: Paul Garvin, Chairman* Rita Taylor, Non-executive Director* Steve Hall, Non-executive Director* Jonathan Erskine, Non-executive Director* Kevin Robinson, Non-executive Director* Alan Foster, Chief Executive* Julie Gillon, Chief Operating Officer/Deputy Chief Executive* Lynne Hodgson, Director of Finance, ICT and Support Services* Caroline Trevena, Acting Director of Finance Ann Burrell, Director of Human Resources and Education Deepak Dwarakanath, Medical Director Designate* Julie Lane, Acting Director of Nursing, Patient Safety and Quality* Barbara Bright, Company Secretary In attendance: Sarah Hutt, Assistant Company Secretary (Note taker) BoD/3064 Apologies for Absence Chairman RT SH JE KR CE COO/DCE DoF,ICT&SS ADoF DoHR&E MD Desig. ADoN,PS&Q CS Apologies for absence were reported from Brian Dinsdale, Non-executive Director and David Emerton, Medical Director. BoD/3065 Declarations of Interest There were no declarations of interest on open agenda items. BoD/3066 Annual Plan The COO/DCE and ADOF jointly presented the Trust s draft Operational Annual Plan for 2016/17, and Sustainability and Transformation Plan Summary to 2020/21, due for submission on 11 April The COO/DCE reminded members of the content and purpose of the Annual Plan, and the Board of Director s responsibility. It forms part of Monitor s Risk Assessment Framework, which from 1 April 2016 became NHS Improvement. Part of the Risk Assessment Framework and a test of being Well Led was an organisation s ability to effectively selfregulate, and to date the Trust had no enforcement action placed upon it in respect of performance, due to its continued effective communication monitoring and management of key improvement actions with Monitor. The Five Year Forward View provided the bedrock of forecast planning to ensure clinical, operational and financial sustainability, and included 10 key objectives: Accelerate design and implementation of new care models Joint working across health and social care Improving productivity, quality and outcomes Improving patient safety 1

20 Meeting NHS Constitution standards Achieving parity for mental health Transforming care of people with learning disabilities Harnessing the information revolution A modern health and care workforce Priorities for operational delivery The NHS was moving towards a system wide infrastructure and change with system leaders, rather than individual localities as part of the Sustainable and Transformation Plan, and through the Better Health Programme. Large scale change was required to ensure future resilience and sustainability of the health system overall, with increasing demand for services, an ageing population and budget cuts. The Sustainability and Transformation Plan (STP) sets out 9 footprint areas nationally, with 9 must do actions which include: Develop high quality STP Return system to aggregate financial balance Address sustainability and quality of general practice Delivery of A&E access and Ambulance waiting times standards Delivery of RTT access standards Delivery of 62 day Cancer standard and progress on improving one-year survival rates Achieve mental health access standards and continue to improve dementia diagnosis rate Transformation of care for patients with Learning Disabilities Implement affordable plans to provide improvements in quality, including publication of annual mortality rates The Trust was actively taking forward aspects of this work already including collaborative working with other trusts and partners within the locality, and developing new models of care. The CE had recently been appointed as Sustainability and Transformational Programme Lead for Durham, Darlington and Tees, Hambleton, Richmondshire and Whitby footprint, which would further advance this work by looking to develop local blue prints for improved healthcare and finances over the next 5 years. The Trust s Corporate Strategy was well embedded within the organisation and the strategic themes aligned to all aspects of its functions including the Clinical Services Strategy. The Trust s key priorities to ensure delivery of quality, safety, and operational performance included: Quality and Safety of Services Patient Satisfaction Staff Satisfaction Maintain and improve core services and become the provider of choice for tendered services Governance The COO/DCE outlined the Trust s implementation plan categorising the priorities into quality, access and finances, highlighting performance in respect of the emergency care, cancer, and referral to treatment (RTT) standards for 2015/16, which constituted residual risks to the Trust. The Trust had seen an overall increase in A&E attendances, admissions and the acuity of patients, and an increase in pressures out of hours, with surges of activity occurring at 8pm and 11pm. Pressures were being felt system wide which further impacted the Trust, and an 2

21 immense amount of work was being undertaken to explore different models of care in conjunction with primary care, including trialing a number of pilots, and new ways of working which prompted discussion. The impact of the Urgent and Emergency Care Review was awaited, however, a transitional Urgent and Emergency Care Model was in the process of being developed which was designed to alleviate the current pressures being faced by managing urgent and emergency care through different routes. There were a number of challenges being faced in respect of achievement of the cancer standards, including patient choice, complex pathways, tertiary pathways, capacity issues and increases in referrals under the 2 week rule. In context, the Trust had received 1314 lung related referrals during 2015/16 under the 2 week rule, which represented 26.3% of all referrals across the North East Cancer Network that included 9 trusts, and was more than double of the neighboring cancer centre. The number of conversions from referrals was c.7%. The Trust would not achieve either the 2 week rule or 62 day referral to treatment standards at quarter 4. Changes to the inter provider transfer guidance were being made which would create further challenges to achieve the pathway standards. A large amount of work was being undertaken as part of the Cancer Improvement Plan including trying to influence system wide change and specifically work with the GP Federation in Hartlepool and Stockton to look at pre-referral triage and management. The Trust had consistently achieved the RTT standards, which had changed in October 2015; however, issues following the implementation of the new patient record system, TrakCare and immense pressure on elective services during the winter period including sustained increased NEEP levels and junior doctor strike action had impacted performance and would mean a starting position of 92.5% for 2016/17. A recovery plan was in place to ensure cancelled patients were re-appointed within the required timescales and a capacity/demand review was being undertaken. The ADoN,PS&Q provided an overview of the clinical and quality priorities and highlighted performance against key areas. The Trust had breached its clostridium difficile annual trajectory of 13, with 35 cases being reported at 31 March The target for 2016/17 would remain at 13 cases which would be a challenge, and would be highlighted as a risk of delivery in the Annual Plan. However, work in relation to the Improvement Pan would continue including reinstating a decant ward to facilitate the enhanced cleaning and fogging programme, reviewing the clostridium difficile treatment policy, continuing and extending the antibiotic audit programme, and training and awareness campaigns to promote the importance of hand hygiene. The Trust had also been invited to take part in a national 90 day improvement programme aimed at reducing the risk of clostridium difficile. The Trust was compliant against all criteria in respect of learning disabilities, however, would continue to focus on further improving access and services for patients with learning disabilities. Following the Care Quality Inspection (CQC) in July 2015, the CQC had signed off the Trust s action plan which contained 14 must do items, the majority of which were complete. Regular progress updates would be provided to the Board of Directors and Patient Safety and Quality Standards Committee. The ADOF outlined the provisional financial assumptions for 2016/17, which had been approved by the Finance Committee. The assumptions would remain draft until contract negotiations were finalised. A surplus of 1.9m was forecast and an efficiency target of 7.9m, which was a reduction on the previous year s target, however, assumptions included 7.9m sustainability and transformation funding and utilisation of a government grant of 2.8m. The Trust s predicted Financial Sustainability Risk Rating by year end would be 4, should all the targets be met. 3

22 The funding for winter pressures was still to be agreed as part of the contract negotiations, and it was recognised this was a key issue given the level of non-funded expenditure incurred by the Trust during this winter that had far exceeded the winter funding allocation of 1.3m from HaST CCG, due to the unprecedented demand on services. A Capital Programme of 11.2m was assumed, including 4.6m in respect of infrastructure work for the University Hospital of North Tees, following approval of a 25m loan to undertake vital work including building a new energy centre to ensure the site remained fit for purpose. It was noted a number of large pieces of medical equipment were due for renewal which could impact the overall capital budget. A number of risks including service developments were outlined which prompted discussion. In summary the Board of Directors was required to be able to declare the organisation as a going concern, to be well governed, to operate effectively, to remain compliant with the conditions of the NHS Provider Licence, and to self-certify against the corporate governance statement. Well led was an aspect that would require focus during 2016/17, having been highlighted as requires improvement in the CQC inspection, and the requirement for trusts to undertake an external review of well led processes every 3 years. The Board of Directors was required to consider the current position, progress and situational risks, and the ability to assure itself in respect of the Corporate Governance Statement. In considering the self-certification statements it was resolved that: BoD/3067 Availability of Resources Statement (1b): The Trust would have the required resources available, subject to sufficient resources for winter and commissioner plans for primary care and demand management; in additiona to a recognised system wide approach to support delivery of the access standards and tackle residual risks to the Trust; Declaration of interim and/or planned term support requirements to be declared as not required; Statement of main factors taking into account in making the above declarations supported by the resources statement and to indicate non achievement of the Clostridium Difficile trajectory; Declaration of review of submitted data The Board of Directors was satisfied that adequate governance measures were in place to ensure the accuracy of data, with concern in respect of achievement of the clostridium difficile trajectory and Access Standards: Referral to Treatment, Emergency Care and Cancer 62 day Standards; The Board wish to confirm therefore the submission of the final operational plan for 2016/17 that would meet the required financial control for 2016/17 thereby agreeing to the conditions associated with the Sustainability and Transformation fund, notwithstanding residual risks and the statement of main factors which have been taken into account as above. Any Other Business There was no other business notified. Resolved: that, the information be noted. The meeting closed at 2.00pm. Signed: Date: 4

23 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Chairman s Report Report of the Chairman Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Manage Our Relationships Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Effective Board Governance 1. Introduction 1.1 The Chairman s Report aims to provide information to the Board of Directors on key local, regional and national issues. 2. Key Issues and Planned Actions 2.1 The following consultant appointments have been made since the last meeting: Dr Kate Armitage, Consultant Physician Medical Education & Acute Medicine Dr Rosin Bevan, Consultant Gastroenterologist Dr Eisha Omar, Consultant Rheumatologist Mr Narendra Ramisetty, Consultant Trauma & Orthopaedics Dr Suma Kodiathodi, Consultant Obstetrician & Gynaecologist Dr Lucy Lowery, Consultant Palliative Care In addition the following board appointments were made: Graham Evans, Chief Information and Technology Officer, and Deepak Dwarakanath, Medical Director. 2.2 The Chief Executive will provide a briefing to the Board in respect of changes to the Assisted Reproduction Unit (ARU), however, I would like to highlight that this is a very small service dealing with about 180 patients per year; 20% of whom are from Hartlepool i.e. 36 per year, which is less than 1 per week. 2.3 Alan and I met with Alex Cunningham, MP for Stockton North and Phil Wilson, MP for Sedgefield to discuss current issues affecting the Trust. 2.4 I attended an NHS Improvement Conference in February and an NHS Providers Chairs and Chief Executives event in March, both were held in London.

24 2.5 Alan and I met with the Chairs and Chief Executives of South Tees Hospitals NHS Foundation Trust to further discuss collaborative working and how to take forward work in respect of the Sustainability and Transformation Plan. 3. Recommendations 3.1 The Board of Directors is asked to note the content of this report. Paul Garvin Chairman

25 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Chief Executive s Report Report of the Chief Executive Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Manage Our Relationships Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Effective Board Governance 1. Introduction 1.1 The Chief Executive s Report aims to provide information to the Board of Directors on key local, regional and national issues. 2. Key Issues & Planned Actions 2.1 On 5 April 2016 a consent order was agreed by the Court in relation to the way forward in order to determine the future of the Assisted Reproduction Unit at the University Hospital of Hartlepool. The Trust is required to enter into engagement and consultation on the future of the licenced fertility treatments at the Unit. This will be led by the Stockton and Hartlepool Clinical Commissioning Group who will be supported by the Trust. In the meantime, the current status quo will remain in place and we are required to use our best endeavours to do this until a final decision about the future of the Unit is taken. 2.2 Board members will be aware that the British Medical Association will escalate the industrial action in relation to the junior doctor s dispute. Full withdrawal of labour provided by the junior doctors will take place from 8 am to 5 pm on Tuesday, 26 and Wednesday, 27 April This action will provide additional risk to the Trust which will need to be managed and will require the majority of our out-patient and elective patient activity to be cancelled. I wish to reassure the Board that contingency planning is taking place in order to minimise the impact of the strike and in order to ensure that all patients requiring urgent and emergency care can be safely dealt with. 2.3 I have had a constructive meeting with Gill Alexander, Chief Executive of Hartlepool Borough Council to discuss our plans for the Hartlepool hospital site. She has arranged for me to meet with David Colin-Thomé, Independent Chair of the Local Health and Social Care Plan Working Group who is leading the work with the Council and the CCG to develop proposals for local consideration. The outcome of this work will be to jointly agree a development for the Hartlepool site in order to see and treat as many patients locally as possible. 1

26 2.4 Since the Board last met I have been formally appointed to lead the development of a Sustainability and Transformation Plan (STP) for Durham, Darlington and Tees, Hambleton, Richmondshire and Whitby. There are nine footprints across the North of England and these are set out in appendix 1. In appendix 2 I have set out the timetable to be followed in order to produce an STP by 30 June Recommendations 3.1 The Board of Directors is asked to note the content of this report. Alan Foster Chief Executive 2

27 D ra ft Appendix 1 3

28 Appendix 2 4

29 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Care Quality Commission Report Update Report of the Acting Director of Nursing, Quality and Patient Safety Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) 1. Introduction 1.1 The purpose of this report is to update the Board of Directors on the progress against the Care Quality Commission (CQC) action plan following the CQC announced inspection on 7-10 July 2015 and the unannounced follow up visit on 29 July An unannounced visit was undertaken on 29 July 2015, which is in line with the CQC inspection process. The team visited three clinical areas with one inspector observing the Trust mortality review meeting. 1.3 Following the inspection a report was received by the Trust which gave an overall rating of Requires Improvement based on an assessment of core services and corporate functions under the five domains. 1.4 The Trust was rated as good for caring and responsive and requires improvement for safe, effective and well led. 1.5 Fourteen areas were identified within the report as must do s with further areas as being recommended to consider review. 1.6 A comprehensive action plan which included the above fourteen areas in addition to the areas which were suggested for review was developed following a Quality Summit and submitted to the CQC within 28 days of the summit and was agreed by the CQC in mid March Delivery of the action plan is overseen and monitored by the Trusts internal CQC project board led by the Acting Director of Nursing, Quality and Patient Safety. 1.8 A CQC web page has been developed on the Trusts internet site to show progress to against the comprehensive action plan and next steps in achieving full implementation of the plan within the agreed timescales. 1

30 2. Recommendations 2.1 The Board of Directors is requested to note the progress to date against the CQC inspection action plan 2.2 The Board of Directors are asked to note the way forward in regard to transparent ongoing monitoring of the action plan. Julie Lane Acting Director of Nursing, Quality and Patient Safety 2

31 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Care Quality Commission Report Update 1. Introduction Report of the Acting Director of Nursing, Quality and Patient Safety As part of the regulatory requirement for NHS organisations North Tees and Hartlepool NHS Foundation Trust underwent an inspection by the Care Quality Commission (CQC) from 7-10 July The inspection was based on defined national standards in relation to the five key domains which assess whether services are: Safe, Caring, Effective, Responsive to people s needs and Well Led. 2. Background 2.1 The inspection of both acute and integrated care services commenced on 7 July 2015 lasting until 10 July The inspection was led by a Head of Hospital Inspection supported by a team of CQC inspectors and managers, clinical experts and experts by experience/patient and public representatives. 2.2 The team undertook a number of focus groups and group and individual interviews in addition to observing practice on ward and department areas.including a review of documentation. 2.3 The Trust was commended for the welcome by the organisation with particular comment on the openness and responsiveness of all staff during the inspection. 2.4 An unannounced visit was undertaken on 29 July 2015, which is in line with the CQC inspection process. The team visited three clinical areas with one inspector observing the Trust mortality review meeting. 3. Action Plan 3.1 Following the inspection a report was received by the Trust which gave an overall rating of Requires Improvement based on an assessment of core services and corporate functions under the five domains. 3.2 The Trust was rated good for caring and responsive and requires improvement for safe, effective and well led. 3.2 Fourteen areas were identified within the report as must do s with further areas as being recommended to consider review. 3

32 3.3 The fourteen areas requiring improvement were: Ensure there are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist. Ensure staff follow Trust policies and procedures for managing medicines, including controlled drugs. Ensure that medicines are stored according to storage requirements to maintain their efficacy in maternity services. Ensure that risk assessments are documented along with personal care and support needs and evidence that a capacity assessment has been carried out where required. Ensure pain in children and young people is assessed and managed effectively. Ensure that the competency criteria for staff triaging patients are clearly documented and include recognised competency based triage training. Ensure that infection control procedures are followed in relation to hand hygiene and use of personal protective equipment. Ensure that resuscitation and emergency equipment is checked on a daily basis in line with Trust guidelines. Ensure cleanliness standards are maintained. Ensure effective systems are in place which enables staff to assess, monitor and mitigate risks relating to the health, safety and welfare of people who use the service. Ensure that all policies and procedures in the In-Hospital care directorate are reviewed and brought up to date. Midwifery policies, guidelines and procedural documents must be up to date and evidence based. Ensure there are always sufficient numbers of suitably qualified, skilled and experienced staff to deliver safe care in a timely manner. Ensure that all annual reviews for midwives take place on a timely basis. Ensure all staff attend the relevant resuscitation training A quality summit was held 29 January led by the CQC to which all key stakeholders were invited. A draft action plan was presented to the summit and further work was undertaken to refine the plan. 3.5 A comprehensive action plan which included the above fourteen areas in addition to the areas which were suggested for review was developed and submitted to the CQC within 28 days of the summit and was agreed by the CQC in mid-march All areas identified within the action plan are either complete or have a plan or process in place to ensure they are delivered in line with the identified timescales. The action plan and progress to date for the fourteen identified areas as requiring improvement can be found in Appendix Monitoring 4.1 Implementation of the action plan is via the Trust s CQC operational group which has representation from the core services in addition to appropriate corporate functions. 4.2 Delivery of the action plan and the work of the operational group is overseen and monitored by the Trusts internal CQC project board led by the Acting Director of Nursing, Quality and Patient Safety. 4

33 4.3 In order to ensure transparency a CQC web page has been developed to show progress to date against the comprehensive action plan and next steps in achieving full implementation of the plan within the agreed timescales. 5. Conclusion 5.1 The Trust underwent an announced inspection of its services by the CQC in July The report which was generated d following the inspection identified that there were areas within the organisation which required improvement and other areas where it was recommended the Trust reviewed services 5.2 A comprehensive action plan was developed following a quality summit held in January 2016 which was by the CQC in March An update against the fourteen areas requiring improvement can be found in Appendix Monitoring against delivery of the plan is overseen by the CQC Project Board with the progress available on the Trust CQC web page. 6. Recommendations 6.1 The Board of Directors is requested to note the progress to date against the CQC inspection action plan 6.2 The Board of Directors are asked to note the way forward in regard to transparent ongoing monitoring of the action plan. Julie Lane Acting Director of Nursing, Quality and Patient Safety 5

34 CQC Inspection Action Plan Update April 2016 Required Outcome Actions Lead Timescale Status Appointment of senior nurse with a Acting Director specific focus on of Nursing, Complete nursing and Quality and midwifery workforce Patient safety 1 Sufficient numbers of suitably qualified, skilled and experienced staff will be available to deliver safe care in a timely manner Review of registered and unregistered nursing staff establishments and requirements Development of the model ward team Refresh of recruitment strategy Assistant Director of Nursing Standards and Workforce Assistant Director of Nursing Standards and Workforce Model delivered in a phased approach throughout 2016 Assistant Director of Nursing Standards and Workforce Pilot to be undertaken re medicine administration Appendix 1 All directorates have agreed current establishments, and vacancies. Staffing review April 2016 Other models under review. Currently working with pharmacy around medicine administration in order to complete phase 1. Plan to profile other roles and responsibilities Complete.

35 Ref. Outcome Actions Lead Timescale Status Audit of Kardex to be Head of Midwifery undertaken to include and Children s February Complete 2 Administration Services /Senior 2016 Missed doses Clinical Matrons Quality of documentation Staff will comply with Trust policies and procedures when managing medicines including controlled drugs Monitor compliance with storage requirements through Staff, Patient Experience and Quality Standards visit (SPEQS) A&E - Omnicell to be upgraded to ensure staff must have a patient identifier to obtain medications Monthly controlled drug (CD) check to be undertaken on each area Appropriate action will be undertaken where non compliance is identified Associate Director of Nursing and Patient Experience Directorate Management Team Monthly Ward/Department Matrons Head of Midwifery and Children s Services /Senior Clinical Matrons Maternity monthly drug Kardex audit commenced February 2016 In hospital Care weekly p review of 5 patient records per ward with specific measurable outcomes. Integral part of (SPEQS) SPEQS results reported within Quality Report to Board of Directors Complete Monthly Ongoing Within planned trust programme of work.. Medication errors will follow agreed process including reflection from the practitioner and review if further investigation is required.

36 Ref. Outcome Actions Lead Timescale Status 3 Pain in young children will be assessed and managed appropriately Pain score tool to be implemented within children s services Head of Midwifery and Children s Services April 2016 Minimise the likelihood of Monitor compliance risk by completing the 5 through audit 4 steps to safer surgery process/spot checks. August 2015 checklist 5 Resuscitation/emergency equipment will be checked on a daily basis in line with Trust guidelines Surgery to work with Anaesthetic directorate to ensure the 5 steps to safer surgery are maintained in line with Trust policy/procedures Monitored through perioperative services group Monitor compliance through Senior Clinical Matron rounds Spot checks will be undertaken Medical Director/Clinical Directors/ senior staff Clinical Director / GM Senior Clinical Nurse April 2016 Senior Clinical Nurse HoM Monthly Monthly Age appropriate pain charts/sop introduced April 2016, when processed via Health care records committee. Pain score also to be incorporated in the PEWS. Complete WHO checklist in use within theatres at time of inspection Complete Adapted tool utilised for ward /department based procedures Maternity check list re daily checks in place. A/E/ In hospital care the directorates have devised a plan of patient safety weekly ward rounds which will include a review of daily resuscitation equipment checks.

37 Ref. Outcome Actions Lead Timescale Status Hand Hygiene procedures will be Monitored through audit led by IPCT Local spot checks, Assistant Director of infection Procedure/tool in place 6 maintained by all staff Staff, Patient Experience and Quality Standards. Prevention and Control, Monthly Staff will utilise personal protective Local spot checks, Staff, Patient Assistant Director of Monthly Audits in place clothing where there is a risk of cross infection Experience and Quality Standards visit. infection Prevention and Control 7 Cleanliness standards will be maintained at all times Monitored locally. Cleaning standards audit in place Assistant Director of infection Prevention and Control, Monthly Maternity ward managers review area standards on a monthly basis. All policies, Ongoing monitoring Assistant Monthly Reported through audit committee. 8 guidelines and of corporate policies Director of procedures be up to Clinical date and evidence Governance based 9 All staff will attend the relevant Resuscitation training. Monthly RAG reports to ensure training is up to date. Non attendance flagged to GM s of staff not attending training. Ward Matrons, GM Clinical Directors Monthly monitoring/reporting Mandatory training compliance of nursing staff reviewed at senior staff and ward matron 1:1 meetings.

38 Ref. Outcome Actions Lead Timescale Status On going monitoring of Assistant Director of In line with 3 implementation of risk Clinical Governance year Risk Progress in line with strategy management strategy. Management strategy plan 10 Board seminar to review implementation of Board Assurance November Framework and Company Secretary 2015 Complete undertake assessment of risk ratings and risk appetite Effective systems will be in place to enable staff to assess, monitor and mitigate risks to staff and those utilising our services Board seminar for end of year review and agreement of strategic risks/key milestones for 2016/2017 Collaborative work with internal audit re Board Assurance Framework and risk registers to ensure future alignment Development of Risk Committee ensuring appropriate governance and reporting structure in place Company Secretary May 2016 Company Secretary /Assistant Director Clinical Governance Complete Acting Director of Nursing, Quality and Patient Safety April 2016 Work undertaken with internal audit and presented to Board of Directors in early April 2016 Complete Risk management committee proposal presented to and supported by Board of Directors in early April 2016

39 11 12 Risk Assessments will be appropriately documented including those for personal care needs and capacity assessments All policies, guidelines and procedures be up to date and evidence based Strengthening of Risk and Governance Management Structure Enhanced risk management training to be implemented All assessments will be completed within given times scale inclusive of reassessments when appropriate. Assessments monitored through local documentation audit through Health Care Record Audits Staff, Patient Experience and Quality Standards visit. Implementation of bimonthly obstetric and gynaecology guideline meeting Monitoring of guidelines through bi- Acting Director of Nursing, Quality and Patient Safety Assistant Director Clinical Governance/Risk Manager General Managers /Heads of Department/ Senior Clinical Nurses SPEQS team General Manager/Head of Midwifery and Children s Services General Manager/Head of Organisational Change commenced 6 April 2016 Workshops delivered to patient safety leads To commence Complete Formal Training programme commenced February 2016 Monthly April 2016 Complete - elearning and workbooks developed and implemented A/E/In hospital care - directorates undertake weekly patient safety walk rounds to monitor compliance for those patients requiring risk assessments as per policy. Maternity implementing adapted intrapartum WHO maternity check list Standing agenda item Complete bi-monthly obstetric and gynaecology guideline meeting in place Monitoring in place Standing

40 13 Annual reviews will be maintained within the 1% threshold monthly patient safety meetings in maternity services Implementation of bimonthly In hospital patient safety meetings Annual reviews will be completed in line with requirements. Appointment of a full time contact supervisor of midwives to oversee midwifery supervision requirements and compliance Compliance will be monitored on a monthly basis by the contact Supervisor Annual review of compliance through the LSA audit process Midwifery and Children s Services General Manager//Directorate management team agenda item Standing agenda item Monitoring in place Supervisors of midwives Complete Head of Midwifery and Children s Services August 2015 Complete Full time contact supervisor appointed Contact Supervisor Monthly Remains within threshold Contact Supervisor August 2016 Revised date of 7 July 2016 received

41 14 Staff undertaking triage in A&E will be appropriately trained using competency based triage training Develop training Package Implement training package Training package to be delivered to all new staff in department. Roll out to existing staff and new starters from February 2016 Senior Clinical Matron Emergency Care Complete - Triage training package developed including PowerPoint presentation. Included in local induction programme Commenced

42 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Quality Report Report of the Acting Director of Nursing, Patient Safety and Quality Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Putting Patients First Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Putting Patients First/Patient Safety 1. Introduction 1.1 Section 2 describes the outcome of the Staff, Patient Experience and Quality Standards (SPEQS) reviews for the full financial year of 2015/2016 where 333 areas were assessed The overall score for 2015/2016 was 96.86% From all the visits in 2015/2016, 100% was achieved 174 times from 333 visits to the wards/areas 2015/2016 averages for the four indicators are: First Impressions, 97.20%, Patient Experience 98.58%, Nursing Evidence 93.03% and Staff Involvement 94.74% The SPEQS process will continue in 2016/2017 with some amendments to the reporting of data; this will give the Trust greater depth and information into specific issues or areas of good practice on each ward/area 1.2 Sections 3 and 4 describes mortality data with Trust HSMR and all-cause mortality data as being out of the as expected range. Latest Trust SHMI data is also reported as being out of the as expected range. This section provides additional information including benchmark data. The HSMR value continues to decrease from (Jan15 to Dec15) to (Feb15 to Jan16) The Trust crude mortality rate for HSMR has decreased to 3.57%from 3.90% The latest SHMI value is (Oct14 to Sep15); this has decreased from the previous value of (Jul14 to Jun15) 1.3 Section 5 describes the Trust s complaints data within the three complaints streams; Stage 1, Stage 2 and Stage 3. The Trust has received 1,314 complaints between 1 April 2015 and 31 March 2016, of which 295 (22.45%) are Stage 3 There are currently 82 open complaints, of which 39 (47.56%) are Stage 3 The compliance rate for responding within the 25 day deadline for February 2016 is %, with the 12 month rolling period (March 2015 to February 2016) averaging at 93.42% The Trust has reduced the number of formal Stage 3 complaints received into the Trust that require a written response from the Chief Executive from 331 in 2014/2015 to 295 in 2015/

43 1.4 Section 6 the Nursing and Midwifery Workforce Report This paper outlines registered and unregistered care staff fill rates across inpatient areas for the months of January, February and March 2016 (appendices 1, 2 and 3) 1.5 Section 7 describes the Safety Thermometer work for in and out of hospital care. The results for the Classic Safety Thermometer are as follows: Pressure Ulcers New: in 2015/ % of patients reviewed had a new pressure ulcer Falls with Harm: in 2015/ % of patients reviewed had a fall with harm Catheter and New UTI: in 2015/ % of patients reviewed had a catheter and a new UTI New VTE (venous thromboembolism): in 2015/ % of patients reviewed had a new VTE The Trust s overall Harm Free care for 2015/2016 was 97.91% 1.6 Section 8 describes the Trust s patient s falls For the 2015/2016 financial year, the Trust has had 33 patients who have suffered a fall with a fracture, 212 patients who have suffered a fall injury with no fracture and 947 patients who have suffered a fall no injury For the 2015/2016 financial year, the Trust experienced 1,192 patient falls. This represents a reduction from the 2014/2015 financial year of 296 falls. 1.7 Section 9 describes the Friends and Family Test The percentage of in-patients who would recommend the Trust s services to their friends and/or family for the financial year 2015/2016 is to 95.97% The percentage of patients who would recommend our Emergency Care (A&E and MIU) services to their friends and/or family for the financial year 2015/2016 is 90.43% The percentage of maternity patients who would recommend our services to their friends and/or family for the financial year 2015/2016 is 94.75% The number of responses for the out-patient s clinics during 2015/2016 was 12,164 The percentage of patients during 2015/2016 who would recommend our outpatient departments to their family and/or friends 89.58% 1.8 Section 10 describes the Quality Accounts 2015/2016 A draft version of the 2015/2016 Quality Accounts was developed in March 2016 and circulated to stakeholders in April 2016 with stakeholder third party narratives expected to be returned to the Trust by the end of April Section 11 describes the information on Never Events There have been two never events in this reporting year for the Trust relating to a retained foreign body post operatively and a wrong side pain relief injection. 2. Recommendation 2.1 The Board of Directors is asked to note the content of this report and acknowledge performance in compliance rates from the complaints team, the continued actions being undertaken to understand and improve the position for SHMI and the excellent improvement for HSMR, the work around the Friends and Famliy Test and the Safety Thermometer data. Julie Lane Acting Director of Nursing, Patient Safety and Quality 2

44 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Quality Report Report of the Acting Director of Nursing, Patient Safety and Quality 1 Introduction/Background 1.1 This quality report aims to describe progress in relation to the following aspects of patient safety and experience. Staff, Patient Experience and Quality Standards (SPEQS) Mortality update Hospital Standardised Mortality Ratio (HSMR) Mortality update Summary Hospital-Level Mortality Indicator (SHMI) Complaints update and performance Nursing and Midwifery workforce report NHS Safety Thermometer Falls data 2015/2016 Friends and Family data 2015/2016 Quality Accounts 2015/2016 Never Events Recommendations 2 Staff & Patient Experience and Quality Standards (SPEQS) 2.1 The Trust continues to embed the combined Acute and Community SPEQS process 2.2 The four sections being assessed are: First Impressions Nursing Evidence Patient Experience Staff Involvement 2.3 The following table relates to the 2015/2016 reporting year with the data currently available from April 2015 to March Q1 Q2 Q3 Q4 SPEQS Visit Month First Impressions 2015/2016 Nursing Evidence 2015/2016 Patient Experience Staff Involvement 2015/2016 April 94.81% 96.30% 98.85% 94.81% May 99.35% (G) 93.03% (R) 97.97% (R) 93.46% (R) June 94.70% (R) 93.18% (G) 98.57% (G) 97.73% (G) July No Visit due to CQC August 99.17% (G) 92.78% (R) 99.54% (G) 97.08% (R) September 98.33% (R) 90.83% (R) 98.43% (R) 89.58% (R) October No Visit due to NEEP Level November No Visit due to NEEP Level December 96.97% (R) 93.18% (G) 98.06% (R) 95.83% (G) January % (G) 91.85% (R) 99.01% (G) 94.07% (R) February No Visit due to NEEP Level March 97.22% (G) 92.59% (G) 98.15% (R) 95.83% (G) 3

45 2.4 The average value for all clinical areas for the 2015/2016 financial year was 96.86%. 2.5 Nursing Evidence completeness has increased in March 2016 to 92.59% from 91.85% in January The updated adult core assessment documentation is now a fundamental part of the patient assessment process, with the individualised care elements which enable holistic planning and delivery. 2.6 The following demonstrates the number of Wards/Areas that have achieved 100% Number of areas with 100% Number of areas visited % with 100% Apr % May % Jun % Jul-15 No Visit due to CQC Aug % Sep % Oct-15 No Visit due to NEEP 4 Nov-15 No Visit due to NEEP 4 Dec % Jan % Feb-15 No Visit due to NEEP 4 Mar % 2.7 The following table demonstrates the Trust s overall position from the SPEQS visits undertaken during 2015/2016. First Impressions Nursing Evidence Patient Experience Staff Involvement % 2015/2016 % 2015/2016 % 2015/2016 % 2015/ % 93.03% 98.58% 94.74% 2.8 There have been 865 toilets inspected since April 2015 of which 850 (98.27%) were seen to be clean on the day of the visit. Of those deemed as not clean at the time of inspection had just been visited by patients and were therefore in need of cleaning. 2.9 There have been 408 Commodes inspected since April 2015 of which 372 (91.18%) were seen to be clean on the day of the visit. Many of the commodes were clean but were not taped and/or signed and therefore they were marked as not clean The following table demonstrates the year on year trends for the four elements included in the SPEQS: 2011/ / / / /2016 First Impressions 91% 85% 92% 97% 97% Nursing Evidence 90% 87% 90% 91% 93% Patient Experience 98% 96% 97% 98% 99% Staff Involvement N/A N/A N/A 95% 95% 2.11 For the 2016/2017 financial year, the SPEQS process has been amended to ensure that all areas are included into the calculations. For example, if a toilet is inspected and failed, this would now count within the calculation, whereas in 2015/2016 it would not. 4

46 2.12 The Trust will continue with a reward and recognition scheme for all the wards/areas that achieve 100% for the four elements and also meet 100% on the clean toilets and commodes. This includes a signed certificate from Julie Lane (Acting Director of Nursing, Patient Safety and Quality) and a basket of fruit/box of chocolates For the 2016/2017 onwards, each area that fails to score 100% will receive a letter from Julie Lane (Acting Director of Nursing, Patient Safety and Quality). The letter will detail the areas that require improvement. Each letter will contain a trending table, so the ward/area can see if it is the same section failing constantly or if it varies. There will also be a Nursing Evidence section; this section will detail the scores for each visit for seven individual areas of nursing evidence reviewed, for example: fluid balance, medications or evidence of intentional rounding. This will allow ward matrons to focus on the areas identified with their team to improve performance. 3 Mortality - Hospital Standardised Mortality Ratio (HSMR) 3.1 Data reported in this document is taken from the Healthcare Evaluation Data (HED) tool which provides mortality data for HSMR up to September The latest HSMR value continues to show an improvement with the value being (February 2015 to January 2016); this has reduced significantly from (January 2015 to December 2015). This value continues to be outside the as expected range; the national mean is There are two other Trusts within the North East that also fall out of the as expected range for HSMR; with a third on the cusp of being out of the as expected range. 3.4 The Trust s rolling 12 month HSMR value has steadily reduced since the 12 month rolling period of April 2014 to March 2015, when the value was The following chart demonstrates the continued reduction to , a fall of points. 5

47 HSMR (12 Month Values) April 2014 to March 2015, peak of HSMR National HSMR Mean 3.5 The Trust crude mortality rate has decreased from 3.90% to 3.57% from the previous reporting period. 3.6 The following table demonstrates the Crude Mortality Rates (CMR) benchmarked against other North East Trusts. As the table demonstrates the Trust has the fifth highest regional CMR value. Trust Name HSMR Number of palliative discharges (rolling 12 month period) Crude mortality rate Trust % Trust % Trust % Trust % North Tees and Hartlepool NHS Foundation Trust % Trust % Trust % Trust % 3.7 Work continues in ensuring accurate recording of primary diagnosis, co-morbidities and specialist palliative care input to allow the model to be applied accurately to patients, assigning the appropriate risk to the value. 4 Mortality - Summary Hospital-Level Mortality Indicator (SHMI) 4.1 SHMI provides mortality data relating to deaths within 30 days of discharge from hospital and does not adjust for end of life care. The latest SHMI data has been released for the time period of October 2014 to September 2015 with the value reducing to from in the previous period; this is a fall of 3.15 points. 6

48 Trust Name SHMI Crude mortality rate North Tees and Hartlepool NHS Foundation Trust % Trust % Trust % Trust % Trust % Trust % Trust % Trust % 4.2 The Trust s crude mortality rate for SHMI continues to decrease from 4.45% (July 14 to June 15) to 4.27% (October 14 to September 15). 4.3 The Trust acknowledges that the HSMR and SHMI values are higher than expected and is working to embed a number of processes/reviews to gain a greater understanding of the quality of care being given to patients. 4.4 The SHMI trend tends to follow the HSMR trend; therefore the Trust can expect to see further falls in the SHMI value in the next few data releases from the Health and Social Care Information Centre (HSCIC). 4.5 The Trust continues to take a key role in regional Community Acquired Pneumonia Project and the Serious Infections SEPSIS Project, with informatics performed by Clarity (external data company) in both instances, both of these projects are running in conjunction with other North East Trusts. 5 Trust Complaints Performance 5.1 For the 2015/2016 financial year, the Trust has received 1,314 complaints; 71.92% were stage 1, 5.63% were stage 2 and 22.37% were stage 3. Currently there are 82 open complaints; 31.71% (26) are stage 1, 20.73% (17) are stage 2 and 47.56%% (39) are stage The Trust also monitors the type of complaints that are being reported. The category of complaint with the highest number is communication insufficient feedback to patients or relatives. Work is ongoing with Directorates to rectify this. 5.3 The themes are collated and aggregated analysis is considered in the Trust s quarterly Complaints, Litigation, Incidents and Performance (CLIP) report. The Directorates identify the top themes within their area and provide actions for improvement which is then followed up in the subsequent quarterly CLIP report. 5.4 In February 2016, the Trust s compliance rate was %, with a 12 month rolling average of 93.42% (March 2015 to February 2016) responded to within the 25 day deadline. 7

49 5.5 The Trust has reduced the number of formal Stage 3 complaints received into the Trust that require a written response from the Chief Executive from 331 in 2014/2015, to 295 in 2015/ NHS Safety Thermometer 6.1 The following data has been provided by the information collected via the NHS Safety Thermometer and includes both In Hospital Care and Out-of-Hospital Care for 2015/2016. Pressure Ulcers New: in 2015/ % of patients reviewed had a new pressure ulcer (90 patients from a sample of 10,904) Falls with Harm: in 2015/ % of patients reviewed had a fall with harm (59 patients from a sample of 10,904) Catheter and New UTI: in 2015/ % of patients reviewed had a catheter and a new UTI (49 patients from a sample of 10,904) New VTE (venous thromboembolism): in 2015/ % of patients reviewed had a new VTE (30 patients from a sample of 10,904) 6.2 The Trust s overall Harm Free care for 2015/2016 was 98.90% (10,583 patients from a sample of 10,904 7 Falls data for 2015/ During the 2015/16 financial year, the Trust experienced 33 falls resulting in a fracture; this total has decreased by six from the 2014/15 reporting period when the Trust had 39 falls with fracture. 7.2 The following table demonstrates the year on year trends from 2013 to / / /16 Apr May Jun Jul Aug Sep Oct

50 Nov Dec Jan Feb Mar Total From the 33 falls with fracture, 29 (87.87%) were aged 70+, with 11 (37.93%) of those patients falling out of hours (8pm to 8am) and 18 (62.06%) falling in hours (8am to 8pm). 7.4 During 2015/16, the Trust experienced 212 falls resulting in an injury and no fracture. This has decreased significantly by 143 falls from 2014/15 reporting period when the Trust experienced 355 falls resulting in an injury and no fracture. 7.5 The following table demonstrates the decrease from 2014/ / / /16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total From the 212 falls with fracture, 167 (78.77%) were aged 70+, with 88 (52.69%) of those patients falling out of hours (8pm to 8am) and 79 (47.30%) falling in hours (8am to 8pm). 7.7 During 2015/16 the Trust has experienced 947 falls resulting in no injury, this has decreased from 1,094 in the 2014/15 reporting period. 7.8 The following table demonstrates the trend from 2013 to / / /16 Apr May Jun Jul Aug Sep Oct Nov Dec

51 Jan Feb Mar Total From the 947 falls with fracture, 649 (68.53%) were aged 70+, with 317 (48.84%) of those patients falling out of hours (8pm to 8am) and 333 (51.31%) falling in hours (8am to 8pm) Overall for the 2015/2016 financial year, the Trust experienced 1,192 patient falls. This represents a reduction from the 2014/2015 financial year of 296 falls. 8. Nursing and Midwifery Workforce 8.1 The purpose of this section is to provide an overview of registered and unregistered care staff fill rates across inpatient areas for the months of January, February and March 2016 (appendices 1, 2, and 3). In addition, this section will provide a rationale for variances within the data where there are high or low percentages for either registered or unregistered care staff. 8.2 The information which is published on the NHS Choices website is an aggregate of the staffing data. Detailed information is published on the Trust website and is accessed via a link to the Trust s Safer Staffing web page from the NHS Choices website. 8.3 The detailed information is broken down into individual ward and departments with staffing information being expressed both in planned and actual hours and percentage fill rates over the month for both day and night duties. 8.4 Variances in percentage fill rates occur for a number of reasons including staff vacancies, sickness and maternity leave and in some areas higher than planned fill rates due to increased acuity and care needs of the patient group. 8.5 A report will be submitted to each Board with the previous months staffing data and reasons for variances. 8.6 The Trust has undertaken a number of recruitment initiatives and has welcomed a number of European Union and international nurses to the organisation during February and March 2016 a further cohort is due to arrive in April These staff are currently working towards registration with the Nursing and Midwifery Council. 9 Family and Friends Test (FFT) 9.1 The following data for Friends and Family relates to the full financial year of 2015/ In-patient Would recommend Wouldn t recommend data Number of forms returned Would recommend 10 Wouldn't recommend Apr % % May % % Jun-15 1,103 1, % % Jul-15 1,156 1, % %

52 Aug-15 1,072 1, % % Sep % % Oct % % Nov-15 1,064 1, % % Dec-15 1, % % Jan-16 1, % % Feb % % Mar % % 9.3 For the full financial year of 2015/2016, inpatient friends and family returns had 95.97% of patients stating that they would recommend the service(s) to friends and family, and 0.96% of patients stating that wouldn t recommend the services(s) to friends and family. 9.4 Emergency Care Would recommend Wouldn t recommend data Number of forms returned Would recommend Wouldn t recommend Apr % % May % % Jun-15* % % Jul % % Aug % % Sep % % Oct % % Nov % % Dec % % Jan % % Feb % % Mar % % *From June 2015 Minor Injuries Unit (MIU) data is included into the Accident & Emergency FFT returns. 9.5 For the full financial year 2015/2016, Emergency Care (Accident & Emergency and Minor Injuries Unit) had 90.43% of patients stating that they would recommend the service(s) to friends and family, and 3.70% of patients stating that wouldn t recommend the services(s) to friends and family. 9.6 Maternity data Would recommend Wouldn t recommend data is combined from all four maternity questions. Number of forms returned Would recommend Wouldn t recommend Apr % % May % % Jun % % Jul % % Aug % % Sep % % Oct % % 11

53 Nov % % Dec % % Jan % % Feb % % Mar % % 9.7 For the full financial year of 2015/2016, maternity friends and family data demonstrated 94.75% of patients stating that they would recommend the service(s) to friends and family, and 3.05% of patients stating that wouldn t recommend the services(s) to friends and family. 9.8 Maternity returns continue to be a challenge across all the services; the challenges are due to women being asked on four occasions in line with the national requirement. The Trust continues to promote returns both within and out with the hospital setting and recognises that these fluctuate month on month. The friends and family questionnaire has been incorporated into the discharge process; early results suggest this has been successful in improving returns. 9.9 The number of responses for the friends and family out-patient s clinics for the 2015/2016 financial year returns were 12,164 returns. From the responses 89.58% patients stated that they would recommend the service(s) to friends and family, and 2.26% of patients stated they wouldn t recommend the services(s) to friends and family. Number of forms returned Would recommend Wouldn't recommend Apr-15 1,660 1, % % May-15 1,315 1, % % Jun-15 1,360 1, % % Jul-15 1,378 1, % % Aug % % Sep % % Oct % % Nov % % Dec % % Jan % % Feb % % Mar % % 10 Quality Accounts 2015/ The Trust produced a draft version of the Quality Accounts for the 2015/2016 financial year in March This document has been circulated to both internal and external stakeholders, with third party narratives due back into the Trust by the end of April The finalised version of the report will be subject to external audit assurance prior to upload in June 2016 to the Trust s website and to NHS Choices. 11 Never Events 11.1 Since 2008 the Trust has had 9 Never Events and they are broken down as follows: 12

54 Reporting Year Number of Never Events 2008/ / / / / / / /16 2 Totals: There has been two Never Event s reported in the period of 2015/ One in September 2015 related to a retained foreign object following surgery and the second in February 2016 related to a wrong side pain relief injection. In both incidents the patients suffered low levels of harm and are fully aware of the investigations. Both incidents were reported to NHS England and Commissioners on the Strategic Executive Information System (STEIS), the Care Quality Commission and Monitor as required The NHS England report can be accessed via: 12 Recommendation 12.1 The Board of Directors is asked to note the content of this report and acknowledge performance in compliance rate from the complaints team, the continued actions being undertaken to understand and improve the position for SHMI and the excellent improvement for HSMR, the work around the Friends and Famliy test and the Safety Thermometer data. Julie Lane Acting Director of Nursing, Patient Safety and Quality 13

55 Appendix 1 Safer Staffing January 2016 March 2016 North Tees and Hartlepool NHS Foundation Trust prides itself on ensuring that safe staffing levels are maintained at all times in line with the national quality board requirements to have the right staff, with the right skills in the right place at the right time. Publication of the National Quality Board document, How to ensure the right people with the right skills, are in the right place at the right time (2013) and the Hard Truths document, (2013) introduce a requirement to publish staffing data on a monthly basis via the NHS Choices website. The data required on the NHS Choices website relates to the number of planned and actual staffing hours for inpatient wards and is presented as a percentage of fill rates. This however does not provide vital information to support the fill rates which will form a part of a briefing to be published on the Trust website which will be hyperlinked to the NHS Choices site. The information below relates to the planned actual staffing levels throughout January 2016 March Differences between the planned and actual staffing maybe for a variety of reasons such as sickness or vacancies, whilst areas which appear to be higher than planned may be due to an increased requirement of a specific staff group to meet the needs of the patients at that time. Duty rotas are planned in advance and staffing needs are reassessed on a daily basis by the senior nursing teams for each area to ensure that changing need are met. Ward name January 2016 Day Dutyregistered nurses/midwives Day Duty - care staff Night Duty - registered nurses/midwives Night Duty - care staff Acute Cardiology Unit 77.5% 90.3% 98.6% 128.4% Critical Care 102.3% 67.2% 98.9% 70.8% Delivery Suite 88.0% 82.6% 92.4% 100.9% Elective Care Unit 85.1% 105.0% 92.8% 138.3% Emergency Assessment Unit 67.3% 105.8% 100.2% 172.5% Neonatal Unit 83.5% 92.5% Paediatrics 83.3% 83.1% 81.4% 58.2% Ward % 163.4% 99.9% 258.6% Ward % 73.5% 98.7% 99.7% Ward % 148.3% 103.2% 123.2% Ward % 169.2% 108.6% 170.8% 14

56 Ward % 150.5% 90.4% 199.1% Ward % 168.9% 100.0% 237.7% Ward % 166.4% 148.0% 144.6% Ward % 134.0% 143.2% 149.4% Ward % 131.4% 98.3% 158.3% Ward % 277.9% 120.1% 428.1% Ward % 169.2% 117.9% 208.5% Ward % 124.4% 88.3% 187.4% Ward % 173.2% 106.6% 225.6% Ward % 152.5% 99.0% 187.6% Ward % 131.5% 71.0% 244.2% Ward % 100.6% 99.4% 258.6% Ward % 130.3% 126.6% 202.1% 79.6% 134.8% 103.2% 180.6% 15

57 February 2016 Ward name Day Dutyregistered nurses/midwives Day Duty - care staff Night Duty - registered nurses/midwives Night Duty - care staff Acute Cardiology Unit 69.6% 97.5% 74.8% 150.8% Critical Care 97.4% 62.0% 98.4% 82.8% Delivery Suite 78.4% 66.3% 77.7% 102.8% Elective Care Unit 81.1% 120.1% 97.7% 148.3% Emergency Assessment Unit 71.3% 101.5% 97.4% 150.9% Neonatal Unit 88.2% 92.2% Paediatrics 80.8% 77.7% 79.9% 63.8% Ward % 155.4% 106.9% 231.2% Ward % 88.3% 89.5% 86.5% Ward % 121.9% 100.8% 168.1% Ward % 189.5% 109.1% 194.1% Ward % 102.4% 105.2% 210.2% Ward % 185.4% 89.7% 242.8% Ward % 173.5% 165.4% 156.0% Ward % 134.1% 149.9% 152.1% Ward % 111.4% 100.7% 160.7% Ward % 255.3% 123.2% 436.0% Ward % 162.9% 122.8% 190.4% Ward % 117.9% 105.8% 197.9% Ward % 179.4% 108.8% 226.6% Ward % 181.9% 108.4% 213.7% Ward % 141.0% 75.9% 247.3% Ward % 109.1% 89.9% 310.6% Ward % 149.0% 126.2% 211.3% 78.6% 134.1% 104.0% 188.5% 17

58 March 2016 Ward name Day Dutyregistered nurses/midwives Day Duty - care staff Night Duty - registered nurses/midwives Night Duty - care staff Acute Cardiology Unit 69.7% 73.4% 72.9% 115.1% Critical Care 104.6% 70.5% 103.2% 77.2% Delivery Suite 68.6% 59.7% 70.6% 114.3% Elective Care Unit 81.3% 103.4% 95.8% 132.9% Emergency Assessment Unit 62.5% 132.7% 95.8% 151.0% Neonatal Unit 84.1% 89.1% Paediatrics 84.7% 84.2% 85.4% 61.3% Ward % 118.3% 104.8% 138.8% Ward % 86.7% 95.5% 105.9% Ward % 186.9% 132.2% 218.5% Ward % 163.8% 119.4% 150.8% Ward % 116.2% 108.1% 239.0% Ward % 221.2% 100.0% 228.3% Ward % 211.3% 150.5% 151.0% Ward % 135.6% 154.5% 140.6% Ward % 129.9% 100.5% 125.2% Ward % 192.0% 133.1% 301.9% Ward % 139.5% 118.6% 122.1% Ward % 146.3% 123.7% 176.8% Ward % 215.0% 103.4% 208.3% Ward % 173.9% 121.1% 211.6% Ward % 149.8% 71.1% 217.7% Ward % 131.8% 118.7% 296.5% Ward % 171.1% 118.4% 223.6% 76.6% 139.7% 107.8% 169.9% 18

59 Safer Staffing Levels January March 2016 Safer staffing Registered and unregistered nurse fill rates fluctuate throughout the month. There are a number of reasons which can impact on the variance between the planned and actual fill rates on a shift by shift basis this includes short term sickness, maternity leave and vacancies. The Trust utilises staff flexibly across the organisation with staffing reviews undertaken regularly throughout the day to mitigate risk and maintain safe staffing. The unregistered planned and actual staffing includes Health Care Assistants and Associate Practitioners who whilst qualified are not registered with the Nursing and Midwifery Council (NMC). This staff group also include the International nurses who have recently joined the Trust who are registered nurses within their home countries however are required to undertake a series of assessments prior to registration with the NMC. Whilst the training of nurses recruited from the European Union is recognised by the NMC they cannot work as a registered nurse until they have achieved registration with the NMC. Therefore, this group of staff cannot be acknowledged within the Registered Nurse compliment until they receive a personal identification number. In the interim period these and the internationally recruited nurses undertake competency corporate and local induction, undergo competency based assessment and are supported by a Registered Nurse at ward level. Where there are lower Registered Nurse fill rates these areas are supported by Associate Practitioners and in a number of areas recently recruited European or internationally recruited nurses. Consequently, the unregistered staff fill rate percentage will tend to be significantly higher than planned particularly where additional health care assistants are rostered to support specialing of patients who require close supervision. Over the three month reporting period there has been no breach of the red rules which includes a minimum Registered Nursing complement and substantive to agency ratio. 19

60 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Infection Prevention and Control Report Report of the Acting Director of Nursing, Patient Safety and Quality/ Director of Infection Prevention and Control (DIPC) Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Maintain Compliance and Performance Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Reduce Hospital Acquired Infections 1. Introduction 1.1 The purpose of this report is to inform the Board of Directors of the healthcare associated infection performance position for the period to 31 March The figures quoted are correct at the time of writing on 15 April Key Issues & Planned Actions 2.1 Clostridium Difficile The Trust has reported five Trust attributed cases of Clostridium Difficile infection for March This gives a total for of 36 cases which exceeds the trajectory for the year. All cases have been subject to root cause analysis. The only recurring theme from RCA is lower than required cleaning scores for patient equipment and this is being addressed by training and monitoring of the cleaning in clinical areas. In the full year 68 community cases were also reported. The infection prevention and control team is targeting those wards considered to be high risk and is concentrating on the basics of good infection prevention practice such as hand hygiene, environmental cleanliness and use of standard precautions. The period of increased bed occupancy and acuity of patients presents a risk in terms of infection prevention as these variables are linked in many studies to an increase in infection rates. 2.2 MSSA Bacteraemia The Trust has reported two cases of MSSA bacteraemia for March There is no external trajectory for this infection but the internal trajectory is 18 cases for the year and the Trust has exceeded this trajectory with 24 cases for the year. The previous year ended with 18 cases reported. Each case is subject to investigation and no common themes relating to clinical practice have been identified. There were 64 community case reported in which is an increase on the previous year s figure of MRSA Bacteraemia 1

61 2.3.1 The Trust has reported no Trust attributed cases of MRSA bacteraemia in March 2016, however, to date the Trust has reported two cases which are Trust attributed which exceeds the zero tolerance trajectory. One case was a contaminant and the other was likely not to be preventable, however learning has been identified from both cases. Two community cases were reported in March 2016 and are still under investigation by the CCG but initial review of information shows no learning for the Trust from these cases. 2.4 Ecoli Bacteraemia The Trust has reported four Trust attributed cases of E coli bacteraemia in March There is no external trajectory but an internal objective of no more than 27 cases has been set based on the previous year outturn and the total for is 44 cases.. There were 224 community cases reported in The number of cases overall has increased compared to the previous year when 204 cases were reported. 2.5 Hand Hygiene The overall Trust compliance score for hand hygiene is 94.87% for March 2016 based on the scores which had been received at the time of writing. This score is just below the Trust internal target of 95%. Initiatives around improved hand hygiene continue to be a focus for action by the Infection Prevention and Control (IPC) team 2.6 Outbreaks There were 11 outbreaks of diarrhoea and vomiting affecting 126 patients in March 2016 leading to partial or full closure of wards and an impact on patient flow. This reflects a number of outbreaks in the community and is a typical pattern for the Trust during the norovirus season. 3. Recommendations 3.1 The Board of Directors is requested to note the work underway to improve performance for C Difficile, and the work continuing across all clinical services to improve hand hygiene scores. Julie Lane Acting Director of Nursing, Patient Safety and Quality/ DIPC 2

62 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Infection Prevention and Control Report Report of the Acting Director of Nursing, Patient Safety and Quality/ DIPC 1. Introduction/Background 1.1 This report will describe the progress to date (at time of writing on 15 April 2016) relating to: Clostridium difficile Methicillin Sensitive Staphylococcus aureus (MSSA) bacteraemia MRSA bacteraemia Escherichia coli bacteraemia Hand Hygiene Outbreaks 2. Healthcare associated infection progress report 2.1 Infections which are reportable under mandatory surveillance programme In line with NHS England requirements the Trust enters information on a monthly basis into healthcare associated infection data capture system which is administered by Public Health England. The infections that are reportable under this process are MRSA bacteraemia in all patients, MSSA bacteraemia in all patients, E coli bacteraemia in all patients and Clostridium difficile diarrhoea in all patients aged 2 and over. Trajectories for MRSA and C difficile (CDI) are set centrally and monitored by commissioners. Clostridium difficile The table below shows performance against trajectory for the period to 31 March There were five Trust attributed cases reported for March and the total of 36 cases to date exceeds the trajectory for the year of 13 cases. It should be noted that even though the annual trajectory has been exceeded, this performance still represents an 83% overall reduction in cases since 2007/8 when the Trust reported 210 cases. Nationally, based on un-validated data, there are 70 out of 155 English Trusts (45%) which have reported an increase in C difficile cases this year and 75 (68%) out of 110 non-teaching acute Trusts, which is the group the Trust falls into, which have hit or breached the annual trajectory compared to 57 (60%) in the previous year. It is felt that the lack of a decant ward this year, combined with increased activity and acuity of patients leading to increased bed occupancy and increased length of stay for a number of very ill patients has contributed to the increased number of cases in

63 Year to date C difficile performance against trajectory Month Trajectory Actual April May June July August September December November December January February March Total Trust attributed C difficile cases Actions to reduce the risk of further cases continue and a task and finish group meets to ensure that all appropriate measures are being taken and that all appropriate directorate staff are engaged with the reduction programme. The improvement plan for will be developed at the April meeting The programme of cleaning and fogging of high risk wards will recommence as soon as the winter resilience ward can be closed and made available for the decant programme which has been developed. This will mean that all high risk wards and as many as possible of the lower risk wards will be cleaned and fogged before the resilience ward is needed again around December Enhanced daily, weekly and monthly cleaning to high risk wards, particularly medical wards will continue throughout the year and the use of additional new technologies to assist with cleanliness is constantly being explored The focus on antibiotic stewardship continues. Hours within the existing pharmacy technician resource have been identified to support the antimicrobial pharmacist and ensure that significantly increased numbers of records have been audited from January 2016 onwards. The audit programme has been revised with streamlining of audits carried out by pharmacy and medical staff, and governance processes for reporting of results improved. 4

64 2.1.6 The Trust will participate in an NHS Improvement 90 day programme commencing in April 2016, the focus of which will be reduction of Clostridium Difficile, and the Trust will have the opportunity to learn from good practice in the 29 other Trusts who are also taking part in the programme. A Trust team of five staff led by the Acting Director of Nursing, Quality and Patient Safety will facilitate the projects for this improvement programme. Updates will be provided in future reports to the Board MSSA bacteraemia Two cases of Trust attributed MSSA bacteraemia were reported in March The Trust has exceeded the internal Trust trajectory of 18 cases with 24 cases reported for the year. Root cause analysis has been completed for each case and no practice related themes have emerged. There is no common ward involved or repeated source of infection identified. It is felt by the microbiologists that many of the cases were not preventable. There have been 64 community cases reported to date which is an increase on the cases reported in the financial year Again the increase in activity and patients with a high acuity coming into the Trust is likely to have contributed to an increase in these infections. MRSA bacteraemia Trust attributed MSSA bacteraemia cases There were no Trust attributed MRSA bacteraemia cases reported in March 2016 therefore the total for the year remains at 2 cases as previously reported. There were 2 non-trust cases reported in March which are still under investigation by the CCG and the Trust is assisting with these investigations, however initial information suggests that no issues or learning for the Trust have been identified. Work continues to reduce the risk of either true Trust attributed cases or contaminated samples and a blood culture pack will be introduced to all areas in the near future which will make it easier for staff to take these samples safely each time. Monitoring of staff training has also been improved Although the two cases for this year mean that the Trust has exceeded the zero tolerance target, it is worth noting that a 91% reduction has been made since when 22 Trust cases were reported. Trust attributed MRSA bacteraemia cases by quarter

65 E coli bacteraemia The Trust has reported four Trust attributed cases of E coli bacteraemia in March 2016 and a total of 44 cases in the year to date. There is no national trajectory for this infection. The most common source of these infections is the urinary tract with patients having an underlying urinary tract infection, however only a small percentage of the cases had a urinary catheter in situ. It is difficult, therefore, to make any practice changes to reduce such cases and the majority of the 44 cases are felt not to be preventable. A total of 224 non-trust cases have been reported to date which is an increase on the same period in the previous year. 2.2 Hand hygiene E coli bacteraemia cases Hand hygiene compliance is assessed by a combination of independent assessment by the infection control and prevention team (IPCT) and self-assessment by departments. Directorate and individual ward scores are displayed on the nursing and midwifery dashboard. The scores are split by staff group to allow intervention to be targeted most effectively. The overall Trust score for March 2016 at the time of writing was 94.87% which is just below the Trust target of 95% but with some scores still to be received. The overall performance has improved since July 2015 with the Trust achieving in excess of 95% in six out of nine months. 6

66 2.2.2 Ward matrons of wards with low compliance are now invited to the Health Care Associated Infection (HCAI) Operational Group to provide assurance to the DIPC that action is being taken to improve compliance. Where staff are noted to be noncompliant with policy they are reminded of their responsibility under the hand hygiene policy on the first occasion. If subsequent non-compliance is noted their name is forwarded to the Clinical Director and General Manager of the directorate for action, which may include disciplinary proceedings. Additional monitoring and support is received by wards reporting low compliance. Since July 2015 a RAG rated league table of compliance scores is published to directorate teams and reviewed at the HCAI Operational Group. Feedback from directorates is that this report is very helpful, and it has led to an increase in submission of audit data It is hoped that with improved staffing over the next few months and a reduction in activity that the 100 plus hand hygiene champions will be able to participate in a range of activities designed to increase awareness of the importance of hand hygiene which are planned by the IPCT, starting with World Hand Hygiene day on 5 May. 2.3 Outbreaks During there have been 22 outbreaks affecting wards and a number of alert situations. Eleven of these outbreaks occurred in March 2016 which added to the already increased pressure on staff and patient flow. Norovirus was identified as the causative agent in each of these outbreaks which led to partial or full closure of wards for up to 16 days. Wards are fully cleaned before reopening to admissions and transfers. 3. Conclusion/Summary 3.1 There has been, and continues to be, much work undertaken to achieve the reductions in healthcare associated infection that is not only required to achieve the Trust targets but is also desirable to achieve the high quality patient experience and outcomes that we want for all of our service users. HCAI remains a high priority for the Trust and further work is required to reduce the risk of additional Clostridium difficile infection cases. 4. Recommendation 4.1 The Board of Directors is requested to note the work underway to improve performance for C Difficile, and the work continuing across all clinical services to improve hand hygiene scores. Julie Lane Acting Director of Nursing, Patient Safety and Quality/ DIPC 7

67 North Tees & Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Strategy Development Progress Report Report of the Chief Operating Officer/Deputy Chief Executive Strategic Aim and Objectives (the full set of Trust Aims can be found at the beginning of the Board of Directors Reports) Putting Patients First 1. Introduction 1.1 The purpose of this report is to provide the Board of Directors with an update on the progress of Strategy development since the most recent update in January 2016; with the emphasis on the Clinical Services Strategy. 1.2 The report summarises the work undertaken to date, in line with the agreed way forward, outlining the next steps in the implementation of the Clinical Services Strategy (Phase 3), the relationship with the development of the Trust s Annual Operating Plan submission, the association with the wider health programme including the Better Health Programme and Sustainability and Transformation Plans, and the continuous update and review of the Corporate Strategy to reflect these developments. 2. Progress Report 2.1 The Trust has made significant progress in developing the Clinical Services Strategy including agreeing the vision for the delivery of services going forward, centred around locality based services, meeting the needs of the local population. 2.2 The methodology for the review of current services has been built around assessing individual service lines based on performance across core standards, quality, operational efficiency, productivity, workforce models market share and financial viability, utilising available data to support the decision making process. 2.3 Phase 3 of the project will see the delivery of the detailed planning required to support the implementation of the plans, culminating in the development of the Outline Business Case for the funding required to support the estate re-developments. 2.4 This report outlines the key progress with the Clinical Services Strategy Phase 3, implementation stage. 3. Recommendations The Board of Directors is asked: The relevance of the principles of the corporate strategy as a framework and reference point for change; and 1

68 To note the continuing development of the Clinical Services Strategy as the means to take the Trust s confirmed values, principles and philosophy within the strategic direction forward; and To support and progress a radical approach in developing service specific strategies to enable the achievement of the significant and wide-ranging changes, and enabling strategies in line with the requirement for clinical, operational and financial sustainability; and To recognise the wider health programme needs to be considered at each stage of development and may ultimately impact on the project deliverables and timelines. Julie Gillon Chief Operating Officer/Deputy Chief Executive 2

69 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Strategy Development Progress Report Report of the Chief Operating Officer/Deputy Chief Executive 1. Introduction and Background 1.1 The purpose of this report is to provide the Board of Directors with an update on the progress of the Clinical Services Strategy development since the most recent update in January 2016; with the emphasis on the clinical services strategy. 1.2 The report summarises the work undertaken to date, in line with the agreed way forward, outlining the next steps in the implementation of the Clinical Services Strategy (Phase 3), the relationship with the development of the Trust s Annual Operating Plan submission, the association with the wider health programme including the Better Health Programme and Sustainability and Transformation Plans, and the continuous update and review of the Corporate Strategy to reflect these developments 2. Progress Report 2.1 The vision of the Momentum: Pathways to Healthcare Programme remains ever relevant, while the context in which the Trust operates continues to present significant challenges in relation to clinical, operational and financial sustainability. 2.2 The range of factors impacting on future service delivery remain, such as population, deprivation and socio economic drivers, and the impact of the services developed via the Better Care Fund, Integrated Personal Commissioning, and other developments arising out of the implementation of the Five Year Forward View (NHSE, 2014), continue to present additional challenges. 2.3 There remains particular concern that there is reducing financial flexibility to support transition between present and desired service models and the Trust remains keen to work with the wider system to understand how such a transition will be managed. Improving the health of the population in the area, with a level of need for health services above the national average, and tackling the legacy of ill-health in an environment with high levels of deprivation, continues to present a major challenge. Whilst meeting the increasing demands of an ageing population, the shape, form and type of healthcare provided to patients needs to be different to that available today, and this is reflected in the Trust s strategic approach and is aligned to the wider health programme, including the Better Health Programme (BHP) and Sustainability and Transformation planning (STP). 2.4 Following a full and in depth analysis and a presentation and discussion at the Board of Directors in January 2016, the key deliverables of the Clinical Services Strategy were agreed, with the implementation stage, Phase 3, now being progressed. 3

70 2.5 This report outlines the requirements for Phase 3 of the Clinical Services Strategy, including the key milestones, and progress to date. 3. Clinical Services Strategy Phase The Trust has made significant progress in developing the Clinical Services Strategy including agreeing the vision for the delivery of services going forward, centred around locality based services, meeting the needs of the local population. 3.2 The methodology for the review of current services has been built around assessing individual service lines based on performance across core standards, quality, operational efficiency, productivity, workforce models market share and financial viability, utilising available data to support the decision making process. 3.3 Phase 3 of the project will see the delivery of the detailed planning required to support the implementation of the plans, culminating in the development of the Outline Business Case for the funding required to support the estate re-developments. 3.4 The objectives identified for Phase 3 implementation stage include: Prepare the agreed five year Clinical Service Strategy for communication and publication by the Trust in the context of BHP and STP; Supporting the planning, implementation and delivery of the Strategy; Submission of funding applications locally within the Trust and nationally to central Government; Re-allocating resources, skills, configuring the estate and IT requirements (including identification of all necessary funding streams); Communicating the strategy to all internal and external stakeholders and partners; Collaboration with local partners for a system wide approach to the future delivery of the strategy. 3.5 Progress to date includes: Prepared and agreed the Project Initiation Document (PID) for Phase 3, including timeline for delivery; Progressed the development of the Clinical Service Strategy document end of April deadline; Established appropriate governance arrangements to ensure the implementation of the strategy and accountability for key work streams; Developed an appropriate delivery mechanism and commenced delivery of all projects, through clinician-led work streams fortnightly meetings; Progressed the underlying development work for the completion of the Outline Business Case (OBC) to Department for Health (DH) within the appropriate timeframe to enable an affordable funding package; Progressed the development of the schedule of accommodation to support the OBC submissions; Progressed enabling strategies to inform the implementation of the Clinical Services Strategy e.g.: Workforce 4

71 Estates IM&T Communications & Engagement 3.6 The overarching principles outlined and agreed within the Clinical Service Strategy have been reflected in the Trust s Annual Operating Plan, submitted to NHS Improvement on 18 th April 2016, (see section 5). 4. Annual Operating Plan 4.1 As outlined above, the Trust s Annual Operating Plan was submitted within the required timescale, on 18 th April The Annual Operating Plan was discussed at Board Seminar on the 4 th April 2016, including: Key principles of the Annual Plan and the development process. The Clinical Services Strategy as bedrock for the plan. Key requirements of the Sustainability and Transformation Plans, including delivery of 2016/17 control totals and delivery of the Referral to Treatment (RTT), Cancer 62 urgent referral to treatment, A&E 4 hour and the 6 week diagnostic standards, and the associated recovery plans. Board governance requirements. Annual Self Certifications. 4.2 The Trust is now working with the local health economy via the leadership of the Trust s Chief Executive as STP Lead to develop the joint STP due for submission in June Sustainability and Transformation Plans 5.1 The Trust is cognisant of the changing landscape of the NHS and the requirement to work with partner organisations to deliver the Five Year Forward View through a robust and joined up STP. 5.2 The Trust is working closely with key stakeholders in an evolving governance structure. 5.3 As one of the 44 footprints across the country the STP will develop local blueprints for improved health, care and finances over the next five years, delivering the NHS Five Year Forward View. 5.4 Chief Executive Alan Foster will be the lead for the in the Durham, Darlington and Tees, Hambleton, Richmondshire and Whitby footprint 6. Better Health Programme 6.1 The local Better Health Programme (formally Securing Quality in Health Services) is examining acute hospital care and the required changes to achieve the desired standards of quality and clinical effectiveness in and out of hospital care across Darlington, Durham and Teesside. This programme includes the potential to centralise individual clinical services on a reduced number of hospital sites. The areas of review include A&E, Acute Surgery, Acute Medicine, Critical Care, Obstetrics, Paediatrics, Neonatology, Interventional Radiology and Elective Care. 5

72 6.2 Executive and Clinical leads from the Trust are involved in the discussions, to ensure sound clinically based evidence is taken into account when planning the proposed changes. 7. Corporate Strategy 7.1 The Trust s Corporate Strategy is continually reviewed and refreshed through an ongoing cycle, alongside the organisation s Business Planning process. 7.2 The Momentum: Pathways to Healthcare values, principles and philosophy continue to summarise the direction for the Trust s Strategy and incorporates the ways in which services will be provided in the future. 7.3 The Clinical Services Strategy provides the means of taking the Trust s confirmed strategic direction forward, and developing service specific strategies to enable the achievement of the significant and wide-ranging changes currently demanded. 7.4 The principles of the Corporate Strategy remain over relevant in the context of the CSS, BHP and STP and the metrics will be reported to the Board of Directors at a future meeting. 8. Summary 8.1 As agreed by the Board of Directors, the next stage of the Clinical Service Strategy requires the implementation of the service line options across the key principle objectives of investment, re-design/ improving operational efficiency and productivity and the potential for partner/collaboration of service delivery with neighbouring organisations. This will be further progressed using the Lord Carter model hospital as a lever for change. 8.2 Key to the successful development and delivery of the Clinical Services Strategy will be the need for partnership working and collaboration between all members of the local health and social care economy in the context of BHP and STP. 8.3 The development of the Outline Business Case to support capital investment will be taken forward within Phase 3 of the project, with a deadline of June 2016 for completion. 8.4 The Trust is cognisant of the wider health programme and will ensure the Clinical Service Strategy, and ultimately the Corporate Strategy, reflect the changing heath landscape. 9 Recommendations 9.2 The Board of Directors is asked: The relevance of the principles of the corporate strategy as a framework and reference point for change; and To note the continuing development of the Clinical Services Strategy as the means to take the Trust s confirmed values, principles and philosophy within the strategic direction forward; and To support and progress a radical approach in developing service specific strategies to enable the achievement of the significant and wide-ranging changes, and enabling strategies in line with the requirement for clinical, operational and financial sustainability; and 6

73 To recognise the wider health programme needs to be considered at each stage of development and may ultimately impact on the project deliverables and timelines. Julie Gillon Chief Operating Officer/Deputy Chief Executive 7

74 North Tees & Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Transformation Programme Update Report of the Director of Human Resources and Education Strategic Aim (the full set of Trust Aims can be found at the beginning of the Board Reports) Integrated Care Pathways, Service Transformation Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Board Reports) Momentum: Pathways to Healthcare Programme 1. Introduction 1.1. The purpose of this report is to provide the Board of Directors with an update on the progress of the Transformation Programme in general, with a focus on key projects and governance. 2. Programme Overview 2.2. The Transformation Committee is due to meet on 22 April 2016 to discuss the progress of the programme following the transfer of the Transformation function to the remit of the Director of Human Resources and Education The inaugural meeting of the Transformation Programme Management Group took place on 1 February 2016 and the next meeting is scheduled for 18 April The report sets out progress on the current projects, namely: Clinical Services Strategy (Work streams) Income Generation signs and symptoms (DQIP) Temporary Staffing NHS Professionals Temporary Staffing Staff Flow Urgent Care Tender Outpatients Integrated Care Pathways (Frail Elderly) Project Management Office 1

75 3. Financial Savings A review of the on-going Transformation programme has been performed to ensure alignment with the strategic vision and Clinical Services Strategy for the Trust. A significant proportion of the 2015/16 programme concerned internal changes to services which did not rely on significant transformational change, but took the opportunity to re-align service provision to deliver incremental improvements in care and outcomes whilst also supporting the delivery of financial savings. In essence, they represented a first and necessary step for transformation but were not reliant on whole system change Work has commenced to financially evaluate from both an investment and savings perspective the programme of work for 2016/17 and onwards. The initial findings are documented in (Appendix 3) 4. Recommendations 4.1. The Transformation Programme will be discussed in more detail at Transformation Committee on 22 April In the interim the Board of Directors is requested to note the progress and current status of the Transformation Programme as presented above. Ann Burrell Director of Human Resources and Education 2

76 North Tees & Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Transformation Programme Update 1. Introduction Report of the Director of Human Resources and Education The purpose of this report is to update the Board of Directors on the progress of the Transformation Programme, the changes that have occurred since January 2016 and the progress on key deliverables. 2. Programme Overview The Trust s Clinical Services Strategy is committed to delivery over a five year period, for review in 2020, with a greater focus on collaboration of services with key partners in the Durham/Tees Valley area. This will enable the organisation to react to the pressures and demands externally, including ageing population and increasing comorbidities, and make changes to the provision, where appropriate, in line with commissioner s requirements and following the high level objectives of the Better Health Programme (formerly SeQiHS) and Sustainability and Transformation Plans. Transformation generates a future state sufficiently different from the current state that people and culture must change to implement it successfully. Projects managed under the Transformation umbrella must deliver significant benefit including clinical sustainability, operational sustainability and financial sustainability. 3. Current Status Following a reorganisation of the Transformation function and the alignment to the HR & Education Directorate, the Transformation team has merged with Organisation Development. This change will ensure that Transformation is both deliverable and sustainable. A number of projects previously managed by Transformation are under review with the intention that wherever possible they are delivered, closed down or handed over to form part of Business as usual. This is to allow the programme to focus on the large scale, longer term (3-5 year) projects in support of the Clinical Services Strategy, aligned with the Better Health Programme. Work has continued to evaluate each project on a weekly basis to establish their current position in regards to the Transformation project management framework (See appendix 1). The portfolio has been split into the following categories; Transitional / Business as Usual Monitoring Transformational 1

77 3.1. Transitional Work is continuing to address transitional projects that will transfer during 2016/17 to the operational service leads as business as usual which cover; Income Generation signs and symptoms (DQIP) The focus of this project is to review clinical coding and data quality at the Trust with the aim of improving expected mortality. Following successful proof of concept, a business case was submitted to Monitor in January 2016 requesting additional external support to continue and evaluate post Trakcare with the aim of reviewing and improving internal processes. The business case was approved by Monitor in February 2016 and the Trust subsequently issued a tender specification for external consultancy to both evaluate coded data post Trakcare and also to perform a service review of the Trust s clinical documentation. In line with the Transformation governance process, a project initiation document has been drafted and will be issued to the Transformation Committee (22 April 2016) for review and approval Temporary Staffing NHS Professionals The NHS Professionals project has been live since November 2013 and, as outlined at the January Board of Directors, a paper was presented on 22 December 2015 to the Executive Team. This paper recommended a number of measures to improve controls, in particular the appointment of a temporary staffing manager with the aim of co-ordinating the provision of all flexible workers to deliver efficiencies and support compliance with the Monitor agency cap rules. The post is in the process of being appointed and it is planned for the Transformation project to be formally closed and responsibility transferred to the staffing manager and relevant service leads Temporary Staffing Staff Flow The Staff Flow system was fully implemented on 28 September 2015 for the direct engagement of agency locum staff. The advantage of the direct engagement model is that an element of the VAT (13% net of fees) associated with medical staff bookings is avoided. A paper was presented to the Executive Team on 23 February 2016 to provide an update and perform an initial post implementation review. The paper highlighted that the saving associated with the VAT ( 64k at M12) is less than anticipated but this was linked to a reduction in locum usage and the impact of the Monitor agency cap reducing locum costs, but if demand was to increase the Trust will minimise future VAT liability through the system. The paper also asked to consider the creation of an internal bank for both medical staff and AfC Admin & Clerical, thereby minimising the requirement for agency staff and associated costs. A scoping paper is being prepared to understand the internal resource implications and key processes to be addressed prior to implementation. As per NHS Professionals, it is planned for this Transformation project to be handed over to the Temporary Staffing Manager as business as usual during 2016/ Monitoring It is envisaged that as schemes progress past implementation (Gateway 3) they will continue to remain within the transformational reporting arrangements, prior to a satisfactory post-implementation review being performed. Once the review is completed, accountability will transfer to operational service leads. The aim is for the Integrated Care Pathways to migrate to this category. 2

78 3.3. Transformational Projects - On going Urgent Care Tender Outpatients Integrated Care Pathways transfer to Monitoring during the year The formulation of the Clinical Services Strategy incorporates a range of actions across all Directorates within the Trust, set against strategic priority themes of: Invest or Retain Divest Collaboration Redesign The activity, analysis and actions across all of these themes will be designed to work together to deliver the long-term goals of the organisation. During the next months, a member of the Transformation team will join each work stream to ensure project outcomes link to the Transformation work. Each work stream (shown in diagram 1) will provide updated progress reports to the Strategy Project Board. Diagram 1 Work streams Emergency and Urgent Care 4. Key areas of progress to note since the last board update 4.1. Urgent Care Tender In Hospital Surgery, Urology & Orthopaedics Anaesthetics Out of Hospital Support Services Radiology, Pathology & Pharmacy Women s and Children s It is evident from historical and recent experience during the continued activity and acuity surge from winter (2015) that there is continued and mounting pressure on A&E Departments within acute trusts. North Tees and Hartlepool NHS Foundation Trust is therefore committed to developing and providing a more integrated and sustainable model of urgent and emergency care provision. Working within the clinical and corporate governance of the trauma network, and as a designated trauma unit, the Trust will build on the need to provide excellent care within the hospitals and local communities. There is a need for signposting appropriate care needs to the right place, at the right time, and to prevent duplication within the system whilst supporting public confidence in local provision, and an understanding of the senior presence and consultant skills seven days a week as a result of centralisation to improve patient outcomes. The Trust believes that its capacity and unrivalled reputation to deliver high quality and clinically safe urgent care services will provide commissioners with the assurance and confidence in its ability to design, develop and deliver the required provision within the agreed timescales, and will be happy to provide the tendering 3

79 organisation with a fully costed and detailed model as part of the next stage of procurement. Currently at Stage 1 of the project, the Trust is preparing to bid for and be selected as the provider of urgent care across the area we serve. The project will concentrate on the emergency and urgent care pathways ensuring clinical sustainability Outpatients Reconfiguration The Trust currently offers outpatient facilities across the University Hospital of North Tees, Hartlepool and Peterlee Community Hospital, along with a wide range of community services in a variety of locations across the local catchment areas. The basic model for delivering outpatient services has remained relatively unchanged for many years. However current and anticipated changes in demography, science and technology, patient expectation and workforce mean that the way in which we provide outpatient care is likely to become increasingly unsustainable in the future. The ability to grow Trust capacity in key specialty areas to provide a competitive service will be important to ensure we remain the hospital of choice and for developing optimum income levels and so sustainable services. The opportunity to expand the Trust s service delivery into other areas will be kept under review, subject to strategic fit with the organisation s key priorities. Currently at Stage 2 of the project, the aim is to transform outpatient services across the locality. Four work streams have been established that will focus on: Process capacity and demand along with pathway redesign People workforce model needed to deliver outpatients services in the future Place physical location of clinics, taking community settings into consideration Productivity Baseline data, success matrix, reporting mechanisms and enablers such as IT infrastructure Integrated Care Pathway (ICP) Frail Elderly The condition of 'frailty' is one of the most challenging consequences of the ageing population. Developing a care pathway for the frail older person when admitted to hospital, to support early facilitated discharge, will assist the frail older person to maintain their own health as long as possible. A multi-disciplinary workforce model to support this approach will be provided enabling social, mental and physical health care needs assessments. The ultimate aim is to maintain and improve the patients health and well being, avoid unnecessarily prolonged admissions, avoid re-admission and prevent transfer on discharge to long term care. This requires collaborative working with key stakeholders to meet the demographic and socioeconomic challenges of the North of Tees population. Currently at Stage 2, the redesign of the pathway is to promote independence and support patients to live well with simple or stable long-term conditions, complex comorbidities, dementia and frailty. The pathway is proposed to develop in three phases, adapting the management of: Specific frail elderly patients in hospital to provide timely and effective interventions Frail elderly patients at front of house to provide effective interventions Frail elderly patients in the Community to provide preventative interventions 4

80 A paper explaining the three phases of the pathway was presented to the Executive Team Meeting on 12th April and the full business case will be re-sent to the Capital and Service Group for approval Project Management Office Currently at Gateway 2 progressing to Stage 3, this project is developing clear guidelines and processes for the effective management of the Transformation programme. The project aims to determine the parameters of Transformation and generate the supporting policy, procedures and processes to facilitate a Transformation culture in the Trust. The development and provision of easily accessible guidance on managing the process from idea generation to realisation of benefits can be accessed via the Trust s Sharepoint site and is currently being tested from March 2016 with a view to formally launch month ending April All governance arrangements for Transformation projects will continue to be via the Transformation Committee. An overview of the current status for each project in relation to the Transformation can be viewed in Appendix 2 5. Transformation Agenda Long Term - financial assessment of schemes The 2015/16 Transformational cash releasing savings outturn position for last financial year is 1.3m and is reported within the Board finance paper Delivering the Financial Savings Programme 2015/16. The outline longer term programme is continuing to be developed as Phase 3 of the implementation and delivery of the Trust s Clinical Services Strategy is being finalised through Directorate workshops. A review of the on-going Transformation programme has been performed to ensure alignment with the strategic vision and Clinical Services Strategy for the Trust. A significant proportion of the 2015/16 programme concerned internal changes to services which did not rely on significant transformational change, but took the opportunity to re-align service provision to deliver incremental improvements in care and outcomes whilst also supporting the delivery of financial savings. In essence, they represented a first and necessary step for transformation, but were not reliant on whole system change. Work has commenced to financially evaluate from both an investment and savings perspective the programme of work for 2016/17 and onwards. The initial findings are documented in (Appendix 3). The Board of Directors will continue to be apprised of the financial investment implications and efficiencies of the longer term programme as developments and plans become formalised in future months. 6. Recommendations The Board of Directors is requested to note the progress and current status of the Transformation Programme as presented above. Ann Burrell Director of Human Resources and Education 5

81 Appendix 1 - Transformation Project Management Framework 6

82 Appendix 2- Overview of Transformation Portfolio Transitional Projects Project Code Stage Transforming Outpatients TS002 2 NHSP TS003 4 DQIP TS004 2 Staff Flow TS005 4 Urgent Care TC001 1 On going Transformation Projects PMO implementation TF001 2 ICP Respiratory TF002 3 ICP Frail Elderly/Dementia TF003 2 ICP End of Life TF004 2 ICP Diabetes TF005 2 Clinical services strategy Work streams In Hospital 0 Out of Hospital 0 Women and Children s 0 Emergency and Urgent Care 0 Surgery, Urology & 0 Orthopaedics Anaesthetics 0 Support Services 0 7

83 Appendix 3 Assessment of Transitional and Current Long-Term Projects (Transformational) /17 onwards Current RAG Rating ( 000) Category Programmes Additional Investment ( 000) * FYE Savings Target ( 000) FYE Income Generation ( 000) FYE Project Sponsor Red Amber Green Projected Savings 2016/ Income Generation 2016/ Transitional / Business as Usual Monitoring / Post implementation Long Term Transformational Projects (12 to 36 months) Income Generation Monitor BC DQIP Staff Flow NHS Professionals Theatres Income Generation Project - signs & symptoms (mortality) ,000 Lynne Hodgson VAT recovery on locum expenditure 200 Julie Lane Creation of Medical Bank (Trust and regional) 200 Julie Lane Creation of A&C Bank 25 Julie Lane Management information / intelligence - effective utilisation 25 Julie Lane More effective use of back-office functions (HR, payroll & Accounts payable) Increased bank recruitment to reduce agency usage Review of internal trust controls and operational efficiencies reduction from ToS Integrated Care Pathways 2 Julie Lane Julie Lane Julie Lane Respiratory stage 4 - as per BC Feb (300k for phase 2 total 916k) Julie Gillon Integrated Care Pathways Personal Health Budgets Diabetes (12 Months) TBC David Emerton Frail / Elderly Dementia (12 months) TBC Julie Gillon Palliative Care (12 months) TBC Julie Gillon Respiratory pilot (age group > 65 year LTC) TBC Julie Parkes Service Re-design / Clinical Services Strategy Emergency Care TBC Julie Gillon In Hospital TBC Julie Gillon Anaesthetics TBC Julie Gillon Outpatients TBC Julie Gillon Surgery, Urology & Ortho TBC Julie Gillon Out of Hospital TBC Julie Gillon Estate Rationalisation Women's & Children's TBC Julie Gillon Support Services TBC Julie Gillon 7 Day Working TBC Alan Foster / David Emerton Single Operating Model TBC TBC Hartlepool Deliverables TBC TBC Technology Developments / New Initiatives Tender Opportunities Urgent Care Tender TBC TBC TBC 0.0 TOTAL * = required investment not currently covered in Transformational expenditure

84 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Capital Programme Performance 2015/16 Report of the Director of Finance, ICT & Support Services Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Manage our relationships Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Finance 1. Introduction The 2015/16 capital programme expenditure plan has altered significantly during Quarter 4. The original capital allocation was m which included provision for a 2m loan. However, the decision was taken not to draw down the loan and so the capital allocation was revised to 8.798m. As the year progressed, 2m of the revised allocation was set aside for potential capitalisation of revenue expenditure to reduce some of the Trust s overspend on revenue. However, having initially indicated that they may require uncommitted capital to be used to assist with the revenue overspend, Monitor ultimately decided that the reduction was not required for North Tees & Hartlepool NHS FT, which gave the Trust the flexibility to review its commitments in quarter 4. A review of the capital programme during Quarter 4 led to a number of technical adjustments and, where appropriate and justifiable, some capitalisation of revenue was made, thus having the effect of reducing the level of uncommitted capital funds. At the end of Quarter 4, expenditure was within the annual profile, and the outturn falls within the Monitor compliance framework of achieving a minimum expenditure of 85% and less than 115% against the capital allocation of 8.789m. 2. Key Issues & Planned Actions 2.1 The revised capital funding for 2015/16 was 8.798m, comprising 2.201m carried forward from 2014/15 EPR programme, 6.447m from internally generated depreciation, and 150k donated funds. The 2015/16 capital programme has progressed as anticipated during Quarter 4. A significant number of schemes have been approved in principle but with progression being deferred until 2016/17 when more funding will be available. 2.2 Preparatory work has progressed well with the planning and specifications for the upgrading of the main electrical supplies of the primary engineering infrastructure at UHNT. A business case was submitted to DoH mid-year and was approved, resulting in a 25m allocation to the Trust which may be drawn down from April Construction work will commence on site early within Quarter 2. 1

85 2.3 The significant elements of the programme to comment upon are: Financial expenditure was aligned to the annual programme and capital cash flow projections/expenditure were in-line with the financial forecast. The TrakCare project has progressed well during Quarter 4 and is now performing as anticipated. Design work on phase 1 of the infrastructure programme to increase electrical capacity has been completed and the scheme continues to progress on schedule. Design work to support the development of an Outline Business Case for investment in the Clinical Services Strategy is progressing well. 3. Recommendation 3.1 The Board is requested to receive this report and note the progress on capital schemes up to 31 March Lynne Hodgson Director of Finance, ICT & Support Services 2

86 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Capital Programme Performance 2015/16 Report of the Director of Finance, ICT & Support Services 1. Introduction/Background To provide an update as at 31 March 2016 on the progress of delivering the 2015/16 capital programme. The initial capital funding for 2015/16 was m, comprising 2.201m carried forward from 2014/15, 6.447m from internally generated depreciation, and 150K donated funds, and provision for a 2m loan. It was subsequently decided not to draw down the loan and so the revised capital allocation was The level of activity at the end of Quarter 4 is reflected through invoices and accruals of 7.828m with further orders placed of 2.977m. Monitor requires that between 85% and 115% of the initial capital allocation should be spent by the year end; the end of year profile of expenditure is shown in Appendix 2, which equates to 89% against the Monitor target. 2. Main content of report 2.1 The 2015/16 capital programme has progressed as anticipated during Quarter 4. A number of schemes have completed during Quarter 4. A number of capital schemes have been approved in principle, but deferred until 2016/17 when more funding will be available. 2.2 The four work-streams of Medical Equipment, ICT, Service Development and Estates Backlog Maintenance have all performed as anticipated in enabling the capital programme to progress to its current position. A detailed summary of each work stream is shown in Appendix The Outline Business Case to support the upgrade of the primary engineering infrastructure is progressing well. The planning application for the new electrical substations will be submitted in April 2016 and a separate planning application for the proposed new energy centre will be submitted in May. A mini competition amongst the Trust s construction framework suppliers will be held to select a contractor to undertake the work. Construction work on the new electrical substations will commence early within Quarter This report shows that, at the end of Quarter 4, 7.828m of the original 8,798 allocation has been invoiced or accrued, which equates to 89% of the annual plan. This has been achieved in spite of the late decision by Monitor not to adjust the Trusts capital metrics to assist with revenue overspends. Commitments made for the PAS/EPR project include milestone payments of 0.526m which fall due in 2016/17 and 1.476m of orders committed against the infrastructure scheme for work to commence in April

87 3. Conclusion/Summary 3.1 The significant elements of the programme to comment upon are: Schemes have been completed in a timely manner with good outcomes and positive feedback. Financial expenditure has been achieved in-line with the annual programme. Compliance with Monitor expenditure projections for Q4 is within the Monitor metrics range. Stage 1 of the TrakCare programme has been implemented to the planned programme. The Trust is progressing successfully, and is on schedule, with the 25m infrastructure investment scheme. Exploratory ground investigations, topography surveys, and the securing of supply contracts with the Regional Electricity Company have all been completed. Development of the Clinical Service Strategy options / estates master plan has been undertaken and continues to be refined through dialogue with clinical directorate work-streams. Development of the refurbished Lecture Theatre has been completed. 3.2 The capital programme has progressed to schedule and the expenditure and cash flow projections were closely aligned with the Trust annual plan. 3.3 The overall financial summary for the period to 31 March 2016 is presented at Appendix Recommendation 4.1 The Board is requested to receive this report and note the progress on capital schemes and delivery of the Monitor financial risk rating at the year end. Lynne Hodgson Director of Finance, ICT & Support Services 4

88 Appendix 1 - Work Stream Reports 1. Medical Equipment 1.1 Eight surgical Diathermy units within the Operating Theatre department were replaced during Quarter 4. They include smoke evacuators which remove smoke produced by the action of the diathermy and filters out the harmful particles. 1.2 Fourteen electric surgical saws and drills have been purchased to replace the aging models currently in use within the operating theatres. 1.3 Three replacement Ultrasound units for use in women s health have been delivered. These provide an improved image of the unborn baby, and the machines are capable of producing a 4D image which can be printed for the expectant parents. 1.4 Seventeen electric profiling beds within the Critical Care Unit have been replaced with new and updated models. The new beds are specifically designed for the specialist requirements of critical care patients and features include tilt and turn facilities in addition to continuous weight measurement. 2. Information Communication & Technology 2.1 The Capital ICT allocation this year has been split into four main streams, all of which supported the wider EPR programme and ability to fulfil on-going business as normal functions within ICT. 2.2 Due to changes with the ICT structure and the centralisation of ICT resources under one service manager, it became apparent that the centralisation of ICT resources on the North Tees site was necessary. A scheme was developed and completed to centralise ICT at the University Hospital of North Tees by using three rooms in part of the former Day Nursery. This enabled the relocation of the ICT Helpdesk from the main office and the centralisation of all 2 nd and 3 rd line support technicians into the main office. There was also the provision of a double desk hot desk office for the use of support staff from Hartlepool plus a Manager s office. 2.3 Specialist software has been procured to provide and permit the automated build and setup documentation of all Servers and PC s within the Trust. This software can be automated on a specified schedule to update the information that is held and also keep a record of the previous data. This will enable documentation to be kept up to date and will enable audit recommendations to be fulfilled. The software also documents systems such as Microsoft Exchange, VMware virtual environments, Citrix and full Microsoft Active directory structures. 2.4 Implementation of the Trust s new EPR system TrakCare The first Patch following go live has been applied to the system which includes fixes to the system that were identified within the first 30 days of live use of TrakCare. Downtime was required in order to apply the patch and this was well planned with all services managing extremely well by utilising their business continuity plans. The EPR team is currently planning for the next patch which is required ahead of the next maintenance release of TrakCare. This includes some key fixes to the Commissioning Data Set and the Personal Demographic Service. The handover process to the system administration team is well underway which will enable them to co-ordinate and manage all future upgrades to the system. 5

89 A number of planning sessions for phase 2 deliverables has been undertaken and the relevant high level project plans are being produced for board review. The supplier has worked closely with the Trust to resolve a number of reporting issues affecting the submission of Trust data, the majority of these have now been resolved. The roll out of TrakCare to Community Midwives who will move their current ante natal manual booking process to be recorded electronically within the patient s electronic record had been slightly delayed due to dependencies on some external infrastructure. Nevertheless, the roll out is due to commence April Service Developments 3.1 During Quarter 4 a series of accommodation moves has been undertaken to facilitate the establishment of a Cancer Information Centre. The centre is located conveniently on the ground floor of the main ward block at UHNT. A satellite unit has also been set up at UHH in the main entrance mall. The centre offers non-clinical advice and information to cancer patients, relatives and carers. This service used to be provided by the George Hardwick Carer s Centre and, since its closure, the Trust has been trying to find a way of re-providing the service. The new centre is the culmination of these efforts and is being financially aided by Macmillan Cancer Support. The enabling works to establish the new centre were financed by charitable trust funds. 3.2 The re-development of the lecture theatre within the Middlefield Centre at UHNT has been completed during Quarter 4. The new facility provides retractable seating which offers the adaptability of a standard lecture theatre to be converted quickly and easily into a multi-functional meeting room or venue for other events. The teaching and learning environment is enhanced and there is the potential and expectation for generating income by hosting external events. 3.3 Exploratory plans have been developed to establish an enhanced research and clinical trials suite within the Middlefield Centre. Interest in a joint venture has been received from an external provider and discussions are on-going. This scheme is already supported in principle by Trust executives but its implementation will be subject to a fully developed and approved business case. 4 Estates Backlog Schemes 4.1 The most notable elements of the Estates Backlog programme of schemes for had all been completed by the end of Quarter 3. 6

90 Appendix 2 North Tees and Hartlepool NHS Foundation Trust Capital Programme 2015/ as at 31 March 2016 Capital Report as at March 2016 Category Funding Allocation '000 Invoices & Accruals '000 Orders Committed & Raised '000 Funding Commitments '000 Total Committed '000 Uncommitte d '000 Medical Equipment Current Allocation 1,279,896 1,231, ,088 1,407, ,117 Prior Year Allocation 296, ,494 72, ,787 40,683 Sub Total Medical Equipment 1,576,000 1,496, , ,743, ,800 ICT & PAS/EPR Current Allocation PAS/EPR 4,063,000 3,611, ,111 4,576, ,659 ICT Rolling Programme 521, , ,368 70,950 Prior Year Allocation 1,318 1,318 1,318 0 Sub Total ICT 4,583,000 4,060, , ,025, ,709 Service Development Reconfiguration Plan 398, ,477 1,518,825 1,874,302 1,476,302 Current Allocation 810, ,422 54, ,833 41,659 Prior Year Allocation 258, ,021 46, ,775 68,733 Sub Total Service Development 1,467,000 1,212,920 1,619, ,832,909 1,365,909 Estates Compliance 143, ,410 20, ,901 19,577 Energy 31,544 27,576 27,576 3,968 Infrastructure 267, ,026 55, , ,136 PEAT 270, ,816 3, , ,012 Prior Year Allocation 309, ,660 62, ,923 21,293 Sub Total Estates 1,022,000 1,165, , ,306, ,896 Donated Funding via Charitable Funds Allocation 2015/16 150, ,815 3, ,439 31,439 Sub Total Donated 150, ,815 3, ,439 31,439 Total 2015/16 Capital Programme 8,798,000 8,113,241 2,977, ,090,755 2,292,755 Original Monitor Plan 8.567m - 85% = 7.3m - 115% 9.8m Source of Funding '000 Internally Generated Depreciation 6,447 Loan 0 Donated Funds Original Allocation 150 Subtotal: Per Board Report 6,597 less TrakCare c/fwd 16/17-890, less Energy Centre c/fwd -1,403, /17 Total committed 15/16 8,797, Total funding allocation 8,798, /16 Uncommitted 15/ Carried Forward from 2014/15 (EPR) 2,201 Total Allocation 8,798 7

91 Reporting against Monitor Metric 2015/16 achievement of 85%/115% of planned Capital Spend Q1 '000 Q2 '000 Q3 '000 Q4 '000 TOTAL Monitor Plan 1,435 1,686 2,623 2,823 8,567 Actual / Forecast 1,290 2,873 1,393 2,823 8,379 % 90% 170% 53% 100% 98% Cumulative Position 90% 133% 97% 98% 98% 8

92 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Compliance and Performance Report Report of the Chief Operating Officer/Deputy Chief Executive Strategic Aim and Strategic Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Board of Directors Reports) Maintain Compliance and Performance 1. Introduction 1.1 The Compliance and Performance Report highlights performance against a range of indicators, including Monitor s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/ /19 indicators, for the month of March and quarter / A new Patient Administrative System TrakCare ; whilst a success, has seen data recording and reporting issues and as a result of the uncertainty around the validity and reliability of data attached to these indictors, a red risk has been recorded against the Corporate Risk Register. This should be considered when reading the performance position against key indicators such as Referral to Treatment (including, RTT standards, median and 95th percentile waits and outcome compliance) and A&E standards. 2. Key issues and Planned Action 2.1 In March and quarter 4 the overall performance against key operational standards and trajectories remains challenging with pressures in the wider health system impacting on the delivery of both elective and non-elective pathways. 2.2 Non elective activity in March 2016 indicated a 9.88% (n=342) increase in comparison to the same period last year. The additional emergency pressures have been felt throughout quarter 4 with an increase of 9.49% (n=949) overall. The significant increase in emergency activity has impacted upon bed occupancy and subsequently, the number of additional beds opened, with evidence of delayed discharges and extended bed days. 2.3 The overall emergency activity in March included 284 patients (451 less than the same period last year) who were treated via Ambulatory care, equating to 7.47% of the total emergency admissions. On review of the data the reduction in Ambulatory care activity is being further investigated with a focus on recording practice and validation. 2.4 Quarter 4 A&E attendances and admissions saw a surge in comparison with the same period last year, reporting at 6.71% (n=1397) and 9.60% (n=417) higher respectively with the acuity of the patients remaining more complex. 2.5 Performance against the emergency care standard under achieved in the month of March, reporting at 90.21% against the national requirement of 95% and quarter 4, reporting at 92.04%. Despite under achieving against the 95% standard in the latter part of the year, the Trust performance has remained within or above national and North East average. Full details are described in the main report (section 3.8). 2.6 Notwithstanding the system pressures, a full and timely review of the key issues has taken place to identify the reasons/causative factors for the recent drop in performance, to ensure 1

93 appropriate mitigation plans are implemented to pull the position back in line with the set targets. 2.7 It is recognised that an increase in activity within the A&E department later in the day ultimately impacts on activity and patient flow out of hours. Detailed analysis can be seen in section The RTT incomplete standard for March and quarter 4 is not available at the time of reporting, however work continues to validate data. 2.9 The Trust has achieved against a number of the core cancer standards in quarter 4 (February latest validated position) however under-achieved against the cancer 62 day referral to treatment standard, reporting at 82.19% against a target of 85% (provisional un-validated position) due to significant pressures within the system specifically capacity at tertiary centres, complex pathways and patient choice. Further details within the main report With regard to Health Care Associated Infections (HCAI), the Trust reported outside the trajectory in March for C-Diff, with the cumulative position of 36 cases over the 2015/16 objective of 13 cases. 3. Key Challenges 3.1 Continuous achievement of elective, emergency and cancer access standards, alongside patient choice, complex pathway management and other variables outside of the control of the Trust within the context of system pressures. 3.2 Greater emphasis on quality indicators into directorate ownership with appropriate supportive governance structures is an on-going requirement. 3.3 Delivery and monitoring of the key standards whilst overcoming the impact and difficulties of the Patient Administration System. Manual data management, whilst resource intensive, continues to pose a risk to the delivery of operational standards; has been added to the Trusts Risk Register. 4. Conclusion/Summary 4.1 The Trust has, in the main, performed well against the majority of key operational standards during March and quarter 4, notwithstanding the considerable challenges associated with ongoing operational, clinical, financial and system wide pressures. The performance reporting framework will continue to develop to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements and principles of Service Line Management. 4.2 Whilst the Trust has robust governance processes in place for the monitoring and management of all performance standards there is recognition that current pressures across the whole health economy may ultimately impact on consistent delivery, therefore presents an on-going risk. 4.3 This risk is outlined within the Trust s Risk Register and Board Assurance Framework, with supporting mitigation plans, alongside internal and external governance assurance processes. 5. Recommendations 5.1 The Board of Directors is asked to note the detail in the Corporate Dashboard and performance against the Risk Assessment Framework and the key national indicators for March and quarter /16, in the context of Monitor s Terms of Licence and the Everyone Counts: Planning for Patients 2014/ /19 document. 5.2 In addition the Board of Directors is asked to note the on-going operational performance risks to regulatory key performance indicators and the work that is being taken forward to address. Julie Gillon Chief Operating Officer/Deputy Chief Executive 2

94 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Compliance and Performance Report Report of the Chief Operating Officer/Deputy Chief Executive 1. Introduction 1.1 The Compliance and Service Performance Report highlights performance against a range of indicators, including Monitor s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/ /19 indicators, for the month of March and Quarter / The Corporate Dashboard and reporting framework will be reviewed and updated to reflect both the mandatory performance frameworks for 2016/17 and the additional internal reporting requirements and key objectives for the forthcoming year. 1.3 Appendix 1 illustrates the monthly and quarterly trend and variance analysis against targets/trajectory profiles; with due consideration given to both positive and negative variances and progress against monthly, annual and in year improvement targets. 1.4 Appendix 2 illustrates a high level view of the Corporate Dashboard and progress against key performance indicators. 1.5 Appendix 3 illustrates the Monitor Risk Assessment Framework triggers of governance concerns. 1.6 This report must be read in conjunction with the additional information as detailed in the Quality report, Infection Prevention and Control report, the Human Resources (HR) report and the Finance and Contract report and the quarter 4 compliance report to Monitor. 1.7 A new Patient Administrative System TrakCare ; whilst a success, has seen data recording and reporting issues and as a result of the uncertainty around the validity and reliability of data attached to these indictors, a red risk has been recorded against the Corporate Risk Register. This should be considered when reading the performance position against key indicators such as Referral to Treatment (including, RTT standards, median and 95th percentile waits and outcome compliance) and A&E standards. 2. Performance Overview 2.1 In quarter 4 the overall performance against key operational standards and trajectories remains challenging. 2.2 Non elective activity in March 2016 indicated a 9.88% (n=342) increase in comparison to the same period last year with the main increases evident in General Medicine, reporting at 8.11% (n=179) higher, Paediatrics reporting at 21.06% (n=111) higher, Gynaecology reporting a 38% (n=19) increase and Orthopaedics reporting at 8.38% (n=14) higher than the same period last year. The additional emergency pressures have been felt throughout quarter 4 with an increase of 9.49% (n=949) overall. The significant increase in emergency activity has impacted upon bed occupancy and subsequently, the number of

95 additional beds opened, with evidence of delayed discharges and extended bed days. 2.3 The overall emergency activity in March included 284 patients (451 less than the same period last year) who were treated via Ambulatory care, equating to 7.47% of the total emergency admissions. However on review of the data the significant reduction in Ambulatory care activity is being further investigated with a focus on recording practice and validation. 2.4 Quarter 4 A&E attendances and admissions saw a surge in comparison with the same period last year, reporting at 6.71% (n=1397) and 9.60% (n=417) higher with the acuity of the patients remaining more complex. This is a similar trend nationally which also reported an increase in attendances and admissions compared to the same period last year. 2.5 This surge in activity saw performance against the emergency care standard under achieve in the month of March, reporting at 90.21% against the national requirement of 95% and quarter 4, reporting at 92.04%. Despite under achieving against the 95% standard in the latter part of the year, the Trust performance has remained within or above National and North East average. 2.6 The Trust is committed to consistent achievement against all access targets and has an excellent track record of delivering in line with the national requirements notwithstanding the system pressures. A full and timely review of the key issues has taken place to identify the reasons/causative factors for the recent drop in performance, to ensure appropriate mitigation plans are implemented to pull the Trust position back in line with the set targets and provide a level of assurance to the Board of Directors with regard to on-going compliance. 2.7 It is recognised that an increase in activity within the A&E department later in the day ultimately impacts on activity and patient flow out of hours. Detailed analysis can be seen in section 3.8. Bed pressures and staffing management have further impacted on emergency service delivery, which has been reflected in the organisation s NEEP status between levels 3 and 4 during the quarter 4 period with an increase to NEEP 5 on two occasions when unprecedented levels of activity were seen within the organisation. 2.8 The RTT incomplete standard for March and quarter 4 is not available at the time of reporting, however work continues to validate data. 2.9 The Trust has achieved against a number of the core cancer standards in quarter 4, however under-achieved against the cancer 62 day referral to treatment standard, reporting at 82.19% against a target of 85% (provisional un-validated position) due to significant pressures within the system specifically capacity at Tertiary centres, complex pathways and patient choice With regard to Health Care Associated Infections (HCAI), the Trust reported outside the trajectory in March for C-Diff, with the cumulative position of 36 cases over the 2015/16 objective of 13 cases. Zero cases of MRSA were reported in March and quarter 4, against the target of zero. Shadow monitoring of HCA Infections to include Methicillin Sensitive Staphylococuss Aureus (MSSA) and E Coli continues through 2015/ Compliance Indicators 3.1 The position against key performance indicators for March and quarter /16 is outlined below: 3.2 Referral to Treatment (RTT) Pathways

96 3.2.1 The national focus for RTT is now one measure of success, the reduction in incomplete pathways, with the admitted and non admitted pathway standards removed from national monitoring from June The NHS standard contract was amended to reflect the changes from October 2015; the original RTT admitted completed pathways (adjusted) is no longer applicable and has therefore not been included in subsequent reports A revised RTT shadow monitoring standard has been introduced from October 2015, which monitors non-adjusted admitted, pathway reflected in the dashboard The RTT incomplete standard for March and quarter 4 is not available at the time of reporting, however work continues to validate data. Intense work is continuous to address the recording and reporting of the RTT pathway data, to ensure accuracy and completeness of the data is recovered in addition to holding the provider to account for urgent fixers National RTT data, February s position (latest published data) indicated the Trust performed above the national average for incomplete pathways. Table 1 demonstrates the Trust s position against the national performance. The national reports are provided at both aggregate and specialty level, with the ability to compare with other individual organisations. These are shared monthly with the directorates for monitoring and management purposes. Table 1: February s RTT Benchmarked Position (latest published data) RTT Measure Incomplete Pathways waiting < 18 wks National Position (February 2016) Trust Position (February 2015) Trust v National 92.1% 92.8% + 0.7% Half of patients wait less than 6 weeks 7 weeks 1 weeks Half of Admitted patients waited less than 19 out of 20 patients wait less than Half of Non admitted Pathways waited less than 19 out of 20 patients wait less than 10 weeks 7 weeks -3 weeks 28 weeks 28 weeks 0 week 6 weeks 4 weeks -2 week 21 weeks 15 weeks -6 weeks A zero tolerance approach to any incomplete RTT non-adjusted pathways over 52 weeks remains within the Everyone Counts: Planning for Patients 2014/ /19 document. This standard was assigned a 5000 penalty within the National Standard Contract. The Trust reported no over 52 week waits in March or quarter 4 and continuously monitors this position on a weekly basis via the Patient Tracking List (PTL) Overall the organisation manages performance against the aggregate standard consistently. The developments to date include the appointment of additional consultants, extended days, additional outpatient, diagnostic and theatre sessions and reviews of individual resources which have supported delivery of the standards. However, with the current limited flexibility in

97 capacity within the system there is significant micro-management on a daily basis to support on-going delivery of the waiting times standards In addition a refresh of the capacity and demand model is underway to fully understand demands within the system around current and forecast pressures. 3.3 Diagnostic Waiting Times Diagnostic pathways continue to be monitored closely to ensure maximum contribution to RTT pathway management and to reduce waiting times. In line with the national trend, the Trust is experiencing increased pressures for the provision of MRI and CT scanning services The maximum 6 week diagnostic wait indicator remains within the Everyone Counts: Planning for Patients 2014/ /19 document. The Trust achieved 99.95% against the target of 99% in March. 3.4 Health Care Associated Infections MRSA The Trust reported zero cases of MRSA bacteraemia in quarter The tolerance for 2015/16 remains at zero cases, in line with the national target of zero tolerance for MRSA. 3.5 Clostridium Difficile (CDI) There were five cases of Trust apportioned Clostridium Difficile reported in March, against the month end target of 1 case, however the cumulative Q4 position has reported above the year end objective at 36 cases against the trajectory of 13 cases. A full report is detailed in the Quarter 4 Compliance Report to Monitor A full health economy governance approach to management has been investigated, according to national directive, and continues to develop in line with local requirements The Clostridium Difficile target for 2016/17 is set at 13 cases. As such, the delivery of the C-diff standard was recognised by the Board of Directors as at risk for 2016/17 against the indicator threshold (Risk Assessment Framework 2015), with a declaration of non-compliance indicated in the Operational Plan submitted to Monitor. 3.6 MSSA and E Coli The DH introduced the requirement to shadow monitor MSSA and E Coli cases from 2011 onwards; a reduction in Trust apportioned cases is expected. In March there were two cases of MSSA reported with a cumulative position of 24, and four Trust apportioned case of E Coli against the monthly internal trajectory of two cases, with a cumulative position of A Full root cause analysis is carried out for each Trust apportioned MSSA and E Coli cases to identify any emerging themes and trends. 3.7 Cancer Standards (February latest validated position and Quarter 4 provisional un-validated position)

98 3.7.1 The Trust continues to experience significant pressures in achieving the cancer pathway standards. The Trust under-achieved in the months of January (77.88%) and February (82.80%) against the Cancer 62 day referral to treatment Standard, therefore despite an improved position of 86% being achieved in March, the overall Q4 position reported below the required 85%, reporting at 82.19% (provisional position until final published figures in May 2016) due to significant pressures within the system and at Tertiary centres, complex pathways and patient choice The latest national position, February data, indicates a number of Trusts are experiencing pressures in delivering the cancer standards with the national average for the 62 day urgent referral to treatment standard reporting at 80.8% against the target of 85%, with seven out of the ten regional organisations breaching the standard. Table 2 62 day urgent referral to treatment Regional Position S Tyneside Sunderland N Cumbria Gateshead Newcastle Northumbria S Tees Table 3 below demonstrates compliance against the 62 day urgent referral to treatment standard demonstrating number of patients seen within quarter 4. Table 3 Quarter 4 (Provisional un-validated position) North Tees & Hartlepool Durham & Darlington Breast 0 (0/0) 0 (0/0) 81.8 (9/11) 100 (25/25) 93.1 (13.5/14.5) 100 (16/16) 93.8 (15/16) 100 (10/10) 100 (14.5/14.5) 96.3 (103/107) 94.6 Lung 76.5 (6.5/8.5) 71.4 (2.5/3.5) 60 (3/5) 81.8 (4.5/5.5) 65.9 (13.5/20.5) 81.8 (4.5/5.5) 45.2 (7/15.5) 83.3 (10/12) 48 (6/12.5) 65 (57.5/88.5) 73.6 Gynae 100 (1/1) 100 (1.5/1.5) 0 (0/1) 70.6 (6/8.5) 87.5 (3.5/4) 75 (3/4) 84.6 (11/13) 66.7 (1/1.5) 57.1 (2/3.5) 76.3 (29/38) 76 Upper GI 80 (2/2.5) 50 (1.5/3) 76.9 (5/6.5) 57.1 (2/3.5) 59.3 (8/13.5) 46.2 (3/6.5) 70 (7/10) 100 (1/1) 100 (5.5/5.5) 67.3 (35/52) 72.2 Lower GI 100 (5/5) 80 (4/5) 64 (8/12.5) 94.1 (8/8.5) 93.3 (7/7.5) 66.7 (6/9) 76.2 (8/10.5) 66.7 (3/4.5) 94.7 (9/9.5) 80.6 (58/72) 70.3 Uro (exc testes) 0 (0/0.5) 65.5 (28.5/43.5) 90.9 (15/16.5) 68.8 (5.5/8) 85.1 (20/23.5) 96 (12/12.5) 67.5 (13.5/20) 73.3 (11/15) 100 (4.5/4.5) 76.4 (110/144) 74.9 Haem (exc AL) 0 (0/1) 100 (2/2) 75 (6/8) 100 (2/2) 100 (3/3) 100 (2/2) 100 (5/5) 0 (0/0) 40 (2/5) 78.6 (22/28) 78.4 Head & Neck 100 (1/1) 100 (4/4) 100 (4/4) 100 (1/1) 87.5 (7/8) 0 (0/0) 75 (3/4) 0 (0/0) 0 (0/0) 90.9 (20/22) 66.9 Skin 0 (0/0) 100 (2.5/2.5) 85.3 (14.5/17) 0 (0/0) 100 (47/47) 87.5 (3.5/4) 91.8 (22.5/24.5) 100 (1.5/1.5) 100 (24.5/24.5) 95.9 (116/121) 95 Sarcoma 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 56.8 Brain/CNS 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) 0 (0/0) #N/A Other 0 (0/0) 0 (0/0) 100 (1/1) 0 (0/0) 83.3 (5/6) 0 (0/0) 100 (2/2) 100 (1/1) 100 (1/1) 90.9 (10/11) 78 All 79.5 (15.5/19.5) 71.5 (46.5/65) 79.4 (65.5/82.5) 87.1 (54/62) 86.4 (127.5/147.5) 84 (50/59.5) 78 (94/120.5) 82.8 (38.5/46.5) 85.7 (69/80.5) 82 (560.5/683.5) 80.8 January February March Provisional (provisional) Q4 Total Number of accountable patients Number of patients who breached Number of full accountable breaches Number of shared accountable breaches Performance 77.88% 82.80% 86% 82.19% The Q4 under-achievement against the Cancer 62 Day standard is, in the main, as a result of the January performance, which reported at 77.88%, with 12.5 breaches reported within the period. This is reflective of the post- Christmas holiday period, impacted on by both patient choice and loss of capacity across bank holidays. In total 160 accountable patients were treated within the Q4 period, with 28.5 accountable breaches reported. NECN National Table 4 below demonstrates compliance against the 62 day urgent referral to treatment standard by specialty for quarter 4 position (provisional), indicating the key areas of pressure within the organisation. An increase in referrals has had a substantial impact on the outpatient and diagnostic services, as each 2 week wait referral has to be seen and diagnosed within the required timescales, which can include multiple appointments and diagnostic tests.

99 Table 4 Quarter 4 performance by specialty Tumour Group 62 day Referral to Treatment standard (85%) Q4 Number of Patients Treated/ Breached Breast 100.0% 36 (0 breaches) Gynaecology 62.5% 8 (2 full, 2 shared breaches) Colorectal 71.8% 19.5 (5 full, 1 shared breaches) Upper GI 71.4% 7 (4 shared breaches) Lung 75.4% 32.5 (2 full, 12 shared breaches) Skin 100.0% 3.5 (0 breaches) Urology 79.3% 41 (5 full, 7 shared breaches) Haematology 88.9% 9 (1 full breach) Other 80.0% 2.5 (1 shared breach) An area where the Trust is reporting a significantly higher referral rate than other organisations in the local Network is Lung referrals, with the Trust 26.3% (n=1314) of the total Lung referrals across the Network (n=4994), double the number received by a local specialist hospital, who received 13.1% (n=656) in the same period. The Trust is currently working with the commissioners to understand this significantly outlying position Improvement plans have been put in place following service reviews to address under-achievement against the cancer standards, with appropriate mitigation plans implemented to address key issues, with the aim to pull the Trust position back in line with the set target and provide a level of assurance to the Board of Directors with regard to on-going compliance, notwithstanding the system wide issues described in this report requiring action to enable consistent delivery. A trajectory improvement plan has been agreed with the CCGs The uptake of patient choice, causing delay in the diagnosis and treatment stages within the pathway, continues to affect the delivery of the cancer standards. In response to the patient choice issue, the Trust continues to work with local GPs to ensure continued support to encourage patients to take up appointments offered within the required timescales, to improve patient information and ensure a continued focus. The Trust continues to pursue this piece of work and remodelling of pathways alongside Commissioners Aligned to national guidance and the weekly submission of the 62 day Patient Tracking List (PTL) to NHS England, from November 2015, the PTL includes long waiters, with Trusts required to report all patients who have breached beyond 104 days from referral to treatment (including with and without a decision to treat) The risk of underachievement against the cancer standards was anticipated by the Board of Directors and acknowledged in the returns to monitor via the Annual Plan Work continues to implement all actions outlined within the updated internal cancer recovery plan, however, it is recognised that the consistent delivery of the cancer standards requires a system wide approach, with pathway reviews essential across the whole health economy The Trust continues to work closely with CCG and GP representatives to review the radical transformational actions required to enable a whole systems approach to management of the cancer pathways to assist in achieving the cancer standards. A detailed report can be found in the Quarter 4 compliance report to Monitor.

100 3.8 Emergency Care Standards The Trust under achieved for the month of March against the emergency care 4 hour arrival to discharge or admission standard, reporting at 90.21% against the target of 95% and struggled to recover the position throughout quarter 4 reporting at 92.04%, providing a year end position of 94.72%. Whilst this is not where the Trust would like to be, it has to be acknowledged that the organisation has experienced significant operational pressures. This, together with the significant pressures faced by the department, and the Trust as a whole, led to an unprecedented challenge with regards to patient flow during quarter 4, with recovery plans in place to review and investigate breaches and patient flow with the emphasis on quality and safety and improvement on patient experience The Trust has consistently performed within or above the national performance throughout the year, however struggled to achieve the standard throughout quarter 4, ultimately affecting the year end position. A number of factors have affected this position regional pressures have significantly impacted upon the department and inevitably patient flow throughout the organisation as the Trust battled with NEEP 3, 4 and 5 together with ambulance deflections/ diverts The Trust is committed to consistent achievement against all access targets and has a good track record of delivering in line with the national requirements. A full and timely review of the key issues has taken place to identify the reasons/causative factors for the recent drop in performance, to ensure appropriate mitigation plans are implemented to pull the Trust position back in line with the set targets and provide a level of assurance to the Board of Directors with regard to on-going compliance. A comprehensive review of the emergency pathway across A&E and In-hospital services is underway Table 5 indicates that England average against the A&E 4 hour standard has remained below the 95% standard throughout 2015/16 with the latest February position reporting at 87.8% The North East position overall achieved in quarter 1 and 2 however under achieved in quarter 3 and the month of February (latest available data) reporting at 91%, with all Trusts within the region also under achieving the standard in January and February The Trust remains above the national average for all periods within 2015/ Pressures faced by A&E was recognised as a national problem with only 46 out of 165 Trusts cited as achieving the A&E 4 hour standard within the Trust Development Authority (TDA) Board report for Q3 2015/16 (latest available data). Within the report they acknowledge the sustained high levels of emergency admissions and lack of available beds had an influence on the overall performance, together with delayed transfers of care and the increased acuity of patients The NHS England published statistical report for the A&E 4 hour standard ( indicates that only 5 out of the 138 acute providers with a Type 1 A&E department achieved the standard in February 2016 (latest available data). The Trust reported in 22 nd position.

101 Table 5: NT&HFT benchmark position against the A&E 4 hour standard in 2014/15 and 2015/16 Name Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16 Q3 2015/16 Jan-16 Feb-16 North Tees And Hartlepool NHS Foundation Trust 95.5% 95.9% 95.0% 94.1% 96.2% 95.7% 94.1% 93.7% 92.4% Trust % 98.1% 90.5% 84.2% 92.5% 95.8% 94.0% 93.8% 92.9% Trust % 93.4% 90.9% 90.3% 95.1% 95.1% 92.8% 89.7% 92.5% Trust % 96.1% 95.4% 94.0% 95.2% 95.8% 93.3% 91.1% 89.5% Trust % 97.1% 94.8% 94.2% 95.0% 95.7% 93.6% 92.2% 91.9% Trust % 96.6% 95.4% 95.1% 97.7% 97.6% 95.0% 90.9% 89.3% Trust % 95.6% 93.7% 93.6% 94.6% 96.9% 95.7% 93.8% 92.8% Trust % 96.0% 94.1% 91.5% 94.1% 97.5% 93.8% 87.1% 86.6% North East Average 96.4% 96.1% 93.7% 92.1% 95.1% 96.3% 94.0% 91.5% 91.0% England 95.1% 95.0% 92.6% 91.8% 94.1% 91.4% 91.5% 88.7% 87.8% *Note: Source figures The Trust recognises an increase in activity within the A&E department later in the day which ultimately impacts on activity and patient flow out of hours. Chart 1 depicts the level of activity within the department from April 2015 to March 2016, over a 24 hour period showing continuous pressure. The departments level of activity peaks between the hours of 18:00 and 19:00 which inevitably impacts on patient flow out of hours. Chart 1: A&E Attendances by hour April 2015 to March Whilst delayed discharges have remained consistent, at an average rate of 12 per day, peaks during admissions surges, weekends and bank holiday periods have created intense pressure on bed occupancy, exacerbated by closure of beds in nursing and residential care homes. With the local authority care homes, including the transitional and rehabilitation facilities, experiencing similar capacity issues to the Trust, this has led to further delays in discharges and increases in delayed bed days creating additional bed pressures A&E quality outcome indicators are published each month. Publication on Trust web sites is a Monitor requirement, mandatory from June Trust data against these supporting indicators is unavailable at the time of reporting due to issues with the Patient Administration System with resolution expected within quarter Ambulance handovers greater than 30 and 60 minutes are monitored within the commissioner reports on a monthly basis. In March the Trust reported ambulance handover greater than 30 minutes and 6 greater than 60 minutes. The Trust has disputed a number of these handover delays and is in the process of validating. In comparison, the North East average handovers greater than 30 minutes reported at (range ), with the average over 60 minutes reporting at 42 (range 1-153). The Trust s overall

102 performance in March indicated 95.37% of ambulance handovers (valid) within 15 minutes Given the recent national publicity around delays in emergency access, the delivery of efficient ambulance turnaround times is currently high profile across the health economy. The Trust reported 87.2% ambulance turnaround times (valid) within 30 minutes during March, in comparison the North East s position at 81.4% with performance ranging between 68.8% and 92.9%. The Ambulance turnaround time is the measurement of the time between the Ambulance arriving at the hospital (electronically captured at base) and the Ambulance leaving the hospital site (electronically captured at base); post the completion of electronic documentation within the A&E department The Quarter 3 TDA report supports the need to address the performance challenge. However, Quarter 4 has seen a worsening position and a stark realisation of the need for system transformation Although improvement in pathway management has been evident, during the times of significant pressure, generally out of hours, it is recognised there is still progress to be made. Assurance and governance to aid recovery of the 4 hour position comprised the Perfect Week and Kick Start January This allowed in depth analysis of patient flow and discharge processes, recommended as good practice by ECIST. The secondment of the Clinical Director of Emergency and Ambulatory Care to ECIST, allowed a country wide review, enabling the sharing of good practice. 3.9 Community Information Dataset (CIDS) Performance indicators for Community Services, with data completeness used as a measure for the three elements of Referral to Treatment (RTT), referral and activity information, with a target of 50% completeness (from Q1 2012/13) remain in the 2015/16 Risk Assessment Framework March s position (latest available data) indicates the Trust has achieved all three CIDs targets for the period, reporting 95.38% (RTT), 93.40% (Referral) and 93.66% (activity) respectively against the 50% target Monitor indicated two further data completeness measures would be introduced within 2012/13, End of Life Pathway and Patient Identifiable Information, however these were subsequently removed from the Risk Assessment Framework. The Trust continues to monitor these indicators in shadow format with achievement against both. 4. Human Resource / Productivity Indicators 4.1 Cancelled Operations In March, non-medical cancelled operations reported at 0.46% (n=16) within the Care Quality Commission target of 0.8% a slight increase on previous months which has been compounded as a result of NEEP levels within the organisation and the industrial action of junior doctors. Table 6 below demonstrates cancelled operations by month for 2015/16. Table 6 Non Medical Cancelled Operations 2015/16 March 16 February 16 January 16 December 15 November 15 October 15 September 15 August 15 July 15 June 15 May 15 April % 0.74% 0.396% 0.40% 0.56% 0.50% 0.38% 0.41% 0.15% 0.39% 0.43% 0.46% Grand Total

103 4.1.2 The Trust was unable to reappoint one patient within 28 days of a nonmedical elective cancellation due to capacity The Department of Health Everyone Counts: Planning for Patients 2014/ /19 document outlines that no urgent operation should be cancelled more than once March and Q4 position reported no urgent procedures had been cancelled. 4.2 Outpatient Attendance Indicators The Trust continues to report progressive positive performance against the national comparative benchmarks for outpatient attendance efficiency indicators. These benchmarks were reviewed in March 2015 to ensure they reflected the current national position and expected benchmark included within the model hospital advocated in the Lord Carter report. Stretch targets will be set going forward into 2016/ The aggregate New to Review ratios in March are reported at 1.18 below the 2015/16 stretch target of Additional individual targets have been agreed with Commissioners for monitoring at specialty level. Further work continues with Clinical Commissioning Groups (CCGs) to develop pathways to support further reduction/exemption, where possible The Trust s performance against New Outpatient DNA rates reported above the agreed 2015/16 stretch target of 5.40%, at 8.06% and Review DNA rates reporting at 11.53% against the 9% target, both of which is a decrease to the previous months Work is on-going to further reduce DNAs, supported by the automated reminder service and partial booking which is now back on line following a period of suspension with the implementation of TrakCare. 4.3 Choose and Book Appointment Slot Issues (ASIs) The National reporting system for Choose and Book was migrated to E- Booking in May Since the introduction of the system there have been a number of issues, most of which have now been resolved with the day to day operating of the system now working as expected. However, the issues with the reporting element of the system has not yet been resolved, therefore at this point in time the monthly ASI position cannot be reported. 4.4 Sickness Absence The Trust reported an aggregate Sickness Absence rate of 5.01% during March 2016 against the set target of 3.5% The Trust focus remains on adherence to policy and management support to deliver a reduction in sickness. The Trust has reviewed and updated the Absence Management Policy, with guidance distributed to all managers. 5. High Level Quality Indicators 5.1 This analysis is supported by the Quality Report. 5.2 HSMR and SHMI The latest HSMR data released from HED for the time period February 2015 to January 2016 demonstrates the Trust is reporting higher than expected at

104 111.60, however is demonstrating continued reduction against previous positions of; ( December 2014 to November 2015) (November 2014 to October 2015) (October 2014 to September 2015) (September 2014 to August 2015) (August 2014 to July 2015) (July 2014 to June 2015) (June 2014 to May 2015) SHMI is also reporting higher than expected at in the most recent Health and Social Care Information Centre rolling 12 month period (October 2014 to September 2015), however this too is demonstrating a continued reduction against previous positions; (July 2014 to June 2015) (April 2014 to March 2015). Note: SHMI includes deaths outside of hospital, within 30 days of discharge Work is on-going to review both the HSMR and SHMI position via the Keogh Delivery Group which addresses the eight key recommendations in the Professor Keogh report (September 2013). In hospital mortalities are reviewed including accurate documentation, clinical coding and weekly clinical led reviews The Trust continues to take a key role in regional Community Acquired Pneumonia Project and the Serious Infections SEPSIS Project, with informatics performed by Clarity (external data company) in both instances, both of these projects are running in conjunction with other North East Trusts The Trust, while using national mortality measures as a warning sign, is investigating more broadly and deeply the quality of care and treatment provided This work is further supported by external peer reviews, commissioned external audits and collaborative working with other regional organisations. 5.3 Readmissions The Trust recognises emergency readmissions as an area requiring further work, in line with national drivers to reduce inappropriate admissions. The Trust is currently reporting emergency readmission rates at 10.45% post emergency admission and 3.59% post elective admission. However the aggregate emergency readmission rate reports at 7.35%, below the revised 2015/16 internal stretch target of 7.70% (based on peer average and year on year improvement) Work is on-going within the individual directorates to review key issues and recognition of avoidable and unavoidable categorisation. This work is supported by clinical audit and clinical debate to inform discussions and negotiation with the Clinical Commissioning Groups. Appropriate governance structures via the Better Care Fund Working will be put in place to ensure that the responsibility of readmissions is shared across the acute, community, primary and social care providers to tackle the key themes associated with avoidable readmissions. 5.4 Unplanned Hospitalisation and Emergency Admissions

105 5.4.1 The Everyone Counts: Planning for Patients 2014/ /19 Framework includes a number of measures aimed at reducing unnecessary hospital admissions for a defined set of acute conditions. These are: Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s Emergency admissions for acute conditions that should not usually require hospital admission Emergency admissions for children with lower respiratory tract infections Although no target has been set to date, there is an expectation that acute providers will deliver a year on year reduction against these key areas. The Trust has re-set the baseline against 2014/15 outturn and monitors delivery on a month on month basis, in addition to continuing joint work with GPs and CCGs to develop pathways to avoid admission where inappropriate Two of the four standards reported an improvement on last year s position, with the remaining two standards reporting an increase in admissions within the defined conditions, Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) and Unplanned hospitalisation for respiratory tract infections in under 19s. 5.5 Venous Thromboembolism (VTE) VTE assessment has now been added to the Corporate Dashboard within the Quality section. This target measures the Trust s compliance with the assessment for VTE on admission for all appropriate admissions. The Trust reported at 81.42% in March (latest available data), below the 95% target. 5.6 Grade 3 & Grade 4 Pressure Sores The monitoring of hospital acquired grade 3 and grade 4 pressures sores has been added to the quality section of the Corporate Dashboard. In March the Trust reported three grade 3 pressure sores and zero grade 4 pressure sores in hospital (hospital acquired). 5.7 In Hospital Falls The performance for total in hospital falls is monitored against last year s position for the comparative period, with an expected improvement. In March 2016 the Trust reported 99 falls in hospital, a decrease of 1% (n=1) on the March 2015 position, which reported 100 falls In March 2016, two of the in hospital patient falls resulted in a fracture, an increase to the same period last year which reported one. This is further addressed in the Quality report. 5.8 NHS Choices The Trust s current score against the NHS Choices section relating to patient experience and recommendation of provider is reported within Appendix 1 of the Corporate Dashboard. Patient experience and choice is high on the Trust s quality agenda, therefore this measure is included as a guide to the patient s perception of the care the two hospital sites are providing This is supplemented by the Friends and Family Indicator report in the Quality Report to Board, with scores for Wards, A&E and Maternity (births element) reported on the quality section of the Corporate Dashboard.

106 5.8.3 NHS England calculates and presents the FFT results as a percentage of respondents who would be extremely likely or likely to recommend the service to their friends and family. 5.9 Out of Hospital The Corporate Dashboard has been updated to include a number of Transforming Community Services Indicators, to provide an overview of the progress being made in delivering improvements across community care TCS 19 Community patients with an unplanned admission of 2 days or less is used to monitor the progress being made in reducing avoidable emergency admissions for patients on a community case load, covering a defined set of conditions : Diabetes complications, Nutritional deficiencies, Iron deficiency anaemia, Hypertension, Congestive heart failure, Angina, Chronic obstructive pulmonary disease and Asthma. The latest position (February 2016) reported an admission rate of 17.54% against the internal target of 17% TCS 24 - The percentage of patients on a community caseload achieving improvement, as measured using a validated assessment tool appropriate to the scope of the practice, is used by the Community Integrated Assessment Team (CIAT) to monitor progress during/post treatment. The latest position (February 2016) indicates % of patients measured are showing an improvement post treatment against an internal target of 93.50% TCS 35 Standard wheelchairs to be delivered within 5 working days, is monitored as one of the key standards for home equipment delivery performance. The latest position (February 2016) reported 62.59% of standard wheelchairs delivered within 5 days, against the internal stretch target of 90%. This is an unfortunate decrease when the service has made significant improvements in achieving this standard (December 2015 reported 94.02% and January 2016 reported 100%) and validation of this is underway The Trust is progressing well against the chosen TCS indicators, with further work on-going to develop appropriate performance monitoring across community services. 6. Contract Key Performance Indicators 6.1 The Trust agreed a significant number of key performance measures for 2015/16 within the NHS standard and local contract negotiations. In line with the NHS England Commissioning Board structure, these are reported to multiple commissioning bodies including: Clinical Commissioning Groups Area Team Local Authority 6.2 The KPIs cover quality requirements across both acute and community services, with financial penalties attached against non compliance. The Trust reports performance to the commissioners on a monthly basis. 6.3 The Trust performed well across the majority of the contract KPIs during the March and quarter 4 period. The main areas of pressure are reflective of the Trust s overall position on Clostridium Difficile, A&E 4 hour standard and some of the cancer standards (14 day and 62 day). 6.4 The performance against the contract KPIs for all commissioners are available via a link within the Corporate Dashboard.

107 7. Conclusion/Summary 7.1 The Trust has, in the main, performed well against the majority of key operational standards during March and quarter 4 despite significant operational and system pressures and financial challenges. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements and principles of Service Line Management. 7.2 The Trust has robust governance processes in place for the monitoring and management of the delivery of all performance standards and will continue to strive to achieve core regulatory requirements. However, there is recognition that current pressures across the whole health economy may ultimately impact on consistent delivery, therefore presents an on-going risk. 7.3 This risk is outlined within the Trust s risk register and the Board Assurance Framework, with supporting mitigation plans, alongside internal and external governance assurance processes. 7.4 The Corporate Dashboard and performance monitoring and management framework will be reviewed and updated to reflect the key deliverables during 2016/17 and will be presented at the May Board of Directors. 8. Recommendations 8.1 The Board of Directors is asked to note the detail in the Corporate Dashboard and performance against the Risk Assessment Framework and the key national indicators, for March and quarter 4, in the context of Monitor s Terms of Licence and the Everyone Counts: Planning for Patients 2014/ /19 document. 8.2 In addition the Board of Directors is asked to note the on-going operational performance risks to regulatory key performance indicators and the work that is being taken forward to address. Julie Gillon Chief Operating Officer/Deputy Chief Executive

108 ID Appendix 2 Published's Date & Time 11/06/ :28 Measure Monthly Target Monitor Score March 2016 March 2016 Act QTR 4 Cum ID Measure 1 A&E 1 New to Review ratio (cons led) A&E 4 hr target (excludes walk-in centres) 95% % 92.04% 94.72% 2 Outpatient DNA (new) 5.40% 8.06% 3 3 Outpatient DNA (review) 9.00% 11.53% 4 Cancer Mar 2016 Provisional 4 Average depth of coding QTR 4 Provisional 5 Length of Stay Elective New Cancer 31 days subsequent Treatment (Drug Therapy) 98% % % % 6 Length of Stay Emergency New Cancer 31 days subsequent Treatment (Surgery) 94% % % 99.03% 7 Day case Rate 69.83% 69.45% 8 New Cancer 62 days (consultant upgrade) 85% % % 83.58% 8 Pre - Op Stays 4.50% 0.90% 9 New Cancer 62 days (screening) 90% % 96.43% 97.07% 9 10 New Cancer GP 62 Day (New Rules) 85% % 82.19% 83.85% 10 Bed Occupancy 11 New Cancer Current 31 Day (New Rules) 96% % 99.04% 99.24% 11 Revised Occupancy Hartlepool 82.00% No Data 12 New Cancer Two week Rule (New Rules) 93% % 93.03% 92.67% 12 Revised Occupancy North Tees 82.00% No Data 13 Breast Symptomatic Two week Rule (New Rules) 93% % 93.61% 94.24% RTT Milestones RTT incomplete pathways wait (92%) 92% Theatre Activity Operation Time Utilisation 76.24% 73.64% Run Time Utilisation 94.54% 88.45% 20 Community Information Dataset 20 Planned Session Utilisation 92.54% 95.34% 21 * Referral to Treatment information 50% 95.38% 21 Cancelled on day of operation 6.18% 6.24% 22 * Referral information 50% % 22 Cancelled (Non medical) 0.80% 0.46% 23 * Treatment Activity Information 50% 93.66% HR 25 HCAI Cumulative YTD Target 25 Staff in post (wte) Staff turnover ratio 10.00% 12.47% 27 C.Diff (diagnosed after 72 hours) Sickness absence % 3.50% 5.01% Mandatory Training 80.00% 95.40% 29 Eliminating Mixed Sex Accommodation 0 N/A Access to Healthcare for People with Learning Disabilities CQC Registration ID Measure Compliance Monitoring Quality Process Monthly Target Annual Target Monthly Target Annual Target March 2016 March 2016 Act Cum ID Measure HR - Productivity & Process Financial Position 1 Mortality rate (HSMR) ACCIDENT AND EMERGENCY Mortality rate (SHIMI) ANAESTHETICS Mortality rate (SHIMI) - {High relative risk CCS's} TBA 15 3 CHIEF EXECUTIVE Readmission rate 30 days (Emergency admission) 9.73% 10.45% 4 EAU & AMBULATORY CARE Readmission rate 30 days (Elective admission) 0.00% 3.59% 5 EDUCATION & ORGANISATION DEVELOPMENT Readmission rate 30 days (Total) 7.70% 7.35% 6 ENDOSCOPY ESTATES Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) FINANCE & ICT Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s HUMAN RESOURCES Emergency admissions for acute conditions that should not usually require hospital admission OUT OF HOSPITAL CARE Unplanned hospitalisation for respiritory tract infections in under 19s IN HOSPITAL CARE MEDICAL DIRECTOR Patient Safety Incidents (All Grades) {per 100 admissions} NURSING AND PATIENT SAFETY Patient Safety Incidents that resulted in Serious Harm - {% of total PSIs} OBS AND GYNAE Complaint response times 79.00% % 15 ORTHOPAEDICS OUTPATIENTS Corporate & Departmental Risks (Red) 9 17 PAEDIATRICS Electronic Discharge Summaries within 24 hours 95.00% No Data 18 PATHOLOGY Grade 3 Pressure sores (Hospital only) PHARMACY Grade 4 Pressure sores (Hospital only) RADIOLOGY Total Falls (Hospital Only) RESEARCH AND DEVELOPMENT Falls with Fracture (STEIS Reportable) STRATEGY, OPERATIONS AND PERFORMANCE VTE 95.00% 81.42% 23 SURGERY AND UROLOGY Hand washing Compliance % 90.67% 24 TRANSFORMATION Cumulative YTD Target 25 TOTAL DIRECTORATE MRSA - Bacteraemia TRANSFORMATION ARRAGEMENTS FOR 15/16 SIEP DELIVERY 27 Methicillin Sensitive Staphylococcus Aureus (MSSA) TRANSFORMATION - 28 E-Coli UNALLOCATED CIP OVERALL PORTFOLIO TOTAL CONTINUITY OF SERVICES RISK RATING 31 Friends & Family 31 CAPITAL SEVICING CAPACITY (50%) Friends & Family - (Ward)-[National Score based on % extremely likely to recommend to F&F] 70% -100% 96.32% 32 LIQUIDITY RATIO (50%) Friends & Family - (A&E)-[National Score based on % extremely likely to recommend to F&F] 70% -100% 91.95% 33 I&E MARGIN (25%) Friends & Family - (Birth)-[National Score based on % extremely likely to recommend to F&F] 70% -100% % 34 VARIANCE IN I&E MARGIN (25%) OVERALL FINANCIAL SUSTAINABILITY RATING - - Revenue Position Act CIP Delivery Cum Strategic CIP Delivery

109 Appendix 1 - Compliance Monitoring Framework A&E left without being seen Return to CDB menu The % of patients whose clock stopped within 18 weeks during the month with an admission (Part1a)** The % of patients whose clock stopped within 18 weeks during the month - non admitted (Part 1b) The % of patients whose clock is still running waiting less than 18 weeks (Part 2) RTT admitted wait (Median)** RTT non admitted wait (Median) RTT incomplete pathways wait (Median) RTT admitted wait (95th percentile)** RTT non admitted wait (95th percentile) RTT incomplete pathways wait (95th percentile) RTT incomplete pathways >52 week wait The % patients treated within 18 weeks of referral to audiology (Hpool site) Audiology non admitted wait (95th percentile) A&E 4 hr target (excludes walk-in centres) A&E Time to Initial Assessment -Ambulance arrivals (95th percentile) A&E Time to Initial Treatment (Median) A&E unplanned returns within 7 days A&E Time to departure (95th percentile) % Ambulance Handover (Valid) within 15 minutes Trust Performance (1) * Data collection, validation and reporting processes prevent these standards from achieving a more timely result April 15 May 15 June 15 July 15 August 15 QTR 1 QTR 2 QTR 3 QTR 4 Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% Actual 91.33% 91.57% 92.96% 92.00% 92.47% 90.64% 90.73% 91.31% 81.52% 75.49% 82.25% 79.75% 81.86% 79.25% - Variance 1.33% 1.57% 2.96% 2.00% 2.47% 0.64% 0.73% 1.31% Profile 95% 95% 95% 95% 95% 95% 95% 95% Actual 98.12% 98.05% 98.38% 98.21% 98.12% 98.13% 98.07% 98.15% 97.70% 97.30% 97.42% 97.47% 97.03% 97.19% - Variance 3.12% 3.05% 3.38% 3.21% 3.12% 3.13% 3.07% 3.15% Profile 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% Actual 96.36% 96.60% 96.85% 96.69% 96.70% 96.83% 96.38% 96.71% 94.57% 95.18% 92.53% 94.11% 92.99% 92.77% - Variance 4.36% 4.60% 4.85% 4.69% 4.70% 4.83% 4.38% 4.71% 2.57% 3.18% 0.53% 0.99% 0.77% Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% Actual % % % % % % % % % Variance 5.0% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% Profile Actual Variance % 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Actual 95.48% 97.27% 96.47% 96.40% 95.56% 94.84% 96.80% 95.74% 93.09% 92.90% 96.47% 94.13% 93.67% 92.36% 90.21% 92.04% Variance 0.48% 2.27% 1.47% 1.40% 0.56% -0.16% 1.80% 0.74% -1.91% -2.10% 1.47% -0.87% -1.33% -2.64% -4.79% -2.96% Profile 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 Actual No Data No Data No Data No Data No Data No Data No Data No Data Variance Profile 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 Actual 00:45 00:42 00:47 00:45 00:49 00:40 00:45 00:45 No Data No Data No Data No Data No Data No Data No Data No Data Variance 00:14 00:17 00:12 00:14 00:10 00:19 00:14 00:14 Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% Actual 4.95% 4.54% 4.79% 4.77% 5.06% 5.20% 5.59% 5.20% No Data No Data No Data No Data No Data No Data No Data No Data Variance -0.05% -0.46% -0.21% -0.23% 0.06% 0.20% 0.59% 0.20% Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% Actual No Data No Data No Data No Data No Data No Data No Data No Data Variance Profile 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 04:00 Actual 03:59 03:58 03:59 03:59 03:59 04:13 03:58 03:59 No Data No Data No Data No Data No Data No Data No Data No Data Variance 00:00 00:01 00:00 00:00 00:00 00:13 00:01 00:00 Profile 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Actual 98.46% 99.14% 98.67% 98.76% 98.90% 98.99% 98.67% 98.89% 98.31% 98.76% 99.52% 98.86% 98.11% 95.89% 95.37% 96.46% Variance -1.54% -0.86% -1.33% -1.24% -1.10% -1.01% -1.33% -1.11% -1.69% -1.24% -0.48% -1.14% -1.89% -4.11% -4.63% -3.54% September 15 October 15 November 15 December 15 January 16 February 16 March 16

110 Appendix 1 - Compliance Monitoring Framework Return to CDB menu New Cancer 31 days subsequent Treatment (Drug Therapy) * New Cancer 31 days subsequent Treatment (Surgery) * New Cancer 62 days (consultant upgrade) * New Cancer 62 days (screening) * New Cancer GP 62 Day (New Rules) * New Cancer Current 31 Day (New Rules) * New Cancer Two week Rule (New Rules) * Breast Symptomatic Two week Rule (New Rules) * MRSA - Bacteraemia (Cumulative)*** Clostridium Difficile Patients - diagnosed after 72 hours all ages (Cumulative)*** Methicillin Sensitive Staphylococcus Aureus (MSSA) (Cumulative)*** E-Coli (Cumulative)*** Stroke admissions 90% of time spent on dedicated Stroke unit * High risk TIAs assessed and treated within 24 hours * TAL's - (No SLOT analysis) * Eliminating Mixed Sex Accommodation Friends & Family - (Ward) [National Score based on % extremely likely to recommend to F&F] Friends & Family - (A&E) [National Score based on % extremely likely to recommend to F&F] Friends & Family - (Birth) ** [National Score based on % extremely likely to recommend to F&F] Outcome Compliance Trust Performance (2) April 15 May 15 June 15 QTR 1 July 15 August 15 September 15 Profile 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% Actual % % % % % % % % % % % % % % % % Variance 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% Profile 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94% Actual % % % % 90.00% % % 96.83% % % % % % % % % Variance 6.0% 6.00% 6.00% 6.00% -4.00% 6.00% 6.00% 2.83% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85% Actual % 75.00% 66.67% 85.00% % % 92.86% 95.45% % 44.44% 75.00% 66.70% % % % % Variance 15.0% % % 0.00% 15.00% 15.00% 7.86% 10.45% 15.00% % % % 15.00% 15.00% 15.00% 15.00% Profile 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90% Actual 98.51% % % 99.50% 97.65% % 90.48% 96.49% 96.30% 95.16% 95.77% 95.70% % % 91.04% 96.43% Variance 8.5% 10.00% 10.00% 9.50% 7.65% 10.00% 0.48% 6.49% 6.30% 5.16% 5.77% 5.70% 10.00% 10.00% 1.04% 6.43% Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85% Actual 85.84% 88.04% 83.06% 85.59% 85.71% 83.33% 80.00% 83.55% 85.42% 81.31% 88.16% 85.16% 77.88% 82.80% 85.96% 82.19% Variance 0.8% 3.04% -1.94% 0.59% 0.71% -1.67% -5.00% -1.45% 0.42% -3.69% 3.16% 0.16% -7.12% -2.20% 0.96% -2.81% Profile 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96% Actual 99.16% 99.04% % 99.12% % % 96.55% 98.91% % % 99.04% 99.69% 99.01% 97.94% % 99.04% Variance 3.2% 3.04% 4.00% 3.12% 4.00% 4.00% 0.55% 2.91% 4.00% 4.00% 3.04% 3.69% 3.01% 1.94% 4.00% 3.04% Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93% Actual 92.88% 94.30% 91.55% 92.87% 90.60% 90.86% 94.12% 91.78% 93.36% 93.15% 92.53% 93.05% 93.06% 91.04% 94.85% 93.03% Variance -0.1% 1.30% -1.45% -0.13% -2.40% -2.14% 1.12% -1.22% 0.36% 0.15% -0.47% 0.05% 0.06% -1.96% 1.85% 0.03% Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93% Actual 96.03% 94.94% 92.61% 94.43% 91.67% 92.31% 96.10% 93.19% 97.16% 95.95% 94.20% 95.68% 95.24% 94.48% 91.33% 93.61% Variance 3.0% 1.94% -0.39% 1.43% -1.33% -0.69% 3.10% 0.19% 4.16% 2.95% 1.20% 2.68% 2.24% 1.48% -1.67% 0.61% Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% Actual 90.91% 77.14% 81.08% 81.40% 91.18% 91.18% 90.00% 77.50% 93.33% 90.70% 80.00% Variance 10.91% -2.86% 1.08% 1.40% 11.18% 11.18% 10.00% -2.50% 13.33% 10.70% 0.00% Profile 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% 75.00% Actual 85.71% % 83.33% 80.00% 37.50% % % 66.70% % 40.00% 87.18% Variance 10.71% 25.00% 8.33% % 5.00% % 25.00% 25.00% -8.30% 25.00% % 12.18% Profile 4% 4% 4% 4.00% 4% 4% 4% 4.00% 4% 4% 4% 4.00% 4% 4% 4% 4.00% Actual 1.71% 2.61% No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data Variance -2% -1.39% Profile Actual Variance Profile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% Actual 94.91% 95.74% 96.89% % 95.52% 95.52% 96.62% 96.03% 96.39% 95.65% 95.64% 96.32% Variance 24.91% 25.74% 26.89% #VALUE! 25.76% 25.52% 25.52% 26.62% 26.03% 26.39% 25.65% 25.64% 26.32% Profile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% Actual 88.24% 90.17% 95.45% % 91.81% 93.88% 94.52% 96.84% 90.80% 89.96% 87.59% 91.95% Variance 18.24% 20.17% 25.45% #VALUE! 20.70% 21.81% 23.88% 24.52% 26.84% 20.80% 19.96% 17.59% 21.95% Profile 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% 70.0% 70.0% 70.0% 70.00% Actual % % 97.29% % 92.86% 95.00% 87.50% % % 86.67% 88.57% % Variance 30.00% 30.00% 27.29% #VALUE! 10.00% 22.86% 25.00% 17.50% 30.00% 30.00% 16.67% 18.57% 30.00% Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Actual 99.33% 97.96% 96.16% 98.37% 99.79% 96.49% 99.34% 99.45% 56.68% No Data No Data No Data No Data No Data No Data No Data Variance 4.33% 2.96% 1.16% 3.37% 4.79% 1.49% 4.34% 4.45% % QTR 2 October 15 November 15 December 15 QTR 3 January 16 February 16 x Mar 16 (Cancer Provisional) QTR 4 (Cancer Provisional) * Data collection, validation and reporting processes prevent these standards from achieving a more timely result ** Mandatory from 2013 *** Figures may change after validation process

111 Appendix 1 - Compliance Monitoring Framework Return to CDB menu Cancelled Operations for non medical reasons Readmission within 28 days of non medical cancelled operation * Number of patients waiting under 6 weeks for diagnostic procedures A & E 12 Hour Trolley waits Cancelled Urgent Operations for second time Late Start % Early Finishes % Session overuns (>30 minutes) Delayed Transfers of Care CIDs -Referral to Treatment information * CIDs - Referral information * Treatment Activity Information * Patient Identifier Indicator * End of Life measure * % Patients recommending University Hospital of Hartlepool % Patients recommending University Hospital of North Tees Trust Performance (3) April 15 May 15 June 15 July 15 Profile 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% Actual 0.31% 0.74% 0.35% 0.40% 0.55% 0.50% 0.38% 0.44% 0.15% 0.39% 0.41% 0.46% Variance -0.49% -0.06% -0.45% -0.40% -0.25% -0.30% -0.42% -0.36% -0.65% -0.41% -0.39% -0.34% Profile Actual Variance Profile 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% Actual 99.49% 99.90% 99.76% 99.80% 99.67% 99.11% % 99.90% 99.49% 99.34% 99.82% 99.95% Variance 0.49% 0.90% 0.76% 0.80% 0.67% 0.11% 1.00% 0.90% 0.49% 0.34% 0.82% 0.95% Profile Actual Variance Profile Actual Variance Profile 22.63% 23.34% 30.06% 22.67% 26.99% 29.49% 35.84% 33.33% 33.33% 33.13% 33.44% 31.83% Actual 24.55% 25.39% 28.50% 33.14% 33.09% 33.77% 37.28% 38.60% 32.41% 33.55% 30.63% 31.61% Variance 1.92% 2.05% -1.56% 10.47% 6.10% 4.28% 1.44% 5.27% -0.92% 0.42% -2.81% -0.22% Profile 51.46% 53.31% 53.57% 55.28% 51.56% 54.42% 56.94% 51.44% 57.04% 51.81% 54.55% 50.99% Actual 55.39% 49.53% 53.44% 52.96% 52.00% 53.25% 51.18% 53.51% 58.97% 59.28% 54.65% 54.19% Variance 3.93% -3.78% -0.13% -2.32% 0.44% -1.17% -5.76% 2.07% 1.93% 7.47% 0.10% 3.20% Profile 17.88% 15.33% 15.18% 12.42% 16.26% 11.26% 11.85% 17.24% 13.75% 12.95% 10.71% 15.77% Actual 12.57% 14.11% 11.70% 14.20% 15.64% 9.87% 15.68% 14.33% 11.03% 14.01% 12.61% 12.58% Variance -5.31% -1.22% -3.48% 1.78% -0.62% -1.39% 3.83% -2.91% -2.72% 1.06% 1.90% -3.19% Profile 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% Actual 2.10% 1.93% 1.39% 1.54% 2.06% 1.45% 1.40% 1.74% 1.42% 2.55% 2.15% 1.58% Variance -1.40% -1.57% -2.11% -1.96% -1.44% -2.05% -2.10% -1.76% -2.08% -0.95% -1.35% -1.92% Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% Actual 92.76% 92.92% 92.41% 92.65% 93.54% 92.73% 92.21% 94.82% 94.30% 95.87% 95.38% Variance 42.76% 42.92% 42.41% 42.65% 43.54% 42.73% 42.21% 44.82% 44.30% 45.87% 45.38% Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% Actual 92.19% 94.14% 92.51% 93.11% 91.90% 92.76% 98.69% 94.41% 88.62% 93.84% 93.40% Variance 42.19% 44.14% 42.51% 43.11% 41.90% 42.76% 48.69% 44.41% 38.62% 43.84% 43.40% Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% Actual 90.15% 94.44% 91.89% 97.77% 94.05% 92.74% 98.37% 93.04% 86.42% 94.07% 93.66% Variance 40.15% 44.44% 41.89% 47.77% 44.05% 42.74% 48.37% 43.04% 36.42% 44.07% 43.66% Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% Actual 90.15% 94.44% 91.89% 97.77% 94.05% 92.74% 98.37% 93.04% 86.42% 94.07% 93.66% Variance 40.15% 44.44% 41.89% 47.77% 44.05% 42.74% 48.37% 43.04% 36.42% 44.07% 43.66% Profile 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% 50.00% Actual 96.15% 97.78% % 98.78% 97.14% 92.86% 89.66% 93.75% 92.67% 94.19% 88.64% Variance 46.15% 47.78% 50.00% 48.78% 47.14% 42.86% 39.66% 43.75% 42.67% 44.19% 38.64% Profile Actual Variance Profile Actual Variance Profile Actual Variance August 15 September 15 October 15 November 15 December 15 January 16 February 16 March 16 * Data collection, validation and reporting processes prevent these standards from achieving a more timely result

112 Appendix 1 - Community Monitoring Framework Return to CDB menu Diabetic Retinopathy Screening Health Visitor numbers TCS 19 - % of Community Patients that have had an unplanned admission LOS <=2 days (Defined set of conditions) TCS 24 - % of Patients achieving improvement using a EQ5 validated assessment tool TCS 35 - % of standard wheelchair referrals completed within five days Trust Performance (4) April 15 May 15 June 15 July 15 Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Actual 92.72% 91.89% 92.85% 92.87% 92.67% 92.84% 92.49% 91.97% 92.33% 92.54% 92.96% 92.91% Variance -2.28% -3.11% -2.15% -2.13% -2.33% -2.16% -2.51% -3.03% -2.67% -2.46% -2.04% -2.09% Profile Actual Variance Profile 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% 17.00% Actual 18.45% 24.43% 18.57% 16.00% 17.61% 23.57% 15.03% 13.57% 17.11% 12.70% 17.54% Variance 1.45% 7.43% 1.57% -1.00% 0.61% 6.57% -1.97% -3.43% 0.11% -4.30% 0.54% Profile 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% 93.50% Actual 96.43% 94.94% 98.35% 95.80% 93.90% 99.07% 96.00% 95.70% % % % Variance 2.93% 1.44% 4.85% 2.30% 0.40% 5.57% 2.50% 2.20% 6.50% 6.50% 6.50% Profile 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% Actual 62.32% % 85.07% 90.70% 78.57% 79.76% 86.84% 95.20% 94.02% % 62.59% Variance % 10.00% -4.93% 0.70% % % -3.16% 5.20% 4.02% 10.00% % Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance Profile Actual Variance August 15 September 15 October 15 November 15 December 15 January 16 February 16 March 16 * Data collection, validation and reporting processes prevent these standards from achieving a more timely result

113 Appendix 3

114 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Finance and Contract Performance Report as at 31 March 2016 Report of the Acting Director of Finance Strategic Aim (The full set of Trust aims can be found at the beginning of the Board Reports) Maintain Compliance and Performance. Strategic Objective (The full set of Trust objectives can be found at the beginning of the Board Reports) Finance 1. Introduction 1.1 The purpose of this report is to inform the Board of Directors of the financial and contract performance position of the Trust for the period to 31 March Key Issues & Planned Actions Financial Risk Rating 2.1 There is a new risk assessment framework in place and the financial performance against the Monitor plan is as follows: 2.2 Summary Financial Position - As at 31 March 2016 the Trust is reporting an operational deficit of 7.396m for the period, which is 2.544m ahead of the planned deficit for the period of 4.852m. The in month surplus was 554k. 2.3 The operational deficit of 7.396m reported is line with the forecast control total agreed with Monitor. 1

115 Income 2.4 There is an over recovery on income against the profiled plan of 1,815k at the end of March The Trust s income is showing an over recovery of 1,815k (0.66%) Expenditure 2.5 To date, pay budgets are over spent against plan by 1,513k. Some spend in relation to locums and agency has continued to cover vacancies and maternity cover, but this has fallen compared to previous months due to corrective action from the Directorate management teams. 2.6 Non pay budgets are 2,413k under-spent for the period to 31 March Service Improvement & Efficiency Programme 2.7 The gross Service Improvement & Efficiency Programme (SIEP) target for 2015/16 of m has been reduced to 4.738m. The Trust has delivered 6.163m of its in-year SIEP. The Trust s expenditure is showing an over-spend of 5,364k (1.96%) Working Capital 2.8 Net cash outflow for the month was 2.278m, resulting in a decrease in cash from m to m as at 31 st March Net current assets at 31 March have increased by 3.66m to m in the month. Summary 2.10 The financial performance for 2015/16 was 2.544m behind planned assumptions however the deficit of 7.396m was in line the forecast control total agreed with Monitor. 3. Recommendations 3.1 The Board of Directors is requested to note the financial position as at Month 12, 31 March In addition, the Board of Directors are requested to note the analysis of performance against the Financial Sustainability risk ratings, as detailed in Appendix 6 which demonstrates that the Trust has reported a risk rating of 2 for 2015/16. Caroline Trevena Acting Director of Finance 2

116 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Finance and Contract Performance Report as at 31 March 2016 Report of the Acting Director of Finance 1. Introduction/Background 1.1 The purpose of this report is to inform the Board of Directors the financial and contract performance position of the Trust for the period to 31 March Main content of report Financial Risk Rating and Summary 2.1 There is a new risk assessment framework in place and the financial performance against the Monitor plan is as follows: 2.2 The table below illustrates that current performance metrics result in a Financial Sustainability Risk Rating of 2 for the period to 31 March 2016, with the variance in I&E Margin reporting a rating of 3 Financial Sustainability Risk Rating (FSRR) Area of Review Overall Financial Risk Rating Year to Date Financial Risk Rating (FSRR) Month 12 Plan Month 12 YTD 2 2 Month 12 Projection 4 Capital Service Capacity (25%) Liquidity (25%) I&E Margin (25%) Variance in I&E Margin (25%) A more detailed analysis of the Financial Sustainability Risk Rating is attached at Appendix 6. This appendix includes a rolling forecast of the risk rating over the next 12 months. 3

117 2.4 Summary Financial Position - As at 31 March 2016 the Trust is reporting an operational deficit of 7.396m for the period, which is 2.544m behind the planned deficit for the period of 4.852m. 2.5 The summarised financial performance is presented as per previous reports in Appendix 1. Income Performance 2.6 There is an over recovery on income against the profiled plan of 1,815k at the end of March Detailed analysis is provided in Appendix The projected income from CCGs as at 31 March 2016 is based on the actual contract activity to September and estimated contract activity for the majority of points of delivery for October to March. Due to issues with TrakCare implementation, data is not currently available for Months 7 to 12. The Trust has therefore assumed a level of over performance in line with activity up to Month 6. The position has been estimated using the SLAM contract model which takes actual performance to month 6 and extrapolates the month 12 year to date performance based on year to date contract value. 2.8 Income from CCG agreements is over recovered by 308k, a movement of 1,441k in month that represents re-classification to other income of clinical excellence awards and disaggregation of Directorate income between clinical and other income. 2.9 There is an over performance against the Hartlepool and Stockton CCG contract of 1,801k which is due to increased non-elective activity in In Hospital Care and Trauma and Orthopaedics. The over performance also includes the full winter resilience funding of 3,400k in the year-end position to reflect the actual costs incurred. The remaining over performance is within the cap. The Trust is reporting the forecast overspend against winter funding to the Systems Resilience Group. The Durham Dales Easington & Sedgefield CCG contract continues to over perform, by 1,745k. This is due to increased elective, non elective and day case activity across most specialties Other income from patient care is over recovered by 149k Income from non-patient care (commercial income) is over recovered by 1,358k. There is an under recovery attributable to car parking income, mainly attributable to offsite parking and the under delivery of directorates income generation schemes offset by re-classification of Directorate income. CQUIN and Penalties 2.12 A summary of the measures used to earn additional income to the Trust in the form of CQUIN, and the penalties that the Trust may be required to pay if the elements of the contracts relating to performance targets and information requested are not met, is reflected in Appendix 11 detailing the impact on income The value of penalties estimated in Month 12 income is 293k, mainly due to instances of hospital acquired infections. The Trust s income is showing an over recovery of 1,815k (0.66%) 4

118 Expenditure Pay: 2.14 To date pay budgets are over spent against plan by 1,513k (after the phased element of the 1.5m non-recurring vacancies factor is taken into account) The main area of overspend has been recourse to locum staff at premium rates in areas where recruitment is difficult The pressure on pay budgets has reduced markedly as a result of the action plans implemented by management teams, with the supplementary pay bill remaining on average 1.0m in March. Additional beds have been opened across different wards to manage the increased pressure that comes in the winter months, and some of this has resulted in the need for recourse to agency staff. The vacancy factor is 1.5m for the year 2015/16. The Trust has exceeded the 3% cap on agency nursing costs as a percentage of their nursing pay bill in month. The in month position is 6.91% and the cumulative position for the six months is 4.13%. The Trust has breached this Monitor metric in 2015/ A breakdown of the employee benefit expense analysis (by value and WTE) is presented in Appendix 9 and highlights expenditure trends on agency, locum, bank, and overtime. This also provides performance against the new Monitor metric in relation to the percentage of agency nursing as a total of nursing spend A graphical presentation of payroll numbers and WTEs for the period to 31 March 2016 and comparison to the previous 12 months is presented at Appendix No expenditure was released from reserves this month to fund locums. Locum rates are now within the capped levels advised by Monitor. The total year to date cost of locum cover is 2,886k, resulting in an increased cost compared to planned posts of 1,347k and is summarised in Table 2: Table 2 Summary of Locum Funding at Month 12 Directorate As at Vacancies Sickness Maternity Released Premium from Charge for Month 12 Other reserves Locum ACCIDENT AND EMERGENCY 118, ,628-44,676 ANAESTHETICS 23,145 23,145 27,535 14,230 IN HOSPITAL CARE 967, , , , ,235 OBS AND GYNAE 140, ,957-8,487 ORTHOPAEDICS 436, , , ,757 OUT OF HOSPTIAL CARE PAEDIATRICS 88,440 88,440-15,579 PATHOLOGY 480, ,911 45, ,273 PHARMACY RADIOLOGY 93,211 93,211 60,670 0 SURGERY AND UROLOGY 537, , , ,270 Total Locum Spend 2,886,278 2,786, , ,137 1,347,507 5

119 Non Pay: 2.20 Non pay budgets are 2,413k under spent against budget for the period to the end of March A summary of expenditure by directorate is presented at Appendix 2, positive variances being highlighted in black and adverse variances being highlighted in red. Service Improvement & Efficiency Programme 2.22 The gross Service Improvement & Efficiency Programme (SIEP) target for 2015/16 of m has been reduced to 4.738m. The Trust has delivered 6.163m of its in-year SIEP There have been two programmes of work in 2015/16: directorate specific programmes and a transformational programme. For 2016/17 it is proposed to implement a matrix programme to support the successful delivery of efficiencies. The matrix structure proposed will involve existing and proposed schemes are aggregated into programmes which will be underpinned by work-streams and individual schemes. The proposed Trust strategic programme streams will be in line with the Lord Carter recommendations For the directorate specific programmes a target of 6.630m of savings was established. At month 12, 4.896m of savings has been made (of which, 2.767m (57%) is recurrent and 2.129m (43%) is non-recurrent) For the transformational/corporate programmes the target is 4.271m of savings to be achieved. As at M12 297k has been delivered through VAT rebates and is shown against Transformation non pay expenditure in the financial position and there has been 971k of cost avoidance schemes. EBITDA (earnings before interest, taxes, depreciation & amortisation) 2.26 The Trust has generated an EBITDA of 1.814m at month 12, 3.549m behind plan, resulting in an EBITDA margin of 0.66%, against a planned margin of 2.0%. Depreciation, PDC Dividend and Interest Receivable 2.27 Depreciation costs and PDC payable to the DH are 5,451k and 3,739k (respectively). Depreciation costs are slightly less than plan as a result of an in depth review of the valuation of the Trust s asset base and the independent valuation of the estate by the District Valuer The Trust has generated interest receivable on investments at the end of Month 12 of 102k, which is slightly below plan; however, interest rates remain at a historically low level preventing improved investments being made. Cash Flow, Working Capital & Balance Sheet 2.29 Cash flow The cash flow statement is presented at Appendix 4. Net cash outflow for the month was 2.278m, resulting in a decrease in cash from m to m as at 31 March Current assets A decrease of 3,127k during the month. Stocks have increased by 395k, debtors have increased by 2,162k and accrued income / prepayments have decreased by 3,406k. The balance of the change in current assets relates to a decrease in cash of 2,278k Current liabilities A decrease of 6,793k during the month. Creditors have decreased by 2,999k. The payment of older invoices has had an adverse effect on the Trust s Better 6

120 Practice Payment Code position as presented in Appendix 8. The PDC dividend creditor decreased by 1,619k due to final payment in March. Current borrowings and lease commitments have remained the same and accruals have decreased by 2,067. Deferred income has decreased by 176k and current provisions have increased by 68k Net current assets at 31 March have increased by 3.66m to m in month Presented at Appendix 3 is the Statement of Financial Position for the year to 31 March 2016, with a comparison to the previous month and Month 12 position for 2014/15. Capital 2.34 The original capital allocation for 2015/16 was m of which 6.447m is internally generated block capital with a carry forward from 2014/15 of 2.201m. The balance reflects 0.15m of donated funds and 2.0m of external financing. However, the Trust has decided not to go ahead with the external funding option and has adjusted the capital allocation budget accordingly. This has resulted in a reduction in funding of 1m for the Estates Reconfiguration Scheme and a 1m for the Service Development Scheme. The total is in line with the Monitor plan The Trust has spent 8.113m in the financial year, with further commitments of 0.684m identified The capital position is summarised in Appendix 5. Financial Indicators 2.37 A detailed pack of additional key financial indicators is provided for information at Appendix 7 to 11. These include: Performance against Monitor s Compliance Framework (Appendix 7); Performance against the Better Practice Payment Code (Appendix 8); Analysis of the employee benefit expense (Appendix 9); WTE Comparison graph (Appendix 10); and Income Statement by Commissioner (Appendix 11). 3. Conclusion/Summary 3.1 The financial performance for 2015/16 was 2.544m behind planned assumptions however the deficit of 7.396m was in line the forecast control total agreed with Monitor. 4. Recommendation 4.1 The Board of Directors is requested to note the financial position as at Month 12, 31 March In addition, the Board of Directors is requested to note the analysis of performance against the Financial Sustainability risk ratings, as detailed in Appendix 6 which demonstrates that the Trust has reported a risk rating of 2 for 2015/16. Caroline Trevena Acting Director of Finance 7

121 APPENDIX 1 Income & Expenditure Summary as at March 2016 Original Budget Setting Annual Budget Budget to Date Actual to Date Variance Income Variance Previous Month Commissioning Agreements (230,248) (228,526) (228,526) (228,834) 308 1,749 Other Income from Patient Care (306) (2,894) (2,894) (3,043) Other Income from Non Patient Care (22,732) (25,412) (25,412) (26,770) 1,358 (747) Passthrough Reserve (16,461) (16,246) (16,246) (16,246) 0 0 Total Income (269,747) (273,078) (273,078) (274,893) 1,815 1,016 Expenditure Pay 185, , , ,286 (1,513) (1,412) Non Pay 63,476 84,206 84,206 81,793 2,413 2,365 Passthrough Expenditure 16, Reserves 9,958 (1,526) (1,526) 0 (1,526) 0 Hosted Services - Audit North (net position) SIEP (10,901) (4,738) (4,738) 0 (4,738) (5,512) Total Expenditure 264, , , ,079 (5,364) (4,559) EBITDA 5,294 5,363 5,363 1,814 (3,549) (3,543) Depreciation 6,324 6,325 6,325 5, Interest Payable Loans & Leases PDC 3,780 3,780 3,780 3, Interest Receivable (150) (150) (150) (102) (48) (45) Operational Surplus / (Deficit) (4,852) (4,852) (4,852) (7,396) (2,544) (3,182) Reversal on impairment 4,754 Total Deficit (2,642) (2,642) EBITDA 5,294 5,363 5,363 1,814 EBITDA Margin % 2.0% 2% 2% 0.66% EBITDA % Achieved 33.82% I&E Margin -1.80% -1.78% -1.78% -2.69% ROA -4.02% -8.04% % Operating Expenditure YTD (273,079)

122 APPENDIX 2 Directorate Summary Position as at March 2016 INCOME Directorate Annual Budget Budget to March Actual to March Variance Variance Previous Month ACCIDENT AND EMERGENCY 0 0 (7,656) 7,656 7,631 ANAESTHETICS (14,487) (14,487) (22,283) 7,796 9,026 CENTRAL EXPENDITURE 0 0 (771,630) 771,630 74,455 CENTRAL INCOME (16,680,719) (16,680,719) (17,187,646) 506,927 (895,313) CONTRACT INCOME (245,539,437) (245,539,437) (245,321,138) (218,299) 1,749,000 EAU & AMBULATORY CARE 0 0 (35,446) 35,446 32,809 EDUCATION & ORGANISATION DEVELOPMENT (94,290) (94,290) (107,919) 13,629 13,887 ENDOSCOPY (3,600) (3,600) (4,358) 758 1,058 ESTATES (5,256,154) (5,256,154) (5,085,533) (170,621) (255,680) FINANCE & ICT (514,982) (514,982) (1,027,457) 512,475 51,603 HUMAN RESOURCES 0 0 (4) 4 4 IN HOSPITAL CARE (231,977) (231,977) (283,832) 51,855 30,359 NURSING AND PATIENT SAFETY (3,431) (3,431) (46,036) 42,605 24,779 OBS AND GYNAE (97,134) (97,134) (82,622) (14,512) (16,504) ORTHOPAEDICS (31,053) (31,053) (29,319) (1,734) 15,870 OUT OF HOSPITAL CARE (1,011,887) (1,011,887) (839,323) (172,564) (17,652) OUTPATIENTS 0 0 (1,740) 1,740 1,740 PAEDIATRICS (31,451) (31,451) (74,651) 43,200 2,790 PATHOLOGY (329,240) (329,240) (391,332) 62,092 42,293 PHARMACY (1,620,684) (1,620,684) (1,679,668) 58,984 47,645 RADIOLOGY (134,412) (134,412) (105,587) (28,825) (30,084) RESEARCH AND DEVELOPMENT (729,192) (729,192) (996,981) 267,789 92,578 STRATEGY, OPERATIONS AND PERFORMANCE (6,512) (6,512) (20,600) 14,088 8,668 SURGERY AND UROLOGY (108,373) (108,373) (109,901) 1,528 1,528 TRANSFORMATION (639,242) (639,242) (659,976) 20,734 23,316 Total Income (273,078,257) (273,078,257) (274,892,638) 1,814,381 1,015,806 PAY EXPENDITURE ACCIDENT AND EMERGENCY 6,698,244 6,698,244 6,805,840 (107,596) (118,781) = ANAESTHETICS 16,810,047 16,810,047 17,156,351 (346,304) (342,730) CENTRAL EXPENDITURE 648, , , ,200 90,674 CHIEF EXECUTIVE 675, , ,751 21,388 26,242 EAU & AMBULATORY CARE 9,104,161 9,104,161 9,596,233 (492,072) (423,602) EDUCATION & ORGANISATION DEVELOPMENT 2,429,216 2,429,216 2,374,138 55,078 53,646 ENDOSCOPY 2,878,363 2,878,363 2,814,226 64,137 77,303 ESTATES 13,068,384 13,068,384 12,940, , ,162 FINANCE & ICT 6,703,568 6,703,568 6,542, , ,205 HUMAN RESOURCES 821, , ,071 57,596 39,614 IN HOSPITAL CARE 24,507,416 24,507,416 24,922,163 (414,747) (312,095) MEDICAL DIRECTOR 99,311 99,311 98, NURSING AND PATIENT SAFETY 3,269,957 3,269,957 3,337,616 (67,659) (54,068) OBS AND GYNAE 11,747,497 11,747,497 11,132, , ,783 ORTHOPAEDICS 10,653,905 10,653,905 10,977,615 (323,710) (221,269) OUT OF HOSPITAL CARE 34,780,655 34,780,655 34,052, , ,757 OUTPATIENTS 1,043,665 1,043,665 1,034,519 9,146 4,011 PAEDIATRICS 9,554,192 9,554,192 9,722,338 (168,146) (102,543) PATHOLOGY 7,124,942 7,124,942 7,627,918 (502,976) (511,471) PHARMACY 3,788,687 3,788,687 3,715,546 73,141 80,694 RADIOLOGY 9,337,421 9,337,421 9,308,299 29,122 (98,373) RESEARCH AND DEVELOPMENT 795, , ,444 (118,227) (90,429) STRATEGY, OPERATIONS & PERFORMANCE 2,448,699 2,448,699 2,261, , ,073 SURGERY AND UROLOGY 11,746,581 11,746,581 11,684,710 61,871 86,121 TRANSFORMATION 538, , ,621 20,554 10,383 VACANCY FACTOR (1,500,000) (1,500,000) 0 (1,500,000) (1,375,000) Total Pay Expenditure 189,773, ,773, ,285,989 (1,512,832) (1,411,344)

123 APPENDIX 2 Directorate Summary Position as at March 2016 Directorate Annual Budget Budget to March Actual to March Variance Variance Previous Month NON PAY EXPENDITURE (INCLUDING PASSTHROUGH EXPENDITURE) ACCIDENT AND EMERGENCY 696, , ,391 (37,393) (20,941) ANAESTHETICS 5,269,674 5,269,674 4,698, , ,950 CENTRAL EXPENDITURE 205, ,440 1,609,274 (1,403,834) (322,052) CHIEF EXECUTIVE 216, , ,038 27,901 28,278 EAU & AMBULATORY CARE 1,563,685 1,563,685 1,561,501 2,184 35,574 EDUCATION & ORGANISATION DEVELOPMENT 652, , ,222 (60,414) (73,973) ENDOSCOPY 1,728,870 1,728,870 1,556, , ,672 ESTATES 10,212,266 10,212,266 9,594, , ,252 FINANCE & ICT 12,060,215 12,060,215 11,612, ,212 1,173,565 HUMAN RESOURCES 481, , , ,467 1,066 IN HOSPITAL CARE 17,632,081 17,632,081 17,713,481 (81,400) (249,441) MEDICAL DIRECTOR 5,300 5, ,158 4,720 NURSING AND PATIENT SAFETY 273, , ,718 (14,276) (3,466) OBS AND GYNAE 2,041,394 2,041,394 2,090,206 (48,812) (97,977) ORTHOPAEDICS 6,709,411 6,709,411 5,430,889 1,278,522 1,048,143 OUT OF HOSPITAL CARE 7,990,860 7,990,860 7,458, , ,064 OUTPATIENTS 625, , ,332 65,097 45,011 PAEDIATRICS 1,569,607 1,569,607 1,482,700 86,907 53,617 PATHOLOGY 5,599,968 5,599,968 5,656,876 (56,908) (115,299) PHARMACY 783, , ,267 (134,997) (61,221) RADIOLOGY 5,314,845 5,314,845 5,323,303 (8,458) (45,571) RESEARCH AND DEVELOPMENT 35,898 35,898 42,345 (6,447) (4,804) STRATEGY, OPERATIONS & PERFORMANCE 123, , ,477 4,891 (26,350) SURGERY AND UROLOGY 2,470,436 2,470,436 2,240, , ,818 TRANSFORMATION (57,668) (57,668) (55,960) (1,708) (5,928) Total Non Pay Expenditure 84,206,497 84,206,497 81,793,154 2,413,343 2,364,707

124 APPENDIX 3 Statement of Financial Position (Balance Sheet) March 2015 March 2016 Previous Month Actual Commissioning Agreements 000's 000's 000's Assets, Non-Current Intangible Assets, Net Property, Plant and Equipment, Net 117, , ,858 Assets under Construction On balance sheet PFI assets, Non-Current PFI: Property, Plant and Equipment, Net Trade and Other Receivables, Net, Non-Current NHS Receivables (Related Party), Non-Current 0 1,123 1,128 Assets, Non-Current, Total 118, , ,894 Assets, Current Inventories 7,935 7,824 8,219 Trade and Other Receivables, Net, Current NHS Trade Receivables (Related Party), Current 6,119 3,967 5,613 Non NHS Trade Receivables, Current 1,034 1,598 2,233 Other Receivables, Current Other Financial Assets, Current Accrued Income 1,160 8,887 6,579 Prepayments, Current Prepayments, Current, non-pfi related 2,198 3,488 2,390 Cash and Cash Equivalents Cash 37,475 25,614 23,336 Assets, Current, Total 56,421 52,110 48,983 ASSETS, TOTAL 174, , ,877 Liabilities Deferred Income, Current (1,861) (2,025) (1,849) Provisions, Current (612) (430) (498) Current Tax Payables Trade and Other Payables, Current Trade Creditors, Current (8,753) (11,529) (13,300) Other Creditors, Current (3,494) (8,368) (3,609) Capital Creditors, Current (287) (276) (265) Other Financial Liabilities, Current Accruals, Current (8,783) (9,333) (7,266) Borrowings, Current (22) 0 0 PFI leases, Current (162) (162) (162) PDC dividend creditor, Current (44) (1,575) 44 Liabilities, Current, Total (24,018) (33,698) (26,905) NET CURRENT ASSETS (LIABILITIES) 32,403 18,412 22,078 Liabilities, Non-Current Deferred Income, Non-Current (5,771) (2,771) (2,771) Provisions, Non-Current (1,378) (1,206) (1,206) Trade and Other Payables, Non-Current Other Creditors, Non-Current Other Financial Liabilities, Non-Current PFI leases, Non-Current (479) (341) (327) Borrowings, Non-Current 0 Liabilities, Non-Current, Total (7,628) (4,318) (4,304) TOTAL ASSETS EMPLOYED 143, , ,668 Taxpayers' and Others' Equity Taxpayers Equity Public dividend capital 130, , ,905 Retained Earnings (Accumulated Losses) 11,569 3,619 8,928 Revaluation Reserve TAXPAYERS EQUITY, TOTAL 143, , ,668

125 APPENDIX 4 Statement of Cash Flow March 2015 March Actual 000 Commissioning Agreements Surplus/(deficit) after tax (3,976) (2,642) Non-cash flows in operating surplus/(deficit) Finance income/(charges) (17) 20 Depreciation and amortisation, total 5,303 5,451 PDC dividend expense 3,164 3,827 Reversal of impairment (4,754) Loss on disposal of land 202 Income recognised in respect of capital donations (95) Other increases/(decreases) to reconcile to profit/(loss) from operations Non-cash flows in operating surplus/(deficit), Total Operating Cash flows before movements in working capital 4,474 2,009 Increase/(Decrease) in working capital (Increase)/decrease in inventories (651) (284) (Increase)/decrease in NHS Trade Receivables (342) 506 (Increase)/decrease in Non NHS Trade Receivables (292) (1,199) (Increase)/decrease in other receivables 165 (113) (Increase)/decrease in accrued income 113 (5,419) (Increase)/decrease in prepayments (274) (192) Increase/(decrease) in Deferred Income (excl. Donated Assets) (2,680) (3,012) Increase/(decrease) in provisions (31) (286) Increase/(decrease) in PDC Creditor 0 0 Increase/(decrease) in Trade Creditors 2,407 4,547 Increase/(decrease) in Other Creditors & Payments on Account (1,909) 115 Increase/(decrease) in accruals 2,710 (1,517) Increase/(decrease) in Other Financial liabilities 0 0 Increase/(decrease) in Other liabilities (non charitable assets) 0 (88) Increase/(Decrease) in working capital, Total (784) (6,942) Net cash inflow/(outflow) from operating activities Net cash inflow/(outflow) from investing activities Property, plant and equipment - maintenance expenditure (11,156) (8,113) Property, plant and equipment - donated Increase/(decrease) in Capital Creditors (113) (22) Net cash inflow/(outflow) before financing (7,371) (12,973) Net cash inflow/(outflow) from financing activities PDC Dividends paid /movement (3,164) (3,827) Interest element of finance lease rental payments - On-balance sheet PFI (134) (137) Capital element of finance lease rental payments - On-balance sheet PFI (145) (174) Interest received on cash and cash equivalents Repayment of Commercial Loans (74) 0 (Increase)/decrease in non-current receivables 0 (1,128) PDC Received 7,134 0 Increase/(decrease) in non-current payables 0 0 Other cash flows from financing activities (31) 3,998 Net cash inflow/(outflow) from financing activities, Total 3,737 (1,166) Net increase/(decrease) in cash and cash equivalents (3,649) (14,139) Opening cash 41,109 37,475 Effect of exchange rates 0 0 Closing cash 37,475 23,336 Analysis of Cash Balances Organisation Nature of Deposit Amount 000 Lloyds - Commercial bank Commercial bank 107 Lloyds - Fixed Term deposit Fixed Term deposit Barclays High Interest Deposit Instant NLF Fixed Term HM Treasury 0 Government Banking GBS Bank 23,229 Cash in hand Petty cash, franking machines, unpresented cheques and undeposited Total 23,336

126 APPENDIX 5 Capital Position as at March 2016 Category Allocated Funding Budget 000s Invoices & Accruals 000s Orders Raised 000s Year to Date Earmarked 000s Committed in 2015/16 000s Uncommitted 000s Medical Equipment Current Allocation 1,280 1, , Prior Year Allocation (40) Total Medical Equipment 1,576 1, , ICT EPR Allocation 4,063 3, , ICT Rolling Programme (1) (1) Total ICT 4,583 4, , Service Development /Transformation Reconfiguration Plan (73) Current Allocation Prior Year Allocation - Service Development Total Service Development 1,467 1, , Estates Compliance Energy Infrastructure (181) PEAT (181) Other (22) Total Estates 1,022 1, ,382 (360) Donated - Funding via Charitable Funds GRAND TOTAL 8,798 8, ,797 1 Memorandum Item: '000 Internally Generated Depreciation 6,447 Donated Funds 150 External Financing - EPR - Funding c/f 2,201 Total Allocation 8,798

127 APPENDIX 6 Financial Sustainability Risk Rating (FSRR) Area of Review Year to Date Financial Risk Rating (FSRR) Month 12 Plan Month 12 YTD Month 12 Projection Overall Financial Risk Rating I&E Margin (25%) Variance in I&E Margin (25%) Rolling Forecast of the Financial Sustainability Risk Rating (FSRR) for the next 12 months Capital Servicing Liquidity Q1 Q2 Q3 Q4 2016/ / / /17 Capital Servicing Capacity Liquidity Days Rating Underlying Performance I&E Margin Variance from Plan Capital Service Capacity (25%) Liquidity (25%) Area of Review 2 4 Annual Plan Variance in I&E Margin Financial Sustainability Risk Rating (FSRR)

128 APPENDIX 7 Finance Risk Indicators (Best Practice - no longer mandated by Monitor) Category Status Description Unplanned decrease in quarterly EBITDA margin in two consecutive quarters Quarterly self-certification by Trust that CSRR may be less than 3 in the next 12 months Not applicable Not applicable CSRR 2 for any one quarter Working capital facility (WCF) agreements includes default clause Two or more changes in Finance Director in 1 12 month period Interim Finance Director in place over more than one quarter end Quarter end cash balance less than 10 days of operating expenses Capital expenditure is less than 85% of plan for the year to date Capital expenditure is greater than 115% of plan for year to date Debtors > 90 days past due account for more than 5% of total debtor balances Creditors > 90 days past due account for more than 5% of total creditor balances Commentary on Compliance Framework Indicator Summary Points Required by Monitor Required by Monitor Not applicable Not applicable Not applicable Not applicable Not applicable On target On target On target On target The Trust has made 811k of capital additions in Month 10 bringing the year to date spend back in line with target at 95.2% of plan.

129 APPENDIX 8 Better Practice Payment Code (BPPC) by Invoice value and count To pay 95% of all NHS and non-nhs trade creditors within 30 days receipt of the goods or a valid invoice Month % Bills Paid Volume % Bills Paid Value Plan Volume Plan Value April May June July August September October November December January February March Total Cumulative Better Payment Performance (Volume) Percentage (%) Percentage (%) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Better Payment Performance (Invoice) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

130 APPENDIX 9 Employee Benefit Expense Analysis ( ) Employee Benefit Expense ( ) In-Month Year to Date Budget 2015/16 m Actual 2015/16 m Variance 2015/16 m Budget 2015/16 m Actual 2015/16 m Variance 2015/16 m Medical (0.09) (2.23) Nursing & Midwifery (0.1) Other clinical staff Scientific, Therapeutic & Technical Director & Senior manager Admin and Clerical (0.1) Vacancy factor (0.13) (0.13) (1.50) (1.50) Total (1.40) Employee Benefit Expense Analysis (WTE) Employee Benefit Expense (WTE) Budget WTE Actual WTE Variance WTE % of Agency Nursing as total of Nursing Spend Cumulative position (%) Current over the last 6 Target (%) Month (%) months of the year Medical Nursing & Midwifery 2,008 2,112 (104) < 3 Other clinical staff Scientific, Therapeutic & Technical Director & Senior manager (1) Admin and Clerical Other pay Total 4,934 4, Analysis of Overtime, Locum, Bank & Agency Analysis of Supplementary Pay Bill In-Month Actual 2015/16 In-Month Year to Date Actual 2015/16 Monthly Average Actual 2015/16 Additional Monitor Metric Monthly Average Actual 2014/15 Agency (not Nursing) 215,957 1,631, , ,993 Agency Nursing 456,454 2,639, , ,679 Locum Expenditure 8,071 2,886, , ,523 Total over-time (not Nursing) 93,499 1,058,832 88,236 50,258 Bank expenditure 393,324 3,583, , ,251 Nursing over-time 98, ,954 79,163 32,683 Total 1,265,878 12,749,397 1,062, ,387

131 APPENDIX 10 WTE Comparison Graph 5, January March 2016 WTE's '000 5, , , , , , , , , , , , Total Budgeted Wte's Total Contracted Wte's Total Actual (Worked) Wte's 0 Month Agency, Bank and Locum Spend ' Locum '000 Agency '000 Bank '000 Month

132 Appendix 11 INCOME STATEMENT BY COMMISSIONER Commissioner 2015/16 Budget Annual Budget Budget to date Actual to date Variance Variance Previous Month Movement NHS Durham Dales, Easington and Sedgefield CCG 33,634 33,634 33,634 35,379 1,745 1, NHS Hartlepool and Stockton-on-Tees CCG 161, , , ,076 1,801 1, Cumbria, Northumberland, Tyne and Wear, Durham, Darlington and Tees Area Team 18,056 18,056 18,056 14,476 (3,580) (1,772) (1,808) Other CCGs (individually less than 5m) 5,536 5,536 5,536 5,308 (228) (118) (110) 2,098 2,098 2,098 1,674 (424) (201) (223) Non Contract Activity Income (CCGs) Other LATs (individually less than 5m) Other Foundation Trusts (116) 116 Public Health England 1,560 1,560 1,560 1,237 (323) (318) (5) Risk Income 2,735 1,013 1,013 2,517 1,504 1, Local Authorities 0 0 Hartlepool Council 1,780 1,780 1,780 1,576 (204) (160) (44) Middlesbrough Council Redcar and Cleveland Council Stockton Council 3,100 3,100 3,100 3, (23) 228, , , ,749 (1,439) Passthrough drugs and devices and other costs 16,461 16,246 16,246 16, Contract income 246, , , , ,749 (1,439) Other 0 Private Patients TEWV Radiology and Pathology Depuy (72) 0 (72) Other income from patient care 306 2,894 2,894 3, (63) Non Patient care income 22,732 25,412 25,412 26,770 1, ,358 **Risk income of 2.3m Deferred Grant Total income 269, , , ,893 1,815 1,749 (144) Quarter 1 Quarter 2 Quarter 3 Quarter 4 Total CQUIN - potential attainment (total) 351,922 1,246,951 1,232,102 2,123,995 4,954,970 NHS Durham Dales, Easington and Sedgefield CCG 56, , , , ,486 NHS Hartlepool and Stockton-on-Tees CCG 267, , ,497 1,619,588 3,823,387 Cumbria, Northumberland, Tyne and Wear, Durham, Darlington and Tees Area Team 18,317 18,317 47, , ,126 Other CCGs (individually less than 5m) 9,378 34,538 33,305 56, ,971 Penalties (maximum exposure) NHS Durham Dales, Easington and Sedgefield CCG 41,540 NHS Hartlepool and Stockton-on-Tees CCG 251, ,140

133 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Human Resources and Education Report /16 Report of the Director of Human Resources and Education Executive Summary Strategic Aim: (The full set of Trust Aims can be found at the beginning of the Board of Directors reports) Maintain Compliance and Performance Strategic Objective: (The full set of Trust Objectives can be found at the beginning of Board of Directors reports) Effective Board Governance 1. Dashboard The Trust headcount has increased by 83 to 5476 at year-end when compared to the end of 2014/15. The sickness absence rate for quarter 4 is 0.16% less than the baseline figure at the end of March 2015; however the sickness information for March 2016 is not currently available. The full year cost of sickness absence has increased by 133,669 between April 2015 and February Turnover/Change in Workforce The turnover rate at the end of 2015/16 is 11.98% where foundation doctors are included and 11.11% without. The turnover rate for each of the months in 2015/16 has been higher than in 2014/15, except for March 2016 where the rates both including and excluding foundation doctors was lower. There have been 770 new starters to the Trust in 2015/16 in comparison to 762 in 2014/ Sickness / Occupational Health The top three sickness absence reasons for quarter 4 are consistent with the reasons reported in quarter 3. The Trust continues to be below the regional absence for sickness (figures available up to quarter 3). There were 774 referrals to Occupational Health in 2015/ Mandatory Training The Education Delivery Team has again made a positive contribution to the overall Trust compliance. Green status has been achieved in a wide range of topics including: Information Governance; Infection Control; Fire; and Resuscitation. 5. Workforce Planning and Resourcing This year has seen workforce planning at the heart of the Directorate s core business through which all workforce activity is driven and following the realignment, has seen enhanced links with the Resourcing team. The key focus for workforce planning has been the development of a Clinical Services Strategy. 1

134 6. Electronic Workforce Solutions The Trust continues to invest in a number of workforce electronic solutions and makes continued use of existing workforce systems. 7. Leadership Building leadership capacity at all levels of the organisation remains a priority and the Trust has continued to invest in resources to develop leaders and managers within the organisation to support the delivery of high quality patient care. 8. Medical Education The Trust has recently had two Medical Education Quality visits from external organisations. The trust s FINEST team has completed two Interprofessional training ward pilots with students from various health professions. Simulation training continues to be delivered on a regular basis to a number of staff groups. 9. Human Resources There were 1178 responses in 2015/16 to the Staff Friends and Family Test (SFFT). The HR Business Partner has consolidated during 15/16 to provide support and guidance to Directorates. 10. Recommendation The Board of Directors is asked to note the content of and accept this report. Ann Burrell Director of HR & Education 2

135 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Human Resources and Education Report /16 Report of the Director of Human Resources and Education 1. Human Resources and Education Directorate Organisational Change At the beginning of 2016 the Transformation team moved to the Human Resources and Education directorate. To ensure that the team was fully integrated in a structured way and to support the delivery of the Clinical Services Strategy a review of the directorate s core business was undertaken, resulting in a realignment of some functions. Workforce Planning, Workforce Systems and Information, and Resourcing now fall under the umbrella of Workforce Design. The HR Business team has moved into Workforce Design to strengthen the links between teams and support integrated working on the Clinical Services Strategy. The Employee Relations team will provide expert HR advice in relation to terms and conditions of employment, policy development and other specialist aspects of the HR function; in the provision of a centre for excellence in support of the Trust corporate and clinical agenda. Owing to the valuable influence the Organisational Development team have during periods of significant transformational change it was felt that they would be better aligned with the work of the Transformation team. This would not only strengthen the organisational development function but would ensure that service transformation is appropriately and effectively supported during its programme of significant change. The strengthened teams will guide a change agenda which supports delivery of the Clinical Services Strategy, organisational development, leadership and culture. A Senior Education Lead has been appointed to lead education delivery, mandatory training, course coordination, medical education, library services, education quality, IT training and elearning, resuscitation and simulation training. 2. Workforce Planning This year has seen workforce planning at the heart of the Directorate s core business through which all workforce activity is driven and following the realignment, has seen enhanced links with the Resourcing team. The key focus for Workforce Planning has been supporting directorates with the development of workforce plans to support the Clinical Services Strategy. This work has involved collaborative working with General Managers, Senior Clinical Matrons, Consultants and representatives from the Performance and Finance teams. The team have supported the development of each directorate s clinical services strategy through undertaking intensive research into alternative workforce models based around the introduction of new roles and technology. The strategies have been underpinned by commissioning intentions where known, and 3

136 have provided the conduit through which the workforce planning process has been strengthened and improved, with clinical engagement from the outset. 3. Resourcing Opportunities to improve the recruitment process were identified as part of a Rapid Process Improvement Workshop (RPIW) which led to a series of developments being implemented in order to streamline the service, improve customer satisfaction and reduce waste. Training days were held with the team including visits from NHS Jobs representatives regarding improvements in its functionality and also from the UK Visa and Immigration Service in relation to regulated identification documents. Three key internal audits were undertaken during 2015/2016; Pre Employment Checks, Overseas Recruitment Checks and Registration Authority. With regards to the Registration Authority audit, (in which the CIS forms part of this process) one recommendation remains outstanding in relation to the implementation of the RA/ESR interface and is scheduled for completion at the end of October The audits were an opportunity to ensure compliance with recruitment functions and processes. In particular the Pre-Employment Check audit led to a number of improvements being made to the recruitment checklist in order to ensure it complies with the NHS Employment Check Standards. This led to further work ensuring that associated policies, procedures and templates were updated accordingly. Options have been explored for improved storage of personal files including the scanning of new and existing files into an electronic file system. Such a system will make the storage of retrieval of files more accessible and free up much required space within the department. This will be explored further during 2016/ Overseas Nurse Recruitment The national shortage of registered nurses led to the Trust recruiting from overseas. A successful recruitment campaign was held in the Philippines during July 2015 from which 37 registered nurses were given conditional offers of employment. The first cohort of 15 nurses arrived in the UK in March and are in the process of completing a period of preceptorship. A further 8 nurses are due to arrive on 18 th April, with plans being made for the deployment of the remaining 14 nurses. Due to the success of the campaign, and the on-going challenges with recruiting nurses locally, a further visit to the Philippines has been confirmed for September A recruitment process for registered nurses, through NHSP, was held during November 2015 in Romania. Thirteen nurses were appointed and arrived in the UK on the 9 th February Whilst the nurses will work within the Trust, they will be employed by NHS Professionals for the first 12 months of their contract, at which point they will be offered substantive posts with the Trust. The success of this recruitment campaign will be evaluated early in 2016/17, at which point consideration will be given to a second recruitment exercise from Romania. 3.2 Electronic Disclosure and Barring Service The electronic Disclosure and Barring Service (e-dbs) system was implemented in the Trust in April This has led to a significant impact on the pre-employment check stage of the recruitment process with a satisfactory certificate being returned, upon average, within 5 days as opposed to, on average, over 6 weeks with the previous paperbased process. 4

137 3.3 NHS Jobs During 2015/16 enhancements to NHS Jobs functionality was introduced, which was considered as part of the RPIW. As a result, processes previously undertaken through a paper-based system can now be done online including short-listing, invite to interviews and a text reminder service for interviews. Occupational Health pre-screening questionnaires and mandatory training are now also available via an electronic links for candidates to upload and complete. 4. Electronic Workforce Solutions 4.1 The Electronic Staff Record (ESR) The Trust continued to make good use of ESR functionality during 2015/16 to aid with workforce reporting requirements. The Trust plans to work closely with IBM during 2016/17 to maximise the potential benefits from future enhancements to functionality. In response to one of the recommendations of the Saville Review, the Trust has begun using ESR to record volunteers working for the Trust in 2015/16. This has enabled a more robust process for the monitoring and reporting of the volunteer workforce, including pre-employment checks and mandatory training. 4.2 Workforce Information A set of workforce information dashboards were initially produced in 2014/15 to report on key workforce indicators such as staff turnover and sickness rates for the clinical directorates. In 2015/16 these were extended to include corporate directorates. The monthly absence management reports produced by the team were also further developed to incorporate an individual sickness rate for all members of staff, to assist managers with ensuring compliance with the Trust s Attendance Management Policy. As part of the preparation for the Care Quality Commission visit, the Management Information team assisted in the completion of Provider Information Requests which was a significant piece of work. They also produced a number of workforce profiles and reports to assist in the development of workforce plans which feed into the Clinical Services Strategy. The team has been working closely with Medical Education and the Trust Doctor Tutor to design and develop a database, enabling users to view all Trust Doctors, their clinical and educational supervisors, and identify where they are working, all from one central point. This gives the Tutor the opportunity to discuss appraisal, revalidation and appropriate continual professional development opportunities. For those Trust Doctors who do not have a portfolio this option will also be discussed. This will ensure Trust Doctors have their input into the organisation and training, to create and maintain a portfolio and to get the most from study leave. The purpose of this process is to ensure that all Trust Doctors receive support from the organisation, feel included and valued. 4.3 Mandatory Training Reports Following the introduction of the new performance management framework, amendments were made to the mandatory training report to incorporate new appraisal requirements for staff on AfC Band 8 and above, to fit with the new requirements for these staff. This is due to be rolled out to Band 7 staff early 2016/17, with further roll out to all other grades expected. 5

138 Training requirements for maternity staff have been updated within the mandatory training report during 2015/16 to include additional required subjects for this particular group of staff. Each year Education & Organisation Development conduct a review of Datix incidents and other sources of information to identify risk areas where particular training needs can be identified and targeted at specific groups of staff in the following year. New subjects covered in 2015/16 included Acute Kidney Injury, Sepsis, Anticoagulants and Palliative Care. Further training is in the process of being identified for 2016/17 which will be incorporated into the mandatory training reports. 4.4 Electronic Workforce Solutions To support the management of its workforce the Trust continues to invest in and utilise a number of information systems, which provide managers with the tools for management of staff, a basis for decision-making and to inform the development of future workforce plans and projections. These systems have supported the adoption of the new agency rules implemented by Monitor and the Trust Development Authority in October 2015, which also seen the introduction of hourly pay caps for agency staff ejobplan Job Planning is a contractual agreement for senior medical staff which requires annual review; the Trust invested in ejobplan software to facilitate and support this process. In light of the new appointment of the Medical Director within the Trust, processes and training will be reviewed and refreshed during 2016/17 to improve user engagement once the new Medical Director team structure is in place erota/emonitor erota/emonitor is used to design, manage and monitor Junior Doctor rotas to ensure compliance with contractual obligations and the working time regulations. This provides Rota Managers with the tools to design efficient and safe rotas. Monitoring of junior doctor working hours should take place twice yearly to ensure that rotas are representative of working patterns and hours. During 2015/16 some monitoring exercises were delayed due to industrial action however they were reschedule to meet the timescales within the contractual requirements. In preparation for implementation of the new Junior Doctor Contract, the system has had two upgrades to assist in the building and testing of rotas against the new requirements HealthRoster HealthRoster is an electronic system currently used by the Trust primarily for rostering and daily management of nursing staff allocated to acute ward areas, providing the ability to move staff around to ensure safe staffing levels are maintained. The system provides a direct link to the bank system for all staff groups other than medical and dental staff. These shifts are offered out to bank staff before release to agency staff. The link enables the Trust to monitor the reasons for the vacant shift and whether any requirements are outside of the agreed staffing templates and establishment. This assists the Trust in their approach to reduce the reliance on agency staff. The project plan was refreshed during 2015/16 and saw the implementation of HealthRoster and the bank link for nursing staff within the Chemotherapy Unit Hartlepool, 6

139 Community services at Hartlepool including District Nursing, District Nursing OOHs; Health Visiting; Rapid Response; Community Matron s and MacMillan services. The ongoing plan includes the next phase of Community Services Stockton to be completed in quarter /17. A pilot of the Safe Care Live module within HealthRoster was undertaken. The module provided an understanding of how actual patient volume, acuity and dependency impacts on planned rosters, and allow alterations to be made in real time, leading to more efficient and cost-effective rosters for nursing staff. Providing assurance of safe staffing within the live ward areas to ensure patient safety and quality is maintained. The Trust continues to report Safer Staffing figures to NHS England on a monthly basis. Following a successful pilot of electronic rostering for Junior Doctors, and on-call for Consultants and Middle Grades in Medicine, the team are now starting implementation for Junior Doctors within Accident & Emergency with the anticipated go-live date to be in time for August 2016 doctor rotations Care Identity Service Work has continued during 2015/16 to utilise additional functionality within the Care Identity Service (CIS) to enable a more robust process for controlling access to Trust IT systems. This work involved creating Position Based Access Control (PBACs); the purpose is to group access rights in to positions. This allows for access to be granted more easily and individual positions do not have to be created for each user. This functionality will allow the Trust to utilise an interface with ESR by linking an employee s job role to the specific access required by that role, through the use of a Smartcard. When an employee moves role within the Trust or leaves the organisation, system access is now automatically granted or removed, dependent on their role, leading to improved governance. The interface development is planned for 2016/17. As part of the PBAC phase of the project, new Registration Authority (RA) forms have been developed and guidance has been written for the sponsors and RA team. This has been circulated and is now in operation. The new forms, in conjunction with the PBACs, make requesting access much simpler for sponsors. Also as part of the CIS project the number of sponsors across the Trust has been significantly increased. Sponsors can request access for users, renew certificates and unlock smartcards. 5. Temporary staffing 5.1 STAFFflow To assist in reducing agency spend for the medical workforce the Trust opted to implement STAFFflow, a direct engagement model offered by Liaison and Price Waterhouse Coopers (PwC), allowing the Trust to make reductions in agency spend without reducing the number of staff required to operate efficiently. The solution involves the Trust recruiting individuals on short fixed-term temporary employment contracts, or directly contracting with those workers who provide their services through a limited company. Savings are made through reduced VAT, process costs and price control. The system was implemented and went live across the organisation in September 2015 for the booking of agency locum medical staff, creating a management information system to increase transparency and improve controls, and the ability to reduce costs relating to Medical Locums. The financial savings realised by reducing the VAT liability through the direct engagement model was 55,000 at the end of March 2016, with further estimated savings expected. The system prevents users from booking temporary workers from non-framework 7

140 agencies, assisting the Trust in meeting requirements and providing assurance. Utilisation is currently at 100% with all medical locum bookings being made through the system. 5.2 NHS Professionals The Trust continues to work in partnership with NHS Professionals (NHSP) to promote the bank and develop its own flexible trained workforce, which is responsive to service demands. NHSP provide an outsourced flexible worker service to provide workers through bank and agency arrangements. The system has a tiered arrangement which allows the shifts to be filled by bank staff before being released to agency staff. It provides the Trust with the functionality to be able to restrict agency usage to those on frameworks and within agreed pricing. Reporting functionality provides insight into the reasons for booking agency staff and transparency in costs so that improvements can be made. In order to increase the number of flexible workers available on the bank, the Trust have been working closely with NHSP to introduce the Sub to Bank process for nursing staff including care support workers and midwifery staff. This process allows multi-post holders who terminate their employment with the Trust to continue to work on the bank via NHSP for a period of three months whilst allowing time for the member of staff to undertake the application process with NHSP if they wish to continue as a bank only worker. Letters were sent to recently retired staff and nurses in non-clinical roles to encourage them to join the Trusts flexible worker bank. A thank you letter was also sent to all staff who worked additional shifts through the bank in order to support the Trust in meeting seasonal pressures Care Support Worker Development Programme The Care Support Worker Development Programme via NHSP was implemented and provides successful applicants with the opportunity to become a care support worker. Interviews for the programme were held on 15 October 2015 from which 17 offers of employment were made. The successful candidates commenced the programme in January Once they have completed the programme they will be eligible to join the bank New Agency Rules In November 2015, Monitor and the Trust Development Authority introduced new agency rules which included hourly rate price caps. These capped rates were reduced in February 2016 with further reductions planned for 1st April Processes have been put into place to support the weekly returns to Monitor on any agency rule breaches, using the relevant electronic workforce systems. 6. Leadership and Management Development Ensuring that there is effective leadership at all levels of the organisation to support the achievement of its strategic aims remains a key priority to the Trust. As a result the Trust has continued to invest in resources to develop leaders and managers within the organisation to support the delivery of high quality patient care. Making effective use of its links with stakeholders, such as the North East Leadership Academy, the Trust continues to offer comprehensive leadership and development programmes and opportunities. This includes holding decision making and leadership 8

141 events in conjunction with the Territorial Army, following the success of the initial cohort further dates are planned in June and September In response to feedback received, an internal training programme has been developed to support managers with the practical skills required to manage and lead day to day, complementing the other opportunities offered. The programme is designed to link with Talent Management and the Local Improvement System (LIS) as part of the wider service improvement and transformation agenda. As we continue to transform our services we need people who can manage the change process, support people through the transition, deal with potential conflict, and issues such as attendance management. The aim is to ensure that our staff are equipped to deal with situations that inevitably arise when significant change takes place. This programme equips individuals with the right skills, knowledge and ability to deploy them in practice. Consolidating and strengthening their understanding of change management, and enhancing their confidence to deal with their role. 7. Medical Education - Quality Assurance Visits The Trust underwent two Medical Education Quality visits recently: Joint Schools QA visit Annual Dean s Quality Monitoring (ADQM) visit Joint Schools QA visit The University of Newcastle Medical School and the Northern Foundation School visit the Trust annually to assure the provision of education and training the Trust provides for medical students and foundation doctors. In a report following the visit the Trust was commended on the support and delivery of the medical education strategy and allocation of Education Supervisors for all final year students. Areas of notable practice were cited and included interprofessional education for final year students and simulation for stage 3 students. Foundation Programme The Trust was praised on being in the top 10 of 7 indicators for the National trainee Survey 2015 with no red outliers. The majority of Foundation Doctors replied that they would recommend the Trust and greatly appreciate the support they receive from the Education team with every communication being responded to quickly and supportively. The annual teaching programme which is mapped to the curricula and the support provided to Foundation Doctors to ensure their e-portfolio and assessments are up-todate was commended. The Trust has not yet received any formal feedback on the ADQM visit as this only took place at the end of March. 7.1 FINEST The FINEST team has completed two interprofessional training ward pilots with students from various health professions on wards 26 and 27. The first pilot took place on ward 27 and lasted one week and involved student doctors, nurses, physiotherapists and occupational therapists. Whilst working alongside each other they became involved in a variety of activities including shadowing staff members from other professions such as pharmacists, dieticians, specialist nurses and consultants. 9

142 Positive outcomes were received and students gained an understanding of the value of good team work and the importance of effective communication across the immediate and wider team. It enabled them to clarify the needs of the patient within their care pathway and facilitate their development into competent, qualified practitioners who work collaboratively. Ward staff saw a benefit by being able to share their specialist knowledge and skills with learners, whilst being able to reflect on their own practices and development. The second interprofessional training ward pilot took place on wards 26 and 27. The week included successful visits to the pathology labs promoting teamwork and communication across professional and departmental boundaries. Due to the success of the first two pilots this model will be used to run further Interprofessional training days including plans to provide educational support to the new Frailty Unit. A one day workshop by the Centre for Advancement for Interprofessional Education (CAIPE) was held at the Trust in December. The session was extremely successful in preparing the training ward project. The CAIPE organisation has recognized this piece of work as unique as training wards are usually set up by universities rather than Trusts. FINEST is working closely with the Assistant Director Of Nursing, Workforce And Quality to launch three new rotational/educational posts for newly qualified nurses in October This will use an interprofessional approach through newly qualified doctors and nurses learning alongside and from each other, whilst receiving support during the transition from student to registered professional. A PhD student was recruited in December from Northumbria University to collect data to support the evaluation of the project. 8. Revalidation Revalidation is the process by which licensed doctors regularly demonstrate to the General Medical Council (GMC) that they are up to date and fit to practice. The process aims to provide patients with assurance about those who treat them. All practising doctors within the UK are required to relate to a Responsible Officer (RO) nominated or appointed by an appropriate healthcare organisation (designated body). The Trusts Medical Director is the RO for North Tees and Hartlepool NHS Foundation Trust, covering all non-training grade doctors. The RO makes a recommendation to the GMC on a doctor s revalidation, based on clear and unambiguous statements from appraisers and reliable information from clinical governance systems. There are 3 possible recommendations that an RO can make, these are: Recommend revalidation of the doctor. Defer the doctor s revalidation to a later date. o This could be due to a lack of supporting information, or; o To allow sufficient time for an investigation to be concluded. Notification of a failure to engage. This option must only be considered as a last resort and the Trust must be able to demonstrate that they have actively tried to engage the doctor in the process before considering the submission of a failure to engage notification. Requirements of Revalidation: Whilst it has been a legislative requirement for all doctors to relate to a designated body since 1 January 2011, the actual Revalidation submissions did not commence until 1st December All doctors are required to revalidate their licence once every five year cycle. 10

143 The Trust continues to provide appraisal and Responsible Officer support to the Butterwick Hospice and Hartlepool Hospice, in line with existing Service Level Agreements; Performance Data (A) Revalidation: Category: Number of Doctors who have a prescribed connection with North Tees and Hartlepool NHS Trust. Number of positive Recommendations submitted by the Trust to the GMC during the current revalidation cycle, i.e. (1 December 2012 to 30 November 2017). Number of doctors who are yet to revalidate during the current revalidation cycle: Up to 31 December 2016: Up to 31 December 2017: Up to 31 December 2018: Number of Deferral Requests: Further information required To allow completion of an on-going investigation Number of Lack of Engagement notifications Category: (B) Appraisals Number: 279 doctors 99 As at 31 March doctors 14 doctors 7 doctors 51 doctors 11 doctors 3 doctors Appraisal information is currently being obtained with the final report being compiled by 30 April The information below is therefore provisional. Number of Doctors with a prescribed connection to the Trust. Number of doctors who have had an annual appraisal which fell between 1 April 2015 and 31 March Number of doctors who have indicated that they have had an appraisal and conformation of this is being obtained. Number of doctors who are currently showing as not having had an appraisal, but for whom an application for deferral of appraisal has been approved. Number of doctors who are currently showing as not having had an appraisal and this has not been approved. Nil Number: 279 doctors 254 doctors (91%) 10 doctors (4%) 6 doctors (2%) 9 doctors (3%) These individuals must ensure an appraisal takes place as soon after 1 April as possible and the RO will be notified of these individuals. Expected compliance rate for 2015/2016: 100% Compliance rate for 2014/2015: 94% 11

144 Whilst the Trust aims to ensure that all doctors receive an annual appraisal which falls between the period 1st April to 31st March of each year, there are certain circumstances where this may not happen and therefore approval for the appraisal to be deferred must be obtained from the Responsible Officer. Valid reasons for deferral include: The doctor is a new employee with less than 9 months service with the Trust. The doctor has been prevented from having their appraisal due to long term sickness absence. The doctor has been on maternity leave, or a career break. The Trust has in place a managed system for ensuring appraisals take place in accordance with the requirements for Revalidation. (C) Revalidation of Training Grade Doctors The process for the revalidation of training grade doctors is different from the non-training grade posts. The Responsible Officer for this group of doctors is Professor Namita Kumar, the Postgraduate Dean. In order for Professor Kumar to be able to make recommendations to the GMC regarding a training grade doctor s revalidation, robust systems have been set up within North Tees and Hartlepool NHS Foundation Trust to provide Health Education North East (HENE) with the necessary information. The Trust reports any serious untoward incidents complaints or conduct/capability issues directly involving a training grade doctor to Health Education North East. A process has been implemented to ensure the training grade doctors are supported during this time and learn from the experience. If the Clinical Supervisor of the training grade doctor has no on-going concerns, the incident is closed from an educational point of view. As well as the live reporting flow, the Trust completes a Collective Exit Report every six months, which lists the number of doctors who are currently in post, or who have rotated out of the Trust for their training programme. Completion of this report allows the Trust to report any new or recently closed incidents that have not been previously reported. Category Number of recognised training posts in North Tees and Hartlepool NHS Foundation Trust Number of live flow reports for the period 1 April 2015 to 31 March 2016 Number of live flow reports for this period currently open (as of 7th April 2016) - Recent incident, awaiting return of forms from Clinical Supervisor Number Further training recommended, which will be discussed at the trainee s ARCP panel 0 Number of doctors reported via the Collective Exit Report September

145 March Simulation Simulation training continues to be delivered on a regular basis to the following staff groups: Nursing staff (including nurse preceptorship, midwives and nurses from acute areas of A&E and EAU/ambulatory care) Doctors in training. Medical students in their 3 rd, 5 th year of study and 4 th year medical student on student selective component placements. These received excellent verbal and written feedback. There are several small projects aimed at evaluating the quality and impact of simulation training. In January the Simulation team ran an Introduction to Simulation course which was attended by 10 members of medical staff who can now act as faculty to ensure continued operation of simulation sessions, particularly simulation in situ. Surgical in situ simulation has also recommenced using scenarios developed from recent serious untoward incidents, and further dates are planned over the coming months. Simulation in situ continues to run in paediatrics, neonates and A&E. The sepsis EAU simulations have now become well established and departmental engagement continues to grow. The Pneumonia Specialist Nurse and Acute Medical Registrars attended the introduction to simulation course, which has enabled them to co-facilitate the sessions. The simulation team are collaborating with the renal team at South Tees, the Trust s Acute Kidney Injury (AKI) group as well as the simulation and education team at County Durham and Darlington Foundation Trust to develop an AKI training package and training day. Use of the community suite continues to increase and is regularly used for technical skills training for community health care assistants. The community nurses have all been trained on the care and use of Hickman lines to support the new orthopaedic home antibiotic pathway. This has helped to create a strong link with the community teams and they have returned to the laparoscopy suite over the last month to receive further training in insertion of mid-lines. This training will help support another outpatient antibiotic pathway currently in development. There are also plans for the nurses to return for clinical and practical skills training in the assessment and management of complex, frail elderly patients. The simulation suite continues to be promoted as a centre for excellence in simulation through social media and work is underway to develop the simulation intranet site which will be facilitated by the newly appointed simulation technician. A presentation by the simulation team was given at the medical grand round to promote and develop links with other departments and potential simulation faculty. The simulation team have also represented the simulation suite at a regional patient safety conference, where two posters showcasing recent projects were exhibited. In the last quarter the simulation suite hosted a regional Acute Care Common Stem (ACCS) trainee course as well as a regional A&E training day, both of which received excellent feedback. There are plans for further collaboration on community projects with Teesside University and North East Ambulance Service. 13

146 10. Human Resources 10.1 HR Business Partner Model The model was introduced in the early part of 2015 and was designed to support the business in providing HR support for day to day operations, enabling managers to effectively manage their services and performance against delivery service plans. The progression in embedding and further developing this new model has continued during 2015/16. Feedback from key stakeholders has identified and recognised the benefits of this way of working in the overall effectiveness and delivery of service strategy and plans. The management of workforce issues and needs are aligned and tuned to the business services strategy through the HR strategy. Continuous improvement and development of systems and practices to realise additional efficiencies, effectiveness and experiences for people within the people management processes has continued Attendance management Improvement to the absence management process being one of the key areas of success has included analysis of trends and proactive measures to support the health and wellbeing of the workforce in conjunction with occupational health. Early intervention in the management of long term cases has been successful as this has reduced the timescale, associated absence costs and released services pressures whilst improving the people experience ER Cases During 2015/16 the HR Business team have supported with an increased number of formal cases which reflects the volume of change within the organisation. The team continue to review and monitor timescales of case management in line with the introduction of key KPI s Staff Friends and Family Test (SFFT) The results of the Staff Friends and Family Test (SFFT) across 2015/16 can be found in the data section of the report. When completing the questionnaire, not every respondent chose to leave comments explaining why they chose a particular option. There are common themes of comments shown throughout the year. Of those that responded to question one, one of the main themes is around the care that has been experienced personally or via a family member or friend (both positive and negative). Within these comments, the professionalism and the commitment of staff was significantly praised and many comments stated that staff are friendly, caring and dedicated to their work. The negative comments involved shortage of staffing and staff members feel overworked with a low morale. The theme of comments received in response to question two appear to show that the positive comments are again related to the high level of patient care delivered, supportive management and good employment terms and conditions. Staff generally consider the Trust to be a good place to work and find colleagues and managers friendly and approachable. Negative comments for question two cite a lack of resources and departments being short staffed which again is impacting on staff morale. The HR department continues to work closely with directorates in relation to raising the profile of the SFFT, with specific targeting of front line staff. For staff members who are unable to access the online questionnaire, paper copies have been made available via the Staff Restaurant and are also provided to ward managers to distribute to staff. Departmental managers are requested to cascade paper copies at staff meetings. 14

147 All opportunities are used to communicate the SFFT questionnaire, utilising online advertising such as SharePoint to ensure all staff members are aware of the process and have the opportunity to share their opinion. Key themes that emerge from the SFFT are fed into on-going work within the culture and values group. Word Clouds are produced at a departmental level and distributed to those areas on a monthly basis. To ensure that there sufficient responses to generate a meaningful Word Cloud, it is essential that response rates are high across all areas Organisational Change Support in managing organisational change to facilitate the implementation of the directorate business plans has been successfully provided by the HR Business team during 2015/16. The team will continue to review the support to be provided by working in conjunction with the workforce planning and transformation teams to facilitate the clinical services strategy. 15

148 Scorecard Summary Baseline 31/03/2015 Q1 Q2 Q3 Q4 Variance Trust Headcount Trust WTE Sickness Absence Rate 5.05% 4.10% 4.57% 4.66% 4.89% -0.16% Short Term Sickness Rate 0.74% 0.54% 0.53% 0.67% 0.80% 0.06% Medium Term Sickness Rate 0.87% 0.84% 1.20% 1.13% 1.20% 0.33% Long Term Sickness Rate 3.46% 2.71% 2.84% 2.86% 2.90% -0.56% Turnover Rate (inc. Foundations) 12.69% 13.53% 13.07% 12.92% 11.98% -0.71% Turnover Rate (exc. Foundations) 11.73% 12.05% 11.99% 11.86% 11.11% -0.62% Change in Workforce (WTE) Q1 Q2 Q3 Q4 Starters Leavers Overall variance in workforce Mandatory Training Target Q1 Q2 Q3 Q4 Variance Overall Compliance Rate 95% 97% 96% 95% 95% 0% Subjects Out of Compliance (Q4 Only) Safeguarding Adults Level 1 100% n/a n/a n/a 94% -6% Appraisal 95% n/a n/a n/a 82% -13% 6.00% 5.00% 4.00% 3.00% 2.00% 1.00% 0.00% Board Report Workforce Information Dashboard Summary 2015/16 Sickness Absence Rates Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2014/ % 3.82% 4.10% 4.24% 4.40% 4.56% 4.34% 4.74% 5.40% 5.27% 4.87% 5.05% 2015/ % 4.11% 4.10% 4.48% 4.65% 4.57% 4.15% 4.67% 5.15% 4.78% 5.02% Target 15/ % 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% 3.50% Cost of Sickness Absence Comparison 2014/ /16 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Ma 14,497 Top 3 Reasons for Sickness Apr 2015 to Feb ,929 21,022 Anxiety/stress/depression/oth psychiatric illnesses Other musculoskeletal problem Gastrointestinal problems * Please note that sickness data for March is not currently available therefore the data provided is for January and February only. 16

149 Workforce Profile by Staff Group Staff Group - WTE Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Difference Add Prof Scientific and Technical Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered Students Total Staff Group - Headcount Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Difference Add Prof Scientific and Technical Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered Students Total Please note that the figures shown in red in the above table indicate an increase to the previous month, there has been an overall increase of WTE and 127 Headcount across 2015/16. All staff groups have seen an increase in their WTE except Additional Clinical Services (remains the same), Healthcare Scientists (reduction of 2.31 WTE), Medical and Dental (reduction of 11.57) and Students (reduction of 11). Medical and Dental (reduction of 1) and Students (reduction of 11) have seen a decrease in their Headcount across 2015/16. Healthcare Scientists have remained static and all other staff groups have seen an increase. 17

150 Workforce Profile by Key Characteristics Quarter /16 Staff Group Headcount Female Male White/British Other Part Time Full Time Add Prof Scientific and Technical Additional Clinical Services Administrative and Clerical Allied Health Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered Students Total Age Profile - WTE & above WTE The headcount at the end of quarter /16 has increased by 35 when compared to the end of quarter /16, from 5441 to There has been an increase of 92 females and a reduction of 9 males when comparing the end of 2015/16 with the end of 2014/15. The number attributed to the White/British category has increased by 82 and the Other category by 1 when comparing the end of 2015/16 with the end of 2014/15. The number of part time employees has increased by 92 whereas the number of full time employees has decreased by 9 when comparing the end of 2015/16 with the end of 2014/15. At the end of 2014/15 the largest age category was with 16.5% of the total WTE. This was consistent with previous years. Whereas in 2015/16 the largest age category is accounting for 16.5% of the total WTE. This demonstrates that the Trusts workforce is increasing in age. 18

151 Turnover (% Headcount) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Add Prof Scientific and Technical Additional Clinical Services Turnover (inc. Foundation Doctors) Administrative and Clerical Turnover with/without Foundation Doctors with without Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar with without Turnover by Staff Group Q4 inc. FD's Allied Health Professionals exc. FD's Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered inc. FD's exc. FD's Turnover (exc. Foundation Doctors) Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar The turnover rate has decreased in quarter /16 when compared to quarter /16, from 12.92% in December 2015 to 11.98% in March 2016 where the rate includes foundation doctors, and from 11.86% in December 2015 to 11.11% in March 2016 where the rate excludes foundation doctors. The turnover rate for each of the months in 2015/16 has been higher than in 2014/15, except for March 2016 where the rates both including and excluding foundation doctors was lower. The turnover rate at the end of 2015/16 is lower, at 11.98%, than at the end of 2014/15, at 12.69%. The Medical and Dental staff group continues to show the highest turnover rate both including and excluding the foundation doctors. However the rate is significantly lower when the foundation doctors are excluded at 17.99% compared to 28.46% when they are included. Add Prof Scientific and Technical are the next high staff group at 14.72%, followed by Allied Health Professionals at 13.44%. Additional Clinical Services has the lowest turnover rate for quarter 4 at 9.88%. 19

152 Change in Workforce Analysis New Starters Headcount WTE Apr / /16 May Starters by Staff Group Headcount WTE Headcount WTE Jun Add Prof Scientific and Technical Q1 2015/ Additional Clinical Services Jul Administrative and Clerical Aug Allied Health Professionals Sep Estates and Ancillary Q2 2015/ Healthcare Scientists Oct Medical and Dental Nov Nursing and Midwifery Registered Dec Students Q3 2015/ Total Jan Feb Mar Q4 2015/ Total 2015/ Q4 2015/16 Reasons for Leaving Headcount WTE Headcount WTE Leavers by Staff Group Headcount WTE Headcount WTE Flexi Retirement Add Prof Scientific and Technical Voluntary Resignation - Other/Not Known Additional Clinical Services Voluntary Resignation - Relocation Administrative and Clerical Voluntary Resignation - Work Life Balance Allied Health Professionals End of Fixed Term Contract Estates and Ancillary Voluntary Resignation - Promotion Healthcare Scientists Retirement Age Medical and Dental Retirement - Ill Health Nursing and Midwifery Registered End of Fixed Term Contract - Completion of Training Scheme Students Redundancy - Compulsory Total Voluntary Resignation - Lack of Opportunities Voluntary Resignation - Better Reward Package Voluntary Resignation - Health Voluntary Resignation - Adult Dependants Dismissal - Some Other Substantial Reason Dismissal - Capability Death in Service Has Not Worked End of Fixed Term Contract - End of Work Requirement Bank Staff not fulfilled minimum work requirement Dismissal - Conduct Employee Transfer End of Fixed Term Contract - External Rotation End of Fixed Term Contract - Other Redundancy - Voluntary Voluntary Resignation - Child Dependants Voluntary Resignation - Incompatible Working Relationships Voluntary Resignation - To undertake further education or training Total / /16 The highest number of starters came to the Trust in quarter /16 and the fewest started in quarter 1. The total number of new starters in 2015/16 was 770 ( WTE), which is an increase of 8 (19.72 WTE) when compared to 2014/15. Additional Clinical Services accounts for the highest number of new starters in 2015/16 with 195. This is consistent with 2014/15. The Nursing and Midwifery Registered staff group accounts for the highest number of leavers in 2015/16 with 166, however this is counter balanced by the number of starters in the year (170). Flexi-retirement remains the top reason for leaving in quarter /16, however, voluntary resignation - other/not known is the highest reason across the year. Please note that the 2015/16 total headcount in the tables may differ by 1, this is due to an individual not being allocated to a specific staff group as a result of a data entry error. 20

153 Sickness Reasons (Quarter 4) Absence Reason WTE Days Lost Episodes Anxiety/stress/depression/other psychiatric illnesses Other musculoskeletal problems Gastrointestinal problems Total Anxiety/Stress/Depression/etc - WTE Days Lost - By Dir Other Musculoskeletal Problems - WTE Days Lost - By Dir Gastrointestinal Problems - WTE Days Lost - By Dir Central Chief Execs Dept Clinical Support 0 Services Finance 64 Human Resources Nursing, 255 Patient Safety & 288 Quality Transformation Operations and Performance Directorate - Corporate Areas Anaesthetics 8 Elective Care Emergency Care Services 88 0 In-Hospital Care Out of Hospital Care38 Womens and Childrens Anxiety/Stress/Depression/etc - WTE Days Lost - By SG Other Musculoskeletal Problems - WTE Days Lost - By SG 384 Estates and Ancillary Medical and Dental Students Gastrointestinal Problems - WTE Days Lost - By SG Gastrointestinal Problems - WTE Days Lost - By SG Add Prof Scientific and Technical Additional Clinical Services 14 Administrative and Clerical Allied Health Professionals Healthcare Scientists Nursing and Midwifery Registered The top three reasons for sickness absence in quarter /16 remain the same as in quarter /16. There has been 202 more WTE days lost in quarter 4 for the top three reasons but 58 fewer episodes when compared to quarter 3. Anxiety/stress/depression/other psychiatric illnesses is the top reason based on WTE days lost, however, gastrointestinal problems account for more episodes of sickness in the quarter. This is consistent with the ranking in quarter /16. The Directorate that has the largest number of WTE days lost for Anxiety/Stress/Depression etc continues to be Out of Hospital Care, as this accounts for 707 WTE days lost. This remains consistent with previous quarters. The staff group that has the largest number of WTE days lost for Anxiety/Stress/Depression is Additional Clinical Services, as this accounts for 863WTE days lost. This is consistent with quarter 3. Out of Hospital Care also accounts for the highest number of WTE days lost for Other Musculoskeletal Problems with 528 WTE days lost. This differs from last quarter when the Finance Directorate accounted for the largest proportion. Nursing and Midwifery Registered is the staff group which has the highest number of WTE days lost (904) for Other Musculoskeletal Problems. This differs from last quarter when Additional Clinical Services accounted for the largest proportion. The Finance Directorate is the directorate with the highest number of WTE days lost (288) for gastrointestinal problems. In quarter 3, the directorate with the highest number was Out of Hospital Care. The Nursing and Midwifery Registered staff group continues to account for the largest amount of WTE Days Lost for Gastrointestinal Problems with

154 Sickness 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1, , , , , , , ,000 0 WTE Days Lost 2015/ /15 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Add Prof Scientific and Technical Additional Clinical Services Sickness Cost by Staff Group 2015/16 Q1 2015/16 Q2 2015/16 Q3 2015/16 Q4 Administrative Allied Health and Clerical Professionals Estates and Ancillary Healthcare Scientists Medical and Dental Nursing and Midwifery Registered Please note that sickness information is not currently available for March The number of WTE days lost to sickness in quarter 4 has decreased by 6095 when compared to quarter 3 however, the data for quarter 4 is not yet complete. The WTE days lost in January 2016 were 630 lower than in January 2015, however, the number of WTE days lost in February 2016 were 488 higher than in February However, the data for quarter 4 is not yet complete so this may change. The Nursing and Midwifery Registered staff group incurs the greatest sickness cost in the Trust for quarter 4 at 402, This has reduced when compared to quarter 3, by 160, However the quarter 4 figure is not yet complete. The staff group with the lowest cost of sickness is no longer Add Prof, Scientific and Technical, but Healthcare Scientists with 25,

155 Regional Sickness (Quarter /16) County Durham & Darlington NHS Foundation Trust Newcastle Upon Tyne Hospital NHS Foundation Trust Northumbria Health Care NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust South Tees Hospitals NHS Foundation Trust The chart above shows the regional sickness absence figures up to quarter 3 for 2015/16. North Tees and Hartlepool Trust continue to have a sickness absence rate that is below the regional average for quarter 3. The average regional sickness absence rate for quarter 3 is 4.90%, whereas the average rate for North Tees and Hartlepool Trust is 4.59%. Regional sickness absence information for quarter /16 is not yet available. Gateshead Health NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust North Tees & Hartlepool NHS Foundation Trust South Tyneside NHS Foundation Trust Northumberland, Tyne and Wear NHS Foundation Trust Quarter Quarter Quarter North Cumbria University Hospital 23

156 Occupational Health - Reasons for Referral Reason for Referral Apr-Jun 2015 Jul-Sep-2015 Oct Dec 2015 Jan Mar 2016 Total Musculoskeletal Stress/Anxiety Post Surgery Frequent STSA Fracture Bereavement Neurological Respiratory Infections Cardiac Total There were 198 referrals to Occupational Health during quarter /16 and a total of 774 referrals across 2015/16. The top reason for referral in quarter 4 continues to Musculoskeletal with 57 referrals.this was followed by Stress/Anxiety with 66 referrals This is consistent with the top reasons for referral across 2015/16. Musculoskeletal accounts for 202 referrals and stress/anxiety for

157 Training Compliance Levels Topic Target compliance % Q1 2015/16 % Q2 2015/16 % Q3 2015/16 % Q4 2015/16 Infection Control Information Governance Medicines Management Corporate Induction Appraisal Patient Handling Resuscitation Dementia 50* Enhanced infection control 80 N/A*** N/A*** N/A*** N/A*** Safeguarding Children (combined levels) Safeguarding Adults (combined levels) Human Factors 80 N/A*** N/A*** N/A*** N/A*** Patient falls (Risk Assessment & Falls) Pressure sores (Prevention of Pressure Sores Overall Trust compliance *Patient Falls is now Risk Assessment & Falls and target for May is 10% *Pressure Sores is now Prevention of Pressure Sores and target for May is 10% The Education Delivery Team has again made a positive contribution to the overall Trust compliance. Green status has been achieved in a wide range of topics including: Information Governance; Infection Control; Fire; and Resuscitation. Green status has also been achieved in all of the 6 additional topics for 2015/16. These are: Palliative Care; Risk Assessment and Falls; Prevention of Pressure Sores; Acute Kidney Injury; Sepsis; and Anticoagulants. Training compliance on a small number of topics remain a challenge, these include: Appraisal 82% of staff have currently undertaken appraisal in the last 12 months. Significant effort is required to prevent the overall compliance from decreasing. The Education Delivery team are working with Directorates to help improve compliance and regular appraisal training continues to be delivered. Clinical pressures and continued high NEEP levels is cited as a barrier. Violence and Aggression A compliance figure of 93% was achieved for this quarter. The once only training is delivered face to face and attendance is often affected by increased clinical pressures. New starters are booked onto this course after attending induction. Patient Handling 72% of staff have undertaken patient handling training which is required every 3 years. Education and Organisation Development are working with the manual handling trainer to provide sufficient training sessions to cover the numbers of non compliant staff. Trust staff continue to be encouraged to access key trainers within their departments to deliver training. During March the number of training completed by e-learning was 1030 which represents 35% of the overall mandatory training that took place across the Trust. This is double the number of completions in the same quarter last year. E-learning continues to grow with more and more training being developed in this format. The new additional topics were presented and approved at the March Patient Safety and Quality Standards committee. New packages are currently being developed and will be ready at the end of April. The new topics to be delivered and monitored on the RAG report for 2016/2017 are: Sepsis ( for all clinical staff); Acute Kidney injury ( for all clinical staff); WRAP and Prevent Training 25

158 26

159 Equality and Diversity Monitoring The Trust monitors and reviews the workforce numbers by protected characteristics to ensure it is reflective of the community we serve. In addition to considering staff in post by protected characteristic within the Trust, the information detailed includes a breakdown of new starters and leavers during 2015/16, split by protected characteristics (ethnicity, religion and belief, age, gender, sexual orientation, disability and marital status/civil partnerships). At present we are unable to report fully on gender reassignment and pregnancy and maternity as we do not have data regarding these characteristics. Details of the local population are provided below to enable a comparison with our workforce. Regional Population Figures provided by the Office for National Statistics indicate that there is a slightly larger female population in the region 51% to 49% male. 93.6% of the regional population are classed as White British with Asians being the next largest group at 2.9%. 67.5% state their religion as Christianity and 24% have no religion. Regionally 46% of the population are married with less than 1% in civil partnerships. *Note: percentages in tables may not sum to exactly 100% due to rounding Workforce - Staff in Post 2015/16 No. of Staff in Post 5476 White British 87% White Other 2% Asian 6% Ethnicity Mixed Race 1% Black/Black British 1% Chinese 0% Other 2% Not stated 2% Christianity 38% Atheism 6% Hinduism 1% Religion / Belief Islam 1% Buddhism/Sikhism/Janism 0% Other 6% Not stated 32% Did not wish to state religion/belief 15% Under 30 17% Age % % 66+ 2% Gender Male 18% Female 82% Heterosexual 54% Sexual Orientation LGBT 1% Not stated 32% Did not wish to state sexuality 13% Disabled 2% Disability Not Disabled 43% Not stated 56% Married 56% Single 34% Divorced 6% Marital Status Legally separated 1% Civil Partnership 0% Widowed 1% Not stated 2% 27

160 Equality and Diversity Monitoring New Starters Leavers 2015/ /16 No. of New Starters 770 No. of Leavers 685 White British 82% White British 81% White Other 4% White Other 3% Asian 8% Asian 7% Ethnicity Mixed Race 1% Mixed Race 1% Ethnicity Black/Black British 2% Black/Black British 2% Chinese 0% Chinese 1% Other 1% Other 1% Not stated 1% Not stated 4% Christianity 47% Christianity 31% Atheism 12% Atheism 8% Hinduism 1% Hinduism 1% Islam 2% Islam 2% Religion / Belief Buddhism/Sikhism/Janism 0% Religion / Belief Buddhism/Sikhism/Janism 0% Other 9% Other 5% Not stated 2% Not stated 28% Did not wish to state religion/belief 26% Did not wish to state religion/belief 25% Under 30 46% Under 30 27% Age % % Age % % 66+ 1% 66+ 4% Gender Male 23% Male 28% Gender Female 77% Female 72% Heterosexual 75% Heterosexual 51% Sexual Orientation LGBT 2% LGBT 1% Sexual Orientation Not stated 2% Not stated 28% Did not wish to state sexuality 21% Did not wish to state sexuality 19% Disabled 3% Disabled 2% Disability Not Disabled 85% Disability Not Disabled 45% Not stated 12% Not stated 54% Married 38% Single 53% Divorced 7% Marital Status Legally separated 1% Civil Partnership 1% Widowed 1% Not stated 1% 28

161 Employee Relations Case Summary Category Cases commenced in 2015/16 Cases concluded in 2015/16 - with outcome (including those carried forward from 2014/15) Total ongoing cases to carry forward 2016/2017 Employment Tribunal Disciplinary & Capability (C) No Further Action* 13 6 Verbal Warning 9 First Written Warning 9 Final Written Warning 8 Dismissed 5 Resigned 1 Redeployed 5 (C) 1 No Further Action* (C) 1(C) 1 Downgraded (C) 2 First Written Warning (C) 1 Final Written Warning (C) 1 Dismissed (C) Grievance 22 2 Resolved 5 11 Not Upheld 2 Partly Upheld 4 Upheld 1 Withdrawn Bully & Harrassment No Further Action* 6 1 Verbal Warning 1 Did Not Proceed Mediation 11 4 Resolved Successfully 1 2 Partially resolved 1 One Party Resigned 2 Did Not Proceed Absence dismissals 25 N/A N/A Organisational Change 49 N/A N/A *No further action - usually indicates no formal action but may involve some management guidance 29

162 Exit Questionnaires 2015/16 Total no of leavers Primary reason for leaving % of responses Number of questionnaires received 26 (3.75%) Promotion 19% Leavers by Dept No of responses Career Change 19% Anaesthetics 1 Poor Promotion Prospects 8% Out of Hospital Care 3 Retirement 8% Education & OD 1 Dissatisfaction with work 8% Finance 1 Ill Health 4% HR 1 Redundancy 4% IT 1 Other 30% In Hospital Care 2 Nutrition & Dietetics 1 Orthopaedics 2 Paediatrics 3 Patient Safety & Nursing 1 Podiatry 1 Psychology 2 Radiology 2 Research & Development 1 Least favourite parts of the job (top 3) Lack of career development Lack of support, staff morale Effect on health, work-life balance Favourite parts of the (top 3) Colleagues, team working Interacting with Patients Staff Commitment Surgery 1 The Department Theatres 2 Felt a valued part of the team 96% Department working efficiently 73% Reason for joining the Trust % of responses The Manager Needed a Job 31% Provided adequate support and engagement 69% Wanted a Change 23% Demonstrated fair and consistent treatment 69% Reputation of the Trust 11% Encouraged career progression 58% Career Advancement 31% The Trust Referred by a friend 4% Recognise and reward achievements 58% Offers career development 50% Communicates effectively with staff 55% Engages with staff 57% Other Responses Recommend the Trust as a good employer 85% 30

163 Staff Friends and Family Test Response Rate Quarter = 5.29%, Quarter 2-307= 5.60%, Quarter completed via 2015 national staff survey = 6.88%, Quarter % Question 1 How likely are you to recommend the Trust to friends and family if they need care or treatment? Question 2 - How likely are you to recommend the Trust to friends and family as a place to work? 31

164 11. Recommendation The Board of Directors is asked to note the content of and accept this report. Ann Burrell Director of HR & Education 32

165 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Executive Summary Revenue and Capital Budgets /17 Report of the Acting Director of Finance Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports) Maintain Compliance and Performance Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Finance 1. Introduction 1.1 The purpose of this report is to present to the Board of Directors the proposed revenue and capital budgets for 2016/17. This report builds on the Trust s draft Annual Plan submitted to Monitor on 8 February 2016 and the draft budgets approved by the Finance Committee in March Further amendments identified by the Trust have been incorporated into the final submission of the Annual Plan made to Monitor on 11 April 2016 and in the budgets presented in this paper. There are no material changes to the draft budgets. The main changes are presentational issues only. 2. Key Issues & Planned Actions 2.1 The report outlines: The proposed revenue and capital budgets for 2016/17 with supporting papers and underpinning analysis; Outline of the key financial risks in respect of 2016/ The Trust has not yet formally signed off all commissioning contracts. The budgets reflect the anticipated financial agreements and the Trust is not expecting any material changes to arise during the final stages of contract negotiation. 3. Recommendation 3.1 The Board of Directors is requested to receive the report and approve the final 2016/17 revenue and capital budgets. Caroline Trevena Acting Director of Finance 1

166 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Revenue and Capital Budgets /17 1. Introduction/Background Report of the Acting Director of Finance 1.1 The purpose of this report is to present to the Board of Directors the proposed revenue and capital budgets for 2016/17. This report builds on the Trust s draft Annual Plan submitted to Monitor on 8 February 2016 and the draft budgets approved by the Finance Committee in March Further amendments identified by the Trust have been incorporated into the final submission of the Annual Plan made to Monitor on 11 April 2016 and in the budgets presented in this paper. The main changes are presentational issues only. 2. Main content of report 2.1 The report outlines: The proposed Income & Expenditure position for 2016/17; Cash-flow forecast for 2016/17; Income statement split by Commissioner for 2016/17; Analysis of Reserves for 2016/17; Analysis of Service Developments for 2016/17; List of the indicative CIP targets for each Directorate for 2016/17; Outline of the key financial risks in respect of 2016/17. Key Points to Note 2.2 The Trust s draft accounts show an operational deficit of 7.4m for 2015/16. The Trust has been set a control total for 2016/17 of 2.050m surplus. The 2016/17 control total surplus has increased by 150k following guidance from Monitor in relation to the treatment of donations. Any deterioration in the 2015/16 position may impact on the control total set for 2016/ The Trust has not yet formally signed off all commissioning contracts. The budgets reflect the anticipated financial agreements and the Trust is not expecting any material changes to arise during the final stages of contract negotiation. 2.4 All Directorates have identified their financial requirements for 2016/17 during the development of the Clinical Services Strategy. Using the forecast outturn for 2015/16 the finance team have challenged the assumptions and produced a summarised budget for the Trust as a whole. This has incorporated some of the financial 2

167 pressures that materialised in 2015/16 and further financial pressures identified for 2016/ The proposed service developments from the 2016/17 Clinical Services Strategy have not been included in the financial estimates, the expectation is that any significant developments will be presented as invest to save schemes or will be backed by increases in income appropriately agreed with commissioners. Key Assumptions 2.6 The assumptions that have been made in setting the budget for 2016/17 are tabulated below. Clinical Income Non Clinical Income Category Contract income Winter Pressures Excluded Drugs and Devices Risk Income MSK / Spinal Services Acute Contract Reduction Sustainability and Transformation Fund Non NHS Clinical Income Assumption The Trust has reached an agreement with the main commissioners with the exception of DDES CCG. The indicative income targets include 100% CQUIN. Agreement on investment from HAST CCG will be via the Systems Resilience Group (SRG). The group is currently considering bids. DDES CCG has not yet agreed an amount. The Trust has assumed income will be in line with the 2015/16 initial allocation of 1.4m. An expenditure reserve for the same value has also been assumed. 16.3m is assumed based on 2015/16 outturn. This is matched by corresponding expenditure (being cost neutral to the Trust). The Trust has assumed 2.1m of risk income from Commissioners. The Orthopaedic Directorate has been given an over performance income target of 1.448m (Note in the draft budget this target was included in reserves.) The Trust will receive 7.9m from the Fund subject to agreed conditions. (Note in the draft budget this income was included in non clinical income.) Education and Training Private Patients 0.1m, Injury Cost Recovery 1m and Overseas visitors 0.1m is assumed based on the 2015/16 outturn plus 1.1%. The Trust received 7.96m in 2015/16 and this has been uplifted for inflation by 1.1% to 8.05m. The Trust has not yet received the contract for 2016/ m will be phased in from the deferred income Government Grant of 4.2m held at the end of 2015/16. Other Other Non-Clinical income targets have been set Directorate at 2015/16 outturn plus 1.1%. Income Expenditure Pay The Trust has rolled over its recurrent pay budgets for WTE and cost ( ). Budgets are costed at the actual pay point for staff in post and vacancies are funded at the bottom of the pay scale. A 1% per cent consolidated uplift for pay award for Agenda for Change and Medical staff, including clinical excellence awards (CEAs) has created a 3

168 Efficiencies Non pay Service Improvement and Efficiency Programme pay reserve of 2.2m. Incremental pay progression equates to 0.87m. Changes to the National Insurance contributions of 2.3m for Agenda for Change staff and 0.6m for Medical staff. 1.0m reserve set aside for Locum and Agency costs. 0.35m for additional costs for junior doctors. This may be required to fund the costs associated with the implementation of the new contract. 1.0m revenue to capital transfer is assumed for Trust employed staff working on capital projects. 1.5m vacancy factor included in budget as in previous years. 0.86m increase in CSNT charges as a result of the removal of risk management discounts and the risk profile of the Trust (total cost 9.1m) 0.63m has been included to meet the revenue costs of TrakCare and SystmOne. Contingency level of 0.5m. 0.5m has been assumed for non-pay inflation with a further 0.17m for non-pass through drugs. This funding will be held in reserves and allocated as and when inflationary pressures arise. The Executive Team have approved variable targets for Directorate savings which is based on savings actually delivered during 2015/16. The %age required is between 1% and 4%. Indicative targets are shown in Appendix 5. These will be reviewed and agreed by the Executive Team. 2.7 The monies held in reserves and service developments approved by the Trust are listed in Appendix The plan assumes these initiatives will impact at various stages during the year. Future service developments have not been included as they are not developed to a stage where costs can be assigned to them. 2.9 Given the current financial position of the Trust it is recommended that no further developments are permitted in 2016/17 unless it is in line with, and supported by, CCG commissioning intentions or are invest to save schemes that will deliver within the current financial year. Capital Programme 2.10 The five year capital plan was presented to the Clinical Services Strategy Board Seminar in February There have been no material changes to this plan. The Trust will spend 11.22m during 2016/17 ( 4.15m on electrical upgrade, 0.5m on energy plant and 6.57m on the Trust s annual capital allocation). The work on the electrical upgrade and energy plant will be funded via a 25m loan. Risks 2.11 The proposed budget plans to deliver the 2.050m surplus control total set by Monitor. The following risks within the draft budget should be noted: 4

169 Contracts have not been signed with all Commissioners. The budgeted income assumes 2.1m risk income to materialise from contract over performance. The potential failure to meet CQUIN targets. (This is compounded as schemes have not yet been agreed with Commissioners). The Trauma & Orthopaedic Directorate has been set an additional income target of 1.45m to reflect the reduction to the acute contract from the new MSK pathway. Additional income will need to be secured via over performance against the lower targets or alternatively the Directorate will need to reduce expenditure in line with reduced activity. The budget assumes expenditure relating to winter resilience will be within the assumed funding of 1.4m. Schemes have not yet been agreed. The Trust will need to deliver agreed trajectories to secure the Sustainability and Transformation Funding. Although at a lower level than 2015/16 the savings target is currently 2.81% of operating expenditure and is over the 2% assumed within the national tariff. 3. Conclusion/Summary 3.1 The 2016/17 budgets have been discussed with the Directorate leads and reflect the resource requirements for the coming financial year. The financial position remains challenging as these budgets result in a planned surplus of 2.050m in line with the control total set by Monitor. 3.2 The longer term financial plans will be refreshed as part of the five year planning requirement for the Sustainability and Transformation Plan which is due in July Recommendation 4.1 The Board of Directors is requested to receive the report and approve the 2016/17 revenue and capital budgets. Caroline Trevena Acting Director of Finance 5

170 List of Appendices Appendix 1 Income & Expenditure Position Appendix 2 Cash-flow statement 2016/17 Appendix 3 Income Statement by Commissioner 2016/17 Appendix 4 Analysis of Reserves and Service Developments 2016/17 Appendix 5 SIEP/CIP Directorate Targets 6

171 Appendix 1 Trust Income & Expenditure Position 2016/17 Proposed Budget Total 000's Income: NHS Clinical Income (263,142) Non NHS Clinical Income (1,305) Non Clinical Income (24,272) Total Income (288,719) Expenditure: Pay 188,723 Non Pay 65,787 Reserves 14,443 Pass-through costs (excluded items) 15,715 Service Improvement & Efficiency Programme (SIEP) (7,918) Total Expenditure 276,750 EBITDA (11,969) Depreciation 6,185 Interest Receivable (108) Total interest payable on loans and leases 108 PDC 3,885 Donations of PPE (150) Total Depreciation / Interest / PDC 9,920 NET SURPLUS (2,050)

172 Appendix 2 Statement of Cashflow 2016/17 Total 000's Surplus/(deficit) after tax 5,785 Non-cash flows in operating surplus/(deficit) Depreciation and amortisation, total 6,185 Non-cash flows in operating surplus/(deficit), Total 6,185 Operating Cash flows before movements in working capital 11,970 Increase/(Decrease) in working capital (Increase)/decrease in inventories (108) (Increase)/decrease in NHS trade receivables (1,594) (Increase)/decrease in Non NHS Trade Receivables (98) (Increase)/decrease in other related party receivables (141) (Increase)/decrease in other receivables 17 (Increase)/decrease in accrued income 4,500 (Increase)/decrease in prepayments (164) Increase/(decrease) in Deferred Income (excl. Donated Assets) (2,873) Increase/(decrease) in provisions (32) Increase/(decrease) in trade payables (835) Increase/(decrease) in other payables 329 Increase/(decrease) in accruals (927) Increase/(decrease) in non-current provisions 561 (Increase)/decrease in non-current receivables (192) Increase/(Decrease) in working capital, Total (1,557) Net cash inflow/(outflow) from operating activities 10,413 Net cash inflow/(outflow) from investing activities Property - new land, buildings or dwellings (4,649) Property - maintenance expenditure (650) Plant and equipment - information technology (2,490) Property, plant and equipment - other expenditure (3,430) Increase/(decrease) in capital creditors 276 Net cash inflow/(outflow) from investing activities, Total (10,943) Net cash inflow/(outflow) from before financing (530) Net cash inflow/(outflow) from financing activities Interest Received 108 PDC Dividends paid /movement (3,874) Interest element of finance lease rental payments - On-balance sheet PFI (108) Drawdown of non-commercial loans 4,646 Net cash inflow/(outflow) from financing activities, Total 772 Net cash inflow/(outflow) from financing activities, Total 242 Opening Cash 23,336 Closing Cash 23,578

173 Appendix 3 Trust Income Position 2016/17 Total 000's NHS Clinical Income: Durham Dales, Easington and Sedgefield CCG 37,192 Hartlepool and Stockton-On-Tees CCG 173,098 NHSE Specialised Commissioning 15,610 NHSE Community Dental 1,723 NHSE Public Health (Screening) 5,257 NHSE Y&H 220 Other CCGs (individually less than 5m) 5,615 Non Contract Activity Income (CCGs) 1,765 Public Health England 1,984 Hartlepool Council 2,262 Middlesbrough Council 145 Redcar and Cleveland Council 134 Stockton Council 4,533 Armed Forces 22 Sustainability and Transformation Funding 7,900 South Tees NHS Foundation Trust 1,366 MSK Orthopaedic income 1,448 Other Directorate Income 718 Risk Income 2,150 Total NHS Clinical Income 263,142 Non NHS Clinical Income: Private Patient Income 145 Injury Cost Recovery 1,034 Overseas Visitors 126 Total Non NHS Clinical Income 1,305 Non Clinical Income: Research and Development 660 Education and Training 8,046 Donations 25 Parking Income 1,713 Catering Income 897 Accommodation Income 345 Non Patient Income from Other NHS Bodies 2,318 Government Grant 2,800 Distinction Awards 262 Other Directorate Income 5,795 Audit North 1,347 Other 64 Total Non Clinical Income 24,272 Total Income 288,719

174 Appendix 4 Trust Reserve Position 2016/17 Budget Pay Non Pay Income Total 000's 000's 000's 000's General Reserves & Contingencies: Contingency Emergency Preparedness Junior Doctors Posts Locum & Agency 1, ,000 Maternity Pathway Nurse Recruitment (Philippines) R&D (CLRN) Redundancy Revenue to Capital Transfers (1,000) 0 0 (1,000) Vacancy Factor (1,500) 0 0 (1,500) Winter 1, ,400 Total General Reserves & Contingencies 2, , /17 Pressures Clinical Excellence CNST Reserve CQC Uplift Electronic Mileage Health Roster Contract Renewal In Hospital Care - Xray equipment Incremental Drift NI Medical NI Non Medical 2, ,305 Non Pay Inflation (Drugs 4.5%) Non Pay Inflation (Other 1.2%) Pathology - Local agreement OOH service Pathology - Managed Service Contract Pay Award 1, ,912 Radiology - Maintenance Contract System One TrakCare Total 2016/17 Pressures 5,941 2, ,540 Service Developments Radiology Additional Provision to Support Cancer Pathways Rheumatology Additional Consultant Bowel Scope Expansion Community - Loss of Non Recurrent Income (537) 0 0 (537) COPD Urogynaecology Development of Service Diabetes Transitional Care (16-19 year olds) EDM - Revision of Business Case Medicines Optimisation Transformation MSK / Spinal Expansion in Community 1, ,326 MSK Acute Reduction (Orthopaedic Income Target - Full Year) Spinal Services Acute Reduction (Orthopaedic Income Target - Full Year) Ortho Expansion Orthopaedic Implant Manager RTest 4 cardiac arrhythmia monitoring devices SafeCare Live Specialist Liver Nurse CHP Rent - Additional Income from CCG System Administrators Total Service Developments 1,575 1, ,103 Sub Total Reserves 9,726 4, ,443 Pass Through Costs Excluded Drugs & Devices 0 15, ,715 Total Pass Through Costs 0 15, ,715 GRAND TOTAL 9,726 20, ,158 Note: The MSK / Spinal Acute Contract Reduction has been moved to Income

175 Appendix 5 Service Improvement and Efficiency (Indicative Targets) Total 000's Directorate Schemes Accident & Emergency 295 Anaesthetics 879 Chief Executive 21 EAU and Ambulatory care 363 Education and Organisation Development 108 Endoscopy 154 Estates 553 Finance and ICT 379 Human Resources 33 In Hospital Care 293 Medical Director 2 Nursing and Patient Safety 45 Obs and Gynae 521 Out of Hospital 1,591 Orthopaedics 238 Outpatients 55 Paediatrics 420 Pathology 446 Pharmacy 114 Radiology 425 Strategy, Operations and Performance 105 Surgery and Urology 430 Unallocated 448 Total 7,918

176 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Quarter /16 (1 January to 31 March 2016) Compliance Report to Monitor Report of the Chief Operating Officer/Deputy Chief Executive Strategic Aim and Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Board Reports Maintain Compliance and Performance 1. Introduction 1.1 The attached report provides members of the Board of Directors with the required information with regard to the quarterly submission to Monitor, including: a financial summary report, detailing the quarter end (year to date) actual position against plan (Appendix 1), the position against national core standards (Appendix 2), an update report (Appendix 3) outlining changes that have occurred in relation to the Licence Conditions and Risk Assessment Framework, since the time of the last formal compliance report (Quarter 3 October to December 2015) proposed actions, timelines for delivery and next steps, Membership and Governor changes (Appendix 4) the in year governance statement (Appendix 5) Quality Governance Metrics (In-year organisational health indicators) (Appendix 6) Governance Statement - Supporting Information (Appendix 7a, 7b and 7c) 1.2 The report focuses predominantly on governance risk ratings in the context of Conditions of Licence. 2. Compliance Requirements 2.1 The Monitor NHS Provider Licence outlines the mandatory set of conditions that all NHS Foundations Trusts must meet. 2.2 Monitor will continue, under the requirements of the Health and Social Care Act 2012, to oversee the governance of NHS Foundation Trusts compliance with two sets of conditions of their licence: those relating to the continued provision of NHS services ( Continuity of Services conditions ), which require relevant providers to ensure amongst other matters that they remain a going concern; and NHS Foundation Trust condition 4 (governance condition) setting out requirements relating to governance at NHS Foundation Trusts. 1

177 2.3 Monitor carries out this oversight role by requiring all Boards to certify ongoing compliance with their governance condition, via the Corporate Governance Statement (as declared in the Annual Plan submission and contained within Appendix 5), subsequently using performance against governance indicators, financial performance, exception reports and third party information to test that certification. 2.4 Monitor uses a combination of financial information and performance against a selected group of national measures as a primary basis for assessing the risk of Trusts breaching their Continuity of Services and Governance conditions respectively. 2.5 Monitor s risk-based framework assigns two risk ratings (Continuity of Service and Governance conditions) to each NHS Foundation Trust on the basis of its forward plan and in-year performance against that plan, and consequently the risk of breach of Continuity of Services or Governance conditions of the licence. 2.6 Monitor amended the Risk Assessment Framework (RAF) in August 2015, with the key changes including; re-introducing two previously used measures: one tracking Foundation Trust deficits and another the accuracy of planning combining a Trust s rating on these new measures with its existing continuity of service ratings (COSRR) to produce a new four-level financial sustainability and performance risk rating, with appropriate regulatory responses to each rating level making two further changes to ensure Trusts make sure they deliver value for money. See further detail in section 4 3. Current Position 3.1 The Board of Directors has effectively planned for the future, assessed risks to compliance with the Licence, reviewed financial viability, overall governance and quality governance. 3.2 Ongoing and assessment actions continue in monitoring and delivery and compliance with the Licence Conditions. There is no further publication from Monitor on Payment of Fees or the formulation of a Risk Pool Levy on which to make a considered judgement. 3.3 The delivery of the C-diff standard was recognised by the Board of Directors as at risk for 2015/16 against the indicator threshold (Risk Assessment Framework 2015), with a declaration of non-compliance indicated in the Operational Plan submitted to Monitor. In addition, the risk of underachievement against access and cancer standards was anticipated by the Board of Directors and acknowledged in the returns to Monitor via the Annual Plan. 3.4 As outlined in section 2.6, there is a new Risk Assessment Framework in place, with revised financial measures. Under the old metrics the Trust performance would have been an overall rating of 3, however, with the addition of the two new metrics focussing on income and expenditure (degree the organisation is producing a surplus or deficit) and the variance from the 2

178 Trust planned I&E position, this has reduced to an overall rating of 2 (Finance and Contract Performance Report, 28 April). 3.5 The Trust has under-achieved against three of the key targets during quarter 4 period, C-Diff standard, the A&E four hour wait standard and 62 day cancer standard. Full analysis with supplementary information are provided in Appendices 7a, 7b and 7c, outlining the current position, historical performance, key issues within the quarter 4 period and the resulting actions and mitigation plans going forward to manage the position against these standards. 3.6 The Monitor Risk Assessment Framework outlines the triggers for concern against the Access and outcomes metrics, as follows: C-Diff: Breaching pre-determined annual C-Diff threshold (either three quarters breach of the year to date threshold or breaching the full year threshold at any time in the year). The Trust has breached the full year threshold (since quarter 2 position). A&E 4 hour wait standard: breaching the A&E waiting times target in two quarters of any four-quarter period and in any additional quarter over the subsequent three quarters. Q4 is the second quarter within 2015/16 under achieving against the 4 hour standard. Cancer 62 day standard: breach of single metrics in three consecutive quarters. The Trust achieved the Cancer 62 day standard in Q3, therefore this trigger does not apply. Breaching of four or more metrics in one quarter can also trigger intervention. This does not apply for Q Following the application of Monitor guidelines regarding priority weighting and thresholds for core standard performance, the Trust has achieved an overall aggregate score of 3 (under-achievement against the three standards outlined above). 3.8 In line with the Risk Assessment Framework this could trigger Monitor intervention. The Trust has provided a full update of the current position, the work to date and on-going actions (see Appendices 7a, 7b and 7c). 3.9 There are no material concerns, at this stage, to alter the position of the Board with regard to the certification contained with the Annual Plan (2015/16) Corporate Governance Statement and thereby requiring exception reporting in line with the Terms of Provider Licence, however reports providing supporting information, see Appendices 7a, 7b and 7c will be submitted to Monitor alongside the quarter 4 submissions, for the areas reporting outside of the required standards, as outlined within this report. 4. Revised Compliance Requirements 4.1 The revised RAF has seen the re-introduction of measures of Foundation Trust deficits and variance from plan. Monitor has retained the existing continuity of service measures (liquidity and capital service capacity) and introduced additional measures into the Risk Assessment Framework. 4.2 A Trust s ratings on these additional measures feeds into its new overall financial sustainability and performance risk rating. 3

179 4.3 Monitor has included a further additional measure within Foundation Trusts governance rating linked to value for money. Monitor may consider investigating if a Foundation Trust demonstrates inefficient or uneconomical spend (actual or forecast) against published benchmarks. 4.4 Changes to the NHS Foundation Trust accounting officer memorandum have also been applied, with the aim to strengthen the requirement to consider value for money. 5. Recommendations 5.1 The Board of Directors is asked to note the quarter end report, outlining current financial position (Appendix 1; full report contained within the Finance and Contract Performance Report, as at 28 April 2016) performance on core national standards (Appendix 2), the update report on the key changes that have taken place in relation to the Licence Conditions and Risk Assessment Framework since the last quarterly submission (Appendix 3), a members and governors update position (Appendix 4) a Quality Governance return outlining the number of current voting members of the Board and any in quarter changes (Appendix 6), and the Governance Statement (Appendix 5) including - Supporting Information (Appendices 7a, 7b and 7c) which will be submitted to Monitor as a requirement of the quarterly compliance return. 5.2 In line with the Monitor Risk Assessment Framework 2015/16 the Board of Directors is also asked to consider the quality governance framework and the requirement to declare ongoing compliance with quality and legal requirements. This is supported by Care Quality Commission information (where appropriate) information on serious incidents, patterns of complaints, and further metrics as contained and explored within Board meetings and sub committee meetings. In addition the Board has also pledged to keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients. 5.3 Monitor has issued guidance on the well-led framework for governance reviews to support NHS Foundation Trusts gain assurance that they remain well led. The framework represents a core reference for NHS Foundation Trusts to follow in structuring reviews of their governance, covering strategy and planning, capability and culture, processes and structure and measurement, using a self-assessment approach. 5.4 Due diligence has been paid by the Board of Directors in assessing ongoing compliance and that of new requirements, specifically that illustrated in regular seminar discussion and Compliance and Performance Reports, Quality Reports, Infection Prevention and Control Reports, Finance and Contract Performance Reports and Board Assurance Framework Reports. 5.5 Board assurance is gained through the regularly review of key risks through a structured assurance framework currently in the process of a radical review. Due diligence has been paid by the Board of Directors and associated Board Committees in assessing the Board Assurance Framework, ensuring thorough oversight of each strategic risk and compliance with risk management processes. The Board of Directors takes due cognisance that the risks to strategic aims and objectives have been duly considered via the Board committee structure in readiness for the declaration contained within the report. 5.6 Finally, the Board of Directors is asked to note the under achievement in the context of the Monitor triggers within the Risk Assessment Framework, 4

180 recognise the work on-going to manage recovery, not withstanding the risks inherent in the health system to financial and operational performance, as discussed at the Board seminar in March 2015 and in each Board meeting since and delegate responsibility to the Chairman to sign the in year governance statement contained within Appendix 5 on behalf of the Board. Julie Gillon Chief Operating Officer/Deputy Chief Executive 5

181 Appendix 1 North Tees and Hartlepool NHS Foundation Trust Quarter Four /16 Financial Summary A commentary on the financial position is submitted separately to Monitor in support of the detailed quarterly financial proformas. The key metrics from the financial report are as follows:

182 Continuity of Services Risk Rating (CSRR) Area of Review Overall Financial Risk Rating Capital Service Capacity (25%) I&E Margin (25%) Variance in I&E Margin (25%) o o o o Liquidity (25%) Month 12 Year to Date Financial Risk Rating (FRR) 2 Plan Month 12 YTD Month 12 Projection Overall financial risk rating of 2 (using the new metrics) with I&E operating deficit of 7.396m the Trust is under-achieving against its plan by 3.455m. CIP performance = Target at baseline of m. The Trust is phasing in the non-delivery of the SIEP over the period of the financial year to avoid any adverse movement in the position towards the year end. The Trust has delivered 5.188m of its in-year SIEP, of which 2.418m (47%) was recurrent and 2.248m (43%) was non recurrent, with the balance of 0.522m (10%) being cash releasing cost avoidance. This is 2.988m behind plan for the third quarter

183 o o The cash balance has been maintained through the third quarter with a net cash inflow of 13k, resulting in a small increase in cash from m at the start of quarter 3 to m as at 31 December Net current assets at 31 December 2015 are m. Despite, overall financial performance for the year being behind plan for the third quarter of 2015/16, the Trust achieved a Continuity of Service Risk rating of a 2 using the new metrics. Financial performance is behind plan for the financial year with operational pay budgets for the Directorates under-pressure because of the reliance on locum and agency staff to meet the unprecedented demand for services. The pressure on pay budgets has reduced as a result of action plans implemented by management teams, resulting in a supplementary pay bill of 1.1m in December. SIEP has under delivered for the third quarter and has resulted in the Trust having to report a larger than planned deficit. The Trust is continuing to maintain an appropriate balance between the challenging financial efficiency agenda and the desire to continue to invest in improving quality, patient experience and service performance. Detailed financial performance meetings have been held with Directorates which has resulted in a revised forecast deficit of c 7.4m by the year end. This remains the current forecast. The actual performance against this position will be monitored monthly to ensure there is no further deterioration in the position. During Quarter 3 the Trust carried out a self assessment using Monitor s Grip and Control checklist and have asked Northumbria Healthcare NHS Foundation Trust to carry out a peer review in order to confirm all possible actions are already in place and no further interventions could be implemented.

184 Click to go to index Declaration of risks against healthcare targets and indicators for by North Tees and Hartlepool NHS Foundation Trust Annual Plan Quarter 1 Quarter 2 Quarter 3 Quarter 4 Scoring Scoring Scoring Per Scoring Per Scoring Per Per Risk Per Risk Scoring Per Targets and indicators as set out in the Risk Assessment Framework (RAF) - definitions per RAF Appendix A Threshold Risk Risk Risk Risk Comments / Assessm Comments / Comments / Assessm Risk NOTE: If a particular indicator does not apply to your FT then please enter "Not relevant" for those lines. or target Performance Declaration Performance Declaration Assess Performance Declaration Performance Declaration Comments / explanations Assessment declared Assessment explanations ent explanations explanations ent Assessment YTD ment Framework Framework Framewo Framewo Framework Framew rk rk ork Key: must complete may need to complete Target or Indicator (per Risk Assessment Framework) Referral to treatment time, 18 weeks in aggregate, incomplete pathways i 92% 1.0 No % Achieved % Achieved % Achieved 0 0.0% Achieved DATA Unavailable at time of Board Submission 0 A&E Clinical Quality - Total Time in A&E under 4 hours i 95% 1.0 No % Achieved % Achieved % Not met Full exception rep % Not met Full exception report submitted 1 Cancer 62 Day Waits for first treatment (from urgent GP referral) - post local breach re-allocation i 85% 1.0 No 85.5% Achieved No Breach realloc 83.1% Not met Exception report su 85.0% Achieved 82.2% Not met Full exception report submitted Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - post local breach re-allocation i 90% 1.0 No 99.5% Achieved No Breach realloc 96.5% Achieved % Achieved 96.4% Achieved Cancer 62 Day Waits for first treatment (from urgent GP referral) - pre local breach re-allocation i 85.5% 83.1% 85.0% 82.2% Cancer 62 Day Waits for first treatment (from NHS Cancer Screening Service referral) - pre local breach re-allocation i 99.5% 96.5% 95.7% 96.4% Cancer 31 day wait for second or subsequent treatment - surgery i 94% 1.0 No 100.0% Achieved 96.8% Achieved 100.0% Achieved 100.0% Achieved Cancer 31 day wait for second or subsequent treatment - drug treatments i 98% 1.0 No % Achieved % Achieved 100.0% Achieved % Achieved 0 Cancer 31 day wait for second or subsequent treatment - radiotherapy i 94% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant Cancer 31 day wait from diagnosis to first treatmen i 96% 1.0 No % Achieved % Achieved % Achieved % Achieved 0 Cancer 2 week (all cancers) i 93% 1.0 No 92.9% Not met Full supporting inf 91.8% Not met Exception report su 93.0% Achieved 93.0% Achieved Cancer 2 week (breast symptoms) i 93% 1.0 No 94.4% Achieved 93.2% Achieved % Achieved 93.6% Achieved Care Programme Approach (CPA) follow up within 7 days of discharge i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant Care Programme Approach (CPA) formal review within 12 months i 95% 1.0 N/A 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0.0% Not relevant Admissions had access to crisis resolution / home treatment teams i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Meeting commitment to serve new psychosis cases by early intervention teams OLD measure - use until Q1 2016/1 i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Ambulance Category A 8 Minute Response Time - Red 1 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Ambulance Category A 8 Minute Response Time - Red 2 Calls i 75% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Ambulance Category A 19 Minute Transportation Time i 95% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 C.Diff due to lapses in care (YTD) i Yes 1 8 Achieved No local process i 0 18 Not met Exception report su 1 25 Not met Full exception rep 1 36 Not met Full exception report submitted 1 Total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review i C.Diff cases under review i Minimising MH delayed transfers of care i <=7.5% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Meeting commitment to serve new psychosis cases by early intervention teams NEW measure (scored from Q4 2015/16 i 50% % Not relevant 0.0% Not relevant 0.0% Not relevant 0.0% Not relevant 0 Improving Access to Psychological Therapies - Patients referred within 6 weeks NEW measure (scored from Q3 2015/16 i 75% % Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0 Improving Access to Psychological Therapies - Patients referred within 18 weeks NEW measure (scored from Q3 2015/16 i 95% % Not relevant 0.0% Not relevant 0.0% Not relevant 0 0.0% Not relevant 0 Data completeness, MH: identifiers i 97% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Data completeness, MH: outcomes i 50% 1.0 N/A 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 0.0% Not relevant 0 Compliance with requirements regarding access to healthcare for people with a learning disability i N/A 1.0 No 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0 N/A Achieved 0 Community care - referral to treatment information completeness i 50% 1.0 No 92.9% Achieved 92.9% Achieved Latest quarterly ave 93.3% Achieved Latest rolling Qtre 95.2% Achieved Latest rolling quarter Dec - Feb Community care - referral information completeness i 50% 1.0 No % Achieved % Achieved Latest quarterly ave 95.3% Achieved Latest rolling Qtre % Achieved Latest rolling quarter Dec - Feb 0 Community care - activity information completeness i 50% 1.0 No 94.4% Achieved 94.6% Achieved Latest quarterly ave % Achieved Latest rolling Qtre 91.4% Achieved Latest rolling quarter Dec - Feb Risk of, or actual, failure to deliver Commissioner Requested Services N/A No No No No No Date of last CQC inspection i N/A N/A 07/07/2015 No report received at time of submission 07/07/2015 Inspected in July, awaiting report at point of sub 07/07/2015 Inspected in July, awaiting report at point of sub 07/07/2015 Report received CQC compliance action outstanding (as at time of submission) N/A No No No No No CQC enforcement action within last 12 months (as at time of submission N/A No No No No No CQC enforcement action (including notices) currently in effect (as at time of submission N/A No No No No No Report by Moderate CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission i N/A No No No No No Exception Major CQC concerns or impacts regarding the safety of healthcare provision (as at time of submission i N/A No No No No No Overall rating from CQC inspection (as at time of submission) i N/A N/A N/A N/A N/A Requires improvement CQC recommendation to place trust into Special Measures (as at time of submission N/A N/A No No No No Trust unable to declare ongoing compliance with minimum standards of CQC registration N/A No No No No No Trust has not complied with the high secure services Directorate (High Secure MH trusts only N/A N/A N/A N/A N/A N/A Results left to complete: i Checks Count: i Checks left to clear: i OK Service Performance Score i Appendix 2

185 Appendix 3 North Tees & Hartlepool NHS Foundation Trust Meeting of Board of Directors 28 April 2016 Quarter 4, 2015/16 (1 January 2016 to 31 March 2016) Update Report Report of the Chief Operating Officer/Deputy Chief Executive 1. Introduction The following report provides an update of the key changes that have occurred since the time of the last formal report to Monitor; the report covers the period of quarter 4 (1 January 2016 to 31 March 2016) and reflects the requirements of the Risk Assessment Framework and the Licence Conditions. 2. Update Report 2.1 Continuity of Services Condition 1: Continuing provision of Commissioner Requested Services This condition prevents licensees from ceasing to provide Commissioner Requested Services, or from changing the way in which they provide Commissioner Requested Services, without the agreement of relevant commissioners. Update Issue: Momentum: Pathways to Healthcare The Momentum: Pathways to Healthcare Programme continues to summarise the direction for the Trust s Strategy and incorporates the ways in which services will be provided in the future and the facilities from which they will be delivered. Following the pause decision on the new hospital development project, the Clinical Services Strategy will provide the means of taking the Trust s strategic direction forward, and developing service specific strategies to enable the achievement of the significant and wide-ranging changes currently demanded. Considerable work has been undertaken during the quarter, incorporating extensive discussion with the clinical teams to develop a range of locality based options for the next two to five years. The results of the Phase 2 development work was presented to the Board in January 2016, including key recommendations. Phase 3 of the Clinical Service Strategy programme of work, the implementation stage, is now being taken forward. The outline plans have been fed into the one year operational plan and will supplement the five year sustainability and transformation plan required during the first half of Key to the successful development and delivery of the Clinical Services Strategy will remain the need for partnership working and collaboration between all members of the local health and social care economy. 1

186 Appendix Transformation Programme The Trust now has an established Transformation Directorate which will oversee the development and implementation of the Transformation Programme. The programme is overseen by the Transformation Committee which is now established as a formal committee of the Board of Directors. Development of training materials, templates and a handbook, utilising Sharepoint continues under the umbrella of a Project Assurance Office establishment project. This was finalised in January and trialled with a live project between January and March, in advance of implementation across all projects within the programme from 1 st April This will be underpinned by a comprehensive communications strategy. This project management approach will also be made available for use in support of projects outside the Transformation programme. The key projects currently allocated to the Transformation Programme are organised into two tranches referred to as Transition (1-2 years) and Transformation (longer term). The transitional projects are under review with the intention that wherever possible they are delivered, closed down or handed over to form part of Business as usual by the end of March, so that the programme can focus on the big ticket transformational agenda in the new financial year and supports delivery of the Clinical Services Strategy Better Care Fund (BCF) The Trust continues to be fully involved in this joint programme of work, as agreed between NHS England and the Local Government Association (LGA) that planned, for 2015/16, to re-allocate a number of existing health and social care funding streams to a local, pooled Better Care Fund used to support greater integration between health and social care services. The on-going Clinical Services Strategy development remains aligned with the planning for the implementation of the Better Care Fund (BCF). The strategic aims are linked to the principles of the Momentum programme, seeking to develop integrated care pathways and expand the portfolio of services to provide integrated care for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible aimed to reduce avoidable admissions by 15%. To affect these changes risk sharing is required and is to be agreed to ensure equitable sustainable outcomes and as such is being discussed at the North of Tees Partnership Board (NoTPB) unit of planning Capital Planning Infrastructure Project Following approval by the Department of Health of the 25m business case to replace and upgrade the ageing engineering infrastructure at the University Hospital of North Tees detailed planning work has commenced. Technical advisors have been appointed to support the Trust in the delivery of this business case with the first phase being the increased electrical capacity and replacement of the main electrical substations, this work will complete during Agreement has been reached with Northern Power grid to increase the electrical intake capacity to the hospital. Tender specifications for phase one are now complete and shall be issued in April 2016, construction of the new sub-stations shall commence in June Planning work to replace the existing 2

187 Appendix 3 energy centre, stand-by emergency generators and Combined Heat and Power plant will commence in April 2016 as the funding from the Department of Health becomes available Hospital Capital Planning Project The outcomes of the Clinical Services Strategy will require an internal reconfiguration of the estate at the University Hospital of North Tees to facilitate the requirements of the health needs of the population. Increased capacity and diagnostic facilities are all under consideration. A long-list option appraisal has been evaluated, an estate master-plan developed. Schedules of accommodation and departmental layout plans have been produced and are currently being refined and approved by clinical directors. Detailed cost assessments of the preferred option will be produced following completion of the clinical reviews. The conclusions of this work will inform a capital outline business case for Department of Health considerations and approval. The business case is anticipated to be submitted to the Department of Health during the summer of Hartlepool Health and Social Care Planning Programme The Trust is working with the Local Hartlepool Health and Social Care Planning Programme, taking part in a number of workshops to review the development of future local healthcare delivery. The workshops to date have included; Services for the frail and elderly Primary and Community based services Urgent Care Services Child and Health and Wellbeing Agenda including maternity and early years Mental Health The workshops have been very successful, promoting constructive discussions and ideas for future service delivery. Actions and Next Steps Continue to support the delivery of the Clinical Services Strategy and Hartlepool Health and Social Care Planning Programme, with the aim to further develop integrated care pathway development and provide local health care infrastructures to support health and social care challenges. The Trust also awaits the final report from the Local Authority due for release in Summer Update Issue: Assisted Reproduction Unit The Trust has reached agreement with the Hartlepool Borough Council to enter into engagement and consultation with key stakeholders about the future of the assisted reproductive unit at the University Hospital of Hartlepool. This agreement has been approved by the High Court, on substantially the same terms as proposed by the Trust in February We look forward to working with key stakeholders about the future of the ARU. 3

188 Appendix NHS Foundation Trust Condition 4: NHS Foundation Trust Governance Arrangements This condition enables Monitor to continue oversight of governance of NHS Foundation Trusts. NHS Foundation Trusts should report to Monitor any further information that could reasonably be regarded as having the potential to affect compliance with the organisation s governance licence condition. Update Issue: Board Appointments The Transformation Change Director left the Trust on 15 January The Director of Human Resources and Education has assumed responsibility for the function of Transformation. A Medical Director has been appointed to replace the existing postholder who will be standing down from this role during the summer. The Director of Finance, ICT and Support Services has tendered resignation and will be leaving the Trust on 29 April The former Deputy Director of Finance has been appointed as Acting Director of Finance on 15 February 2016 and the role of Chief Information Technology Officer was appointed to on 7 March (due to join the Trust in July 2016). Update Issue: Governors A nomination has been instated as Appointed Governor for Teesside University, and the Trust received notification that the current Governor would be stepping down as the Appointed Governor for Newcastle University, with no immediate replacement Membership The Trust membership at 31 March 2016 was 11,139, comprising 5,898 public members, (incorporating 211 non-core other area public members), and 5,241 staff members. Work continues to improve member engagement and involvement of the Governors with member recruitment to increase representation from a wider group, which will continue into 2016/17. The Trust continues to communicate with and inform members regularly regarding key issues or developments, via , social network sites, its website and quarterly member magazine, Anthem. A bulletin from the Chairman is sent out following each Board of Directors meeting to keep members updated with key issues and developments. The programme of quarterly member events continue, including interactive market place events showcasing the work of the Trust..A dedicated section on the website and in Anthem has been created to highlight the work of our Governors. 4

189 Appendix 3 Actions and Next Steps: The Trust will continue to recruit new members maintaining its target level of 6,000, as well as improving engagement with wider groups of the population. A new contract will commence on 1 May 2016 for a membership database provider Quality Governance Standardised Hospital Mortality Indicator (SHMI) SHMI is reporting higher than expected at in the most recent Health and Social Care Information Centre rolling 12 month period (October 2014 to September 2015). However, the value has reduced by 3.15 points from the previous release (July 2014 to June 2015) value of Hospital Standardised Mortality Ratio (HSMR) The Trust acknowledges that the HSMR value is higher than expected and has implemented a number of processes/reviews to gain a greater understanding to the quality of care being given to patients and the process, infrastructure and governance to support change. There are still a small number of remaining actions to implement, but once these have been embedded into standard practice, the Trust should expect to see further improvements in the HSMR value. The HSMR value has decreased significantly from (January 2015 to December 2015) to (February 2015 to January 2016), this value continues to be outside the as expected range, but with further process to come on line, this should fall within the expected range this year; the national mean is 100. The Trust s rolling 12 month HSMR value has steadily been reducing since the 12 month rolling period of April 2014 to March 2015, when the value was at its highest with , the current value of represents a fall of points. A robust governance structure surrounds improvement actions around mortality. This action plan is governed at the bi- monthly Keogh Delivery Group meeting, providing updates around each key area. The Trust has implemented measures for improvement and targets for reducing the Trust s mortality. The areas included are Frail Elderly, Specialist Palliative Care, Clinical Coding, Community Acquired Pneumonia, Sepsis, Acute kidney Injury (AKI) and working with GPs regarding mortality. Significant progress and improvements have been made in the current medical documentation which will allow for more accurate recording of main diagnosis and improved co-morbidity coding. A review of the current weekly mortality meetings has resulted in a change of format and increase in frequency. The Trust continues to focus upon the diagnostic group related to Pneumonia and Sepsis as monitored by the Clarity CAP/Sepsis project team. 5

190 Appendix 3 Work is ongoing with GPs addressing the high proportion of deaths in short stay patients, and an audit concluding around mortality associated with weekend admission. Actions and Next Steps for SHMI and HSMR: Advancing Quality Alliance (AQuA) has provided the Trust with independent support in January and February 2016 where the focus of work is around (out of hours) Sepsis and Acute Kidney Injury (AKI). This will include a review of current pathways and best practice, looking at the Trust s mortality data, conducting clinical reviews and reviewing the organisation s safety culture. Update Issue Trakcare (Patient Administrative System) The initial problems experienced with data quality and reporting from the new Patient Administrative System TrakCare which went live in October 2015 have started to ease, with a full Commissioning Data Set (CDS) having been produced at month 4. An exercise to validate the data has commenced to ensure that future service performance and operational indicators are robust. Actions and Next Steps Further validation and robust governance structure are in place to ensure the quality of data and reporting from the system is robust. Update Issue NHS Foundation Trust General Condition 7: Registration with the CQC The Trust underwent an announced inspection of its services by the CQC in July The report which was generated following the inspection identified there were areas within the organisation which required improvement and other areas where it was recommended the Trust reviewed services. The Trust was rated as good for safe, caring and responsive and requires improvement for effective and well led. Fourteen areas were identified within the report as must do s with further areas as being recommended to consider review. A comprehensive action plan was developed following the quality summit held in January 2016 which was by led the CQC. The Trust is currently implementing the action plan with on-going monitoring against delivery being overseen by an internal Project Board led by the Acting Director of Nursing, Quality and Patient Safety. 3. Conclusion and Recommendation Monitor is asked to note the update report, which provides supplementary information within the requirement of the Licence Conditions and Risk Assessment Framework with regard to events having occurred within the quarter 4 period. 6

191 Click to go to index List of Governors' elections for North Tees and Hartlepool NHS Foundation Trust Appendix 4 The Risk Assessment Framework requires a quarterly report of elections held and results as below: Constituency Type Full Name of Constituency No. of candidates No. of Votes cast No. of Eligible Turnout Date of election voters Elections held in the quarter ending 31 Mar 2016 NIL RETURN Example Public North West ourtown 4 1, % 8,230 01/05/2010 WTE 1 WTE 2 WTE 3 WTE 4 WTE 5 WTE 6 WTE 7 WTE 8 WTE 9 WTE 10 WTE 11 WTE 12 WTE 13 WTE 14 WTE 15 WTE 16 WTE 17 WTE 18 WTE 19 WTE 20 WTE 21 WTE 22 WTE 23 WTE 24 WTE 25 WTE 26 WTE 27 WTE 28 WTE 29 WTE 30 WTE 31 WTE 32 WTE 33 WTE 34 WTE 35 WTE 36 WTE 37 WTE 38 WTE 39 WTE 40

192 Click to go to index Appendix 5 In Year Governance Statement from the Board of North Tees and Hartlepool NHS Foundat The board are required to respond "Confirmed" or "Not confirmed" to the following statements (see notes below) Board Response For finance, that: The board anticipates that the trust will continue to maintain a financial sustainability risk rating of at least 3 over the next 12 months. The Board anticipates that the trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return. For governance, that: A B The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards. Otherwise: The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per the Risk Assessment Framework, Table 3) which have not already been reported. Consolidated subsidiaries: Number of subsidiaries included in the finances of this return. This template should not include the results of your NHS charitable funds. Signed on behalf of the board of directors Signature Name Signature Name Capacity [job title here] Capacity [job title here] Date Date Responses still to complete: 5 Notes: Monitor will accept either 1) electronic signatures pasted into this worksheet or 2) hand written signatures on a paper printout of this declaration posted to Monitor to arrive by the submission deadline. In the event than an NHS foundation trust is unable to confirm these statements it should NOT select 'Confirmed in the relevant box. It must provide a response (using the section below) explaining the reasons for the absence of a full certification and the action it proposes to take to address it. This may include any significant prospective risks and concerns the foundation trust has in respect of delivering quality services and effective quality governance. Monitor may adjust the relevant risk rating if there are significant issues arising and this may increase the frequency and intensity of monitoring for the NHS foundation trust. The board is unable to make one of more of the confirmations in the section above on this page and accordingly responds: C

193 Click to go to index In Year Organisational Health Indicators for North Tees and Hartlepool NHS Foundation Trust The Risk Assessment Framework (table 7) sets out that Monitor will use executive team turnover as one of the potential indicators of quality governance concerns. Please provide the information requested below and ensure that any changes are explained in your commentary: Executive Directors units Actual For Quarter ending 30-Jun-15 Actual For Quarter ending 30-Sep-15 Actual For Quarter ending 31-Dec-15 Appendix 6 Total number of Executive posts on the Board (voting) Posts Number of posts currently vacant Posts Number of posts currently filled by interim appointments Posts Number of resignations in quarter Resignations Number of appointments in quarter Appointments Actual For Quarter ending 31-Mar-16

194 Appendix 7a North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Governance Statement Supporting Information C difficile Standard Quarter /16 (1 January to 31March 2016) Report of the Chief Operating Officer/Deputy Chief Executive The following target (after application of thresholds) has not been met during the period of monitoring (Quarter 4) which has led the Board to review the current position, actions to date and risks to future compliance and assurance before signing the Governance declaration stating on-going compliance. All targets refer to the Monitor Risk Assessment framework, around healthcare and other standards that the Trust shall put in place and comply with, for the purpose of monitoring and improving the quality of health care provided by the Trust. This is in line with Monitor NHS Provider Licencing conditions The following report provides supplementary information detailing the current position against the Clostridium Difficile target, the root cause analysis which has taken place to identify issues, the mitigation and proposed actions to reduce future risk against delivery of this standard 1. Standard Clostridium Difficile Infection (CDI) 13 cases 2. The Issue During the quarter 2 period the Trust exceeded the annual CDI trajectory as set by the Department of Health (and local contractual commitments), and subsequently at the end of Quarter 4 (1 January to 31 March 2016) a further 11 cases were reported against a trajectory for the Quarter of 3. This brings the total for the year to date to 36 cases. The Trust is committed to continuing the work to reduce the number of further Trust attributed CDI cases, as it has done in the previous two reporting years, therefore full root cause analysis (RCA) has continued to be completed for each case in order to identify the reasons/causative factors for these cases and to ensure appropriate mitigation plans are implemented, to reduce the risk of repeated themes in cases. This process is consultant led, multidisciplinary and completed within 3 working days of notification. A number of cases associated with one ward over a short time period has been investigated as an outbreak as genetic typing has shown the cases are linked. This accounted for 4 of the reported cases. An action plan for the outbreak was developed and all actions will be complete by the end of April 2016.

195 As chart 1 indicates, despite the breach of trajectory, the Trust has made significant improvements against the CDI target since April 2007, with a more challenging target for this year of 13 cases following a successful year in 2014/15. The 36 cases to date still represent an 83% reduction since when the Trust reported 210 cases (n = 174). Chart 1: CDI performance April 07 March 16 A significant amount of work has been undertaken to reduce the risk of CDI across the patient pathway, including collaborative work with Commissioners and GPs to improve prescribing in primary care, and work with care homes to improve knowledge in staff and provide training and support on cleaning and management of symptomatic patients. The impact of this work can be seen in the reduced number of community cases as shown in Chart 2. Chart 2: Non trust attributed cases This report gives actions to date and the agreed mitigation plans. 3. Work to Date Governance and Assurance A comprehensive review of performance, reporting, testing and actions taken was produced as a formal response to the communication from Monitor on 15 September This report has also been shared with commissioners to provide assurance that appropriate actions are being taken

196 A Trust action plan is developed and reviewed by a multidisciplinary task and finish group to ensure that actions are identified and monitored and any barriers to implementation can be escalated appropriately, reporting to the Healthcare Associated Infection (HCAI) Operational Group. The HCAI Operational Group continues to meet and review risks, action and performance related to CDI. This group reports to the Infection Control Committee which meets quarterly and has Non Executive Director chairmanship and members. All actions arising from RCA are entered on to an action tracker system which is discussed and followed up at the Operational Group. As each trust attributed case is considered a untoward incident the process for monitoring and challenge to the RCA is under review with the likely process going forward being presentation by the clinical team at the Incident Review Panel, unless the case is considered to be a serious incident, in which case it will be presented to the SUI panel following an investigation led by an independent person. External reviews in July and September 2015 provided assurance that no major actions were required whilst making some recommendations for actions which may assist with improved performance. These actions have been incorporated into the trust action plan. 4. Actions to Date and On-going Monitoring The Trust CDI action plan is updated at each task and finish group, reviewed by the Operational Group and received by the Infection Control Committee. The updated action plan is shared regularly with commissioners and governed via the Patient Safety and Quality Standards Committee. The following areas are covered in detail; Environmental Cleanliness An enhanced cleaning service is maintained to ensure cleaning and fogging of vacated rooms is carried out appropriately, with additional cleaning of high risk touch points on key wards. A proactive programme of cleaning and fogging with hydrogen peroxide vapour has been developed and is underway. The Trust established an in house mattress decontamination service in 2014/15 and this has contributed to improved standards in the cleanliness of this equipment. A project to improve cleaning of patient equipment by nursing staff is also underway and the Trust is piloting use of ultra violet light decontamination to enhance the current programme. Maintenance of the programme during the winter months has been problematic given the levels of increased activity and bed occupancy, however all of the additional equipment cleaning continues and additional daily touch point cleaning is in place on all high risk wards. Reactive cleaning and fogging of rooms housing patients known to have CDI has continued throughout the winter. Point of Care Practices new staff and public posters, displays and information cards have been developed to further raise awareness of the importance of hand hygiene to all and hand hygiene was the focus of the events held around International Infection Prevention Week in October Unannounced hand hygiene observation has continued and has seen an improvement in compliance across all groups of staff. Over 100 hand hygiene champions, including the Chief Executive were recruited in May 2015 and a programme of activities is planned for spring onwards. From 1 st July 2015 a league table of hand hygiene compliance has been shared with clinical areas monthly and areas with sustained good performance receive a certificate and prize each quarter. Overall hand hygiene across the Trust has improved in the last 9 months with overall compliance being in excess of the 95% internal target for 6 out of the 9 months. General practices are reviewed daily on wards with confirmed cases of CDI during the daily review visit by a infection prevention and control nurse. Isolation Facilities as single rooms are limited and much sought after a flow chart to assist clinical decision making has been reviewed and revised. The use of single rooms is regularly reviewed by the infection prevention and control team. The most recent audit identified that

197 19/93 (20.4%) single rooms reviewed were occupied by patients who did not require a single room. However on each of the 19 occasions this was because of overall activity and a plan was in place to house the patients appropriately when alternative accommodation became available. Another recent audit of isolation facilities and the isolation policy in October 2015 identified that all patients with diarrhoea were appropriately placed in single rooms which was an improvement on the previous audit. Facilities are constantly under review and all potential projects to increase the number of single rooms discussed at HCAI Operational Group. The use of the winter resilience ward increased the availability of isolation facilities by 8 rooms and during reviews of single room usage in winter there has been no issue identified relating to not being able to isolate a patient with diarrhoea. Antibiotic Prescribing The Trust antibiotic guideline has been reviewed and made available to staff. Updated pocket sized guides are being produced for prescribers as a reference tool and use of an application for smart phones is being explored. The Trust audit programme has been reviewed in line with the recommendations of the updated Start Smart Then Focus document with all audits streamlined and reporting processes agreed. To improve the collection of audit data hours for a pharmacy technician are in place since January 2016 to support the antimicrobial pharmacist. This will increase the number of audits completed and also facilitate follow up of actions from audits. Immediate feedback is provided to the ward team following the audit and an overview of audit findings is discussed at the Infection Control Committee. The Trust now has a number of Antibiotic Guardians as part of a national programme to promote antibiotic stewardship. Each directorate has an antibiotic champion and a revised Trust Antibiotic Group will operate from May Current Position and Next Steps Review of the information from the national healthcare associated infection data capture system shows that a national increase in cases has been seen with 68% (75/110) of non-teaching acute Trusts having breached their annual trajectory (subject to validation). A national increase in cases of 6% was seen in and Public Health England has stated that this increase is under investigation. Of 155 Trusts of all specialities in England 70 have reported a deterioration in performance this year. In line with this national picture NHS England has published trajectories for 2016/17 which will remain the same as 2015/16 meaning that the Trust continues to have a trajectory of 13 cases for the year. Clearly this will be a great challenge but the Trust will strive to reduce infection in patients. The work undertaken to create a winter resilience ward will mean that the full decant programme is planned for April 2016 onwards which will give the Trust a good start to the new reporting year. The focus on good basic practices and sound prescribing choices will be promoted during 2016/17 to maintain efforts to reduce the number of additional cases. In addition the Trust will participate in a 90 day improvement programme facilitated by NHS Improvement, along with 29 other Trusts, commencing in April The focus of improvement work will be CDI and there is an opportunity to learn from the other Trusts at the 4 learning events planned. 5. Conclusion The Trust is committed, despite the fact that the trajectory for 2016/17 will once again be challenging, to taking all measures appropriate to reducing the risk of C difficile infections across both acute and community settings. The challenge in reducing the hospital acquired CDI numbers is not to be underestimated and it is recognised, with a legacy of successful performance that further and continued focus will assist with controlling and managing potential numbers.

198 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors 28 April 2016 Appendix 7b Governance Statement - Supporting Information A&E 4 Hour Standard Quarter /16 (1 January to 31 March 2016) Report of the Chief Operating Officer/Deputy Chief Executive The following target (after application of thresholds) has not been met during the period of monitoring (quarter 4 and year end 2015/16) which has led the Board to review the current position, actions to date and risks to future compliance and assurance before signing the Governance declaration stating on-going compliance. All targets refer to the Monitor Risk Assessment Framework, around health care and other standards that the Trust shall put in place and comply with, for the purpose of monitoring and improving the quality of health care provided by the Trust. This is in line with Monitor NHS Provider Licencing conditions. The following supporting information details the current position against the A&E 4 hour Standard, which has been under achieved against the expected standard in Q4, the root cause analysis which has taken place to identify issues, the mitigation and actual and proposed actions to reduce future risk against delivery of this standard. 1. The Standard A&E 4 Hour standard 95% 2. The Issue During the quarter 4 period, 1 January to 31 March 2016, the Trust has under-achieved against the A&E 4 Hour Standard reporting at; 92.04% against the 95% standard during quarter 4 The Trust is committed to consistent achievement against all access targets and has a good track record of delivering in line with the national requirements. A full and timely review of the key issues has taken place to identify the reasons/causative factors for the recent drop in performance, to ensure appropriate mitigation plans are implemented to pull the Trust position back in line with the set targets and provide a level of assurance to the Board of Directors with regard to on-going compliance. 3. Current Position 3.1 A&E 4 Hour Standard Performance The Trust has under-achieved against the A&E 4 hour standard in Q4 for the second time this financial year which has resulted in an under achievement of this target in three quarters of any four-quarter period having breached in Q4 2014/15 and Q3 2015/16. 1

199 Appendix 7b As Table 1 indicates, historically the Trust has consistently performed well against the A&E 4 hour standard, reporting within or above the national performance between the periods Q1 2013/14 to Q3 2015/16 (latest available quarterly data), with Q4 2014/15 the only quarter within this period where the Trust under achieved against the standard. However, a number of pressures within the organisation during the Q3 2015/16 period has resulted in the Trust under achieving the standard in October (93.09%) and November 2015 (92.9%), which, despite December reporting at 96.47%, ultimately impacted on the quarterly performance, resulting in an overall position of 94.13%. This seasonal pressure has continued throughout quarter 4 which has resulted in an under achievement against the quarter 4 position reporting at 92.04% with attendances and admissions to A&E unprecedented, also with the acuity of patients remaining high. Table 1: Historical A&E 4 hour standard performance A & E 4 Hour Standard Q1 2013/14 Q2 2013/14 Q3 2013/14 Q4 2013/14 Q1 2014/15 Q2 2014/15 Q3 2014/15 Q4 2014/15 Q1 2015/16 Q2 2015/16 Q3 2015/16 National Position NT&HFT In addition, a new Patient Administrative System TrakCare went live in October Whilst a success, as with all new systems, there was some initial data recording and reporting issues, which impacted on patient flow during quarter 3 which continued into quarter 4, as staff learnt the systems functionalities. This risk factor must be considered in the context of the under achievement given the additional operational pressures when contextualizing the performance position. As chart 1 indicates, nationally there has been a gradual reduction in performance since the decision was made to re-set the target at 95% in 2010, with the 2014/15 position indicating the steepest drop in the 10 year period and Q3 and Q4 2015/16 struggling to achieve. Chart 1: England 10 year trend in A&E 4 hour standard performance As reported within the national media, and highlighted by the Department of Health through weekly publications, the NHS has experienced significant pressures through the winter period which has 2

200 Appendix 7b impacted on the delivery of emergency services, with one of the main indicators being the decline of performance against the A&E 4 hour standard for the majority of acute providers. As table 2 below indicates, the initial decline in performance was evident across the North East in Q3 2014/15, with a further decline in Q4 2014/15 dropping to 92.1%, with only one local organisation meeting the standard. The Trust position improved during Q1 and Q2 2015/16, achieving the 95% standard, with a similar trend across the region, despite the national average remaining below the 95% standard. All Trusts across the region under achieved in January The table also shows that the England average against the A&E 4 hour standard has remained below the 95% standard throughout 2015/16 with the latest February position reporting at 87.8%. A comparison to the regional and national position for Q4 and 2015/16 can not be made as the data has not been published at the time of this report. The NHS England published statistical report for the A&E 4 hour standard ( indicates that only 5 out of the 138 acute providers with a Type 1 A&E department achieved the standard in February 2016 (latest available data). The Trust reported in 22 nd position. Table 2: NT&HFT benchmark position against the A&E 4 hour standard (latest available data) *Note: Source figures It is evidence that the whole system is under pressure as indicated in the Ambulance Handover and Turnaround times. Ambulance handovers greater than 30 and 60 minutes are monitored within the commissioner reports on a monthly basis. In March the Trust reported ambulance handovers greater than 30 minutes and 6 greater than 60 minutes. The Trust has disputed a number of these handover delays and is in the process of validating. In comparison, the North East average handovers greater than 30 minutes reported at (range ), with the average over 60 minutes reporting at 42 (range 1-153). The Trust s overall performance in March indicated 95.37% of ambulance handovers (valid) within 15 minutes. Given the recent national publicity around delays in emergency access, the delivery of efficient ambulance turnaround times is currently high profile across the health economy. The Trust reported 87.2% ambulance turnaround times (valid) within 30 minutes during March, in comparison the North East s position is at 81.4% with performance ranging between 68.8% and 92.9%. The Ambulance turnaround time is the measurement of the time between the Ambulance arriving at the hospital (electronically captured at base) and the Ambulance leaving the hospital site (electronically captured at base); post the completion of electronic documentation within the A&E department. A detailed review of breaches has been undertaken to influence change, with trends monitored by reasons, hour of day, day of week etc. to identify key issues. Q4 breach reasons are shown in Table 3 below, however it should be noted this is the key reason recorded against the breach; breaches can 3

201 Appendix 7b have a number of underlying causes within the pathways. The main reasons highlighted below include bed waits/ pressures (28%), clinical need (18%) and delays within the A&E department (39%). Table 3: Quarter 4 Key Breach Reasons Breach Reason Q4 2015/16 % of Breaches A&E Delay % Ambulance delay % Clinical reason % EAU Bed Wait % Ward bed wait % AMBU bed wait % Bed waits % Investigations % Joint delay with A&E and Bed wait % Joint delay with A&E and investigations % Joint delay with A&E and specialty % Unable to determine % Waiting for specialty doctor/team % Paed bed wait % Not recorded % Awaiting validation % Wait for 1st Assesment % Wait for bed % wait for NHS transport % wait for specialty doctor/team % Other % TOTAL 1769 Breach Reason Q4 2015/16 % of Breaches A&E Delay % Ambulance delay % Clinical reason % Bed Waits % Investigations % Joint delay with A&E and Bed wait % Joint delay with A&E and investigations % Joint delay with A&E and specialty % Unable to determine % Waiting for specialty doctor/team % Not recorded and awaiting validation % Wait for 1st Assessment % Wait for NHS transport % Other % 4

202 Appendix 7b TOTAL 1768 A review of the activity at the North Tees A&E department (Type 1) over the individual months within the Q4 period, see Table 4, gives an indication of the pressures within the system during the period of under-achievement. Table 4 below demonstrates that attendances were higher during January (n=310), February (n=689) and March (n=222) in comparison to the same period last year. Admissions showed a similar trend with increased levels seen within January with a surge in February and March, with high occupancy in resuscitation areas and major area, an indication of the acuity of the patients coming through the department. The increase in conversion rate to admissions inevitably impacted on the pressures within the department and attributed to the extended length of pathways. Table 4: North Tees A&E department (Type 1) Activity January to March 2016 NT A&E activity Jan-15 Jan-16 Diff +/- Feb-15 Feb-16 Diff +/- Mar-15 Mar-16 Diff +/- Attend Admissions Conversion to Admissions 26.71% 26.15% % 26.83% % 26.23% 0.92 The activity trend also indicates an increase in activity within the A&E department later in the day which ultimately impacts on activity and patient flow out of hours. Chart 2 depicts the level of activity within the department over a 24 hour period showing continuous pressure. The departments level of activity peaks between the hours of 18:00 and 19:00 which inevitably impacts on patient flow and clinical oversight out of hours. This is further addressed within section 4. Chart 2: A&E Attendances by hour April to March 2015/16 Alongside regional peers, the Trust has experienced significant emergency pressures through the latter end of 2015/16 and particularly during Q3 and Q4, further impacting on the A&E 4 hour performance within the period. 5

203 Appendix 7b The quarter 4 bed average occupancy position reflected pressures beyond the A&E department, with the bed occupancy across the organisation indicating a significant increase on last year across the quarter (see Table 5). The recommended occupancy to operate efficient pathways is 85%. Whilst the average bed occupancy is a proxy indicator it masks the specialty level surges. Table 5: Bed Occupancy January to March 2015/16 Jan-15 Jan-16 Diff +/- Feb-15 Feb-16 Diff +/- Mar-15 Mar-16 Diff +/- Bed Occupancy 91.85% 94.07% 2.22% 92.88% 93.85% 0.97% 93.49% 95.22% 1.73% Staffing management, during periods of increased sickness absence and availability, have further impacted on emergency service delivery, which has been reflected in the organisation s NEEP status reporting between level 3 and 4 on a significant number of days within the quarter 4 period and on two occasions reporting NEEP 5. Chart 3 provides an overview of the escalation beds (overnight and 24 hour provision) open on a daily basis between January to March 2016, which peaked at 81 in the period, with the daily NEEP escalation levels indicating the prolonged periods of level 3 and 4. Chart 3: Escalation beds and NEEP levels January to March 2015/16 Whilst delayed discharges have remained consistent, at an average rate of 8 per day (equating to 521 associated beds days within the January to March period), peaks during admissions surges weekends 6

204 Appendix 7b and bank holiday periods, have created intense pressure on bed occupancy, exacerbated by closure of beds in nursing and residential care homes. Negotiation and flexibility of protocols proved beneficial but were insufficient to overcome the issues encountered. The Trust continues to work closely with the local authorities and social care to improve assessment, placement and discharge processes, with the aim to expedite timely safe discharge. The Trust s emergency preparedness and resilience plan, in addition to numerous supplementary measures, has been fully implemented to support the delivery of emergency services and maintain the safety and quality of patient care. Additional daily governance structures have been implemented to support core services, with the aim to reinforce the front line resilience. The next section outlines the work to date, the current governance processes and the future plans for intense management of the A&E 4 hour standard. 4. Actions to Date The Trust has consistently monitored and reviewed emergency care pathway delivery with the aim of improving performance against the emergency care standards. To some extent, performance was hindered during Q3 and into Q4 when the Trust implemented a new Patient Administration System. Difficulties were experienced with information flows, which ultimately impacted on service delivery and decision making. A significant amount of work has been, and continues to be undertaken within the emergency care pathways to avoid admissions, manage patient flow and discharge processes. Chief Operating Officer (Director) led breach analysis meetings commenced every morning which not only identified current issues, but also reviewed breaches to gain assurance that procedures and processes were being followed with regards to validating and learning lessons from delays to flow. These continue, now governed through the Manager on Call. Key themes around delays are displayed in Table 3 above however; further analysis demonstrates delays to pathways were a result of; out of hours activity and acuity, delays within the majors stream in A&E, staffing cover overnight/out of hours, discharge processes and bed occupancy The Trust launched the Emergency Care Collaborative in 2013, setting up a number of workstreams to review pathways such as majors, minors and Paediatric A&E pathways, together with specialty specific pathways such as fracture neck of femur, emergency patient flow and mental health pathways. This was supported by a number of Rapid Improvement Work Shops, with clinical leads for each key project. Examples of the pathway improvements include; see and treat for the minors stream of patients, the introduction of a streaming nurse to ensure patients are directed to the appropriate service if necessary i.e. Walk in centres, improved rapid access to mental health, physiotherapy and occupational health teams, escalation procedures based on RAG rating, rapid assessment and treatment (RAT) area supporting direct admissions, direct admissions for specific clinical pathways i.e. Stroke, access to Trauma practitioners to improve major trauma pathways i.e. Fracture Neck of Femur. A pilot of GP support also commenced in A&E which initially only covered weekends (commenced April 2015) with further funding secured to continue with this service including weekdays during winter until March The Trust implemented the perfect week in October 2015, as recommended by NHS England in Breaking the Cycle (April 2015) guidance which allowed a deep dive into discharge processes. As a result of this, and breach analysis, a number of key actions were agreed and implemented, including; 7

205 Appendix 7b A kick start January 2016 week further consolidated learning with an emphasis on discharge processes and flow. Although improvement in pathway management has been evident, further work continues to review and improve patient flow during periods of surge. A focused plan is in place to tackle Escalation and immediate response and clear deliverables Redesign of operational model and bed configuration to limit points of access Clinical oversight hospital at night model out of hours Review of resources to support patient flow, decision making and autonomy Manager on call rota review Use and facilitation of clinical skills in the workforce Pilot of Advanced Practitioner in A&E Full workforce infrastructure review A major project on discharge processes has commenced including; o Infrastructure and resource review commenced 6 day working pilot o Data gathering and intelligence management dashboard in place o Patient choice policy review commenced 1 April 2016 o Outcomes across the system linked to Better Care Fund outcomes Despite discussions with commissioners to improve system resilience, with recognition that a review of whole system delivery was required to support emergency care pathway provision, and to ensure financial support for the cost of the impact on Acute Trust resilience, support has occurred but wider system response and resilience remains a risk to the Trust. The Clinical Director of Emergency Assessment Unit and Ambulatory Care has been seconded to the Emergency Care Intensive Support Team (ECIST), to support country wide reviews and enable the sharing of good practice and bring back lessons that can be learnt. 5. Governance The delivery of the emergency care standard is led by the Chief Operating Officer and Medical Director. The emergency care standard is monitored on a daily basis and shared across the organisation. The performance against the A&E 4 hour standard is reported on a monthly basis within the Corporate Dashboard and Board reports, shared with all levels of the organisation and published on the Trust s web site. The lack of further supporting information flows has proven difficult therefore adding a risk into the system and impacting on decision making. The governance structure is through the following groups; Planning, Performance and Compliance Committee In line with the Monitor Risk Assessment Framework (RAF) requirements, the Trust continues to ensure the organisation is well led, having robust processes in place to support the delivery of quality, sustainable services and all core performance standards led by a Non-Executive Director and support by a key working group infrastructure including: The Business Performance, Planning and Delivery Group Emergency Care Collaborative and sub groups 8

206 Appendix 7b A&E Operational Group A&E Directorate Meeting Trust Resilience Forum The Trust is a proactive member of the Urgent and Emergency Care Network, Vanguard Programme Board and SRG s and uses such to influence change. 6. Next Steps The Trust continues to monitor the performance position on a daily basis, with the aim to gradually recover the position during Q1 2016/17, notwithstanding system wide pressures. A trajectory improvement plan has been agreed with CCGs. It is recognised further work is required to improve system resilience, which will continue to impact on the delivery of emergency care standards, and as such is highlighted as a risk to delivery. 7. Conclusion The Trust is committed to delivering against all the emergency care standards, through efficient, streamlined patient pathways. It is recognised this can only be achieved if robust, processes and procedures are in place to support capacity planning, standardised pathway management and the ability to flex resources at times of pressure, in and out of hours. A number of factors are thought to have impacted on the achievement of the 4 hour A&E standard during the last two quarters of 2015/16, notwithstanding winter pressures. The implementation of the new Patient Administrative System TrakCare during Q3 is known to have impacted on patient flow which continued into quarter 4. In addition to the wide array of system issues, it is also recognised that close working with external stakeholders is a key element to ensuring patients are fully informed of the appropriate emergency services, therefore reducing avoidable pressures within the emergency departments. The lack of control over the activity coming through the doors of the A&E department is therefore recognised as an on-going risk. The Trust will continue to work closely with the commissioners and NHS North East Team to review emergency care delivery and address any issues at an early stage, with the aim to eliminate avoidable attendances and admissions. A&E performance will continue to be closely monitored through the internal governance processes, with robust escalation frameworks in place to support on-going compliance. A robust internal action plan is in place supported by governance processes, however, the internal programme of work, whilst appropriate and radical, will not negate the pressure in the system. Whilst the Better Care Fund (BCF) programme of work is in place, to reduce avoidable admissions and manage timely discharges, the confidence in impact is slim, supported by research from the Kings Fund, HSJ and Serco that such will only, at best, flat line the demand. Julie Gillon Chief Operating Officer/Deputy Chief Executive April

207 North Tees and Hartlepool NHS Foundation Trust Meeting of the Board of Directors April 2016 Appendix 7c Governance Statement - Supporting Information Cancer Standards Quarter /16 (1 January 31 March 2016) Report of the Chief Operating Officer/Deputy Chief Executive The following target (after application of thresholds) have not been met during the period of monitoring (quarter 4) which has led the Board to review the current position, actions to date and risks to future compliance and assurance before signing the Governance declaration stating on-going compliance. All targets refer to the Monitor Risk Assessment Framework, around health care and other standards that the Trust shall put in place and comply with, for the purpose of monitoring and improving the quality of health care provided by the Trust. This is in line with Monitor NHS Provider Licencing conditions. The following supporting information details the current position against the 62 day Urgent Referral to Treatment Standard, the root cause analysis which has taken place to identify issues, the mitigation and proposed actions to reduce future risk against delivery of this standard. 1. Standards Cancer 62 day referral to treatment standard 85% 2. The Issue During the quarter 4 period, 1 January to 31 March 2015/16, the Trust has under-achieved against the following standard Cancer 62 day referral to treatment Standard; reporting at 82% against the 85% standard (provisional position until final published figures in May 2016) The Trust is committed to consistent achievement against all cancer targets and has a good track record of delivering above the national and local requirements. A full and timely review of the key issues has taken place to identify the reasons/causative factors for under-achievement against the cancer standards, with appropriate mitigation plans implemented to address key issues, with the aim to pull the Trust position back in line with the set target and provide a level of assurance to the Board of Directors with regard to on-going compliance; notwithstanding the system wide issues described in this report requiring action to enable consistent delivery. 3. Current Position 3.1 Referral Increases North Tees and Hartlepool NHS FT (NT&HFT) has continued to see an increase in Cancer 2 week referrals over the 2015/16 period, with year-end position indicating a further 5% (n=547) increase in 1

208 Appendix 7c comparison to 2014/15. Chart 1 below provides an overview of the increase in referrals from April 2013 to March 2016 (including Breast Symptomatic). The continued increase in referrals has been influenced by both the NICE revised cancer referral guidelines and Be Clear on Cancer Campaigns, with significant peaks in demand evident during periods when the campaigns are running. The campaigns during 2015/16 included Oesophago Gastric cancers, Breast cancer in over 70 age group and Blood in Pee, with a Respiratory cancer awareness campaign due to run between July and August Chart 1: Cancer 2 Week Referrals (April 2012 March 2016) Despite the increase in referrals, historical evidence indicates the conversion rate to confirmed cancers (62 day pathway) have reduced overall at approximately 8% (n= 892 with cancer diagnosis/11, 452 number of referrals) in 2015 (January to December position), compared to 9% (n= 972 with cancer/ 10, 925 number of referrals) in the same period in 2014, with a similar pattern evident across all tumour groups. An area where the Trust is reporting a significantly higher referral rate than other organisations in the local Network is Lung referrals. NT&HFT is receiving 26.3% (n=1314) of the total Lung referrals across the Network (n=4994), double the number received by South Tees specialist hospital, who received 13.1% (n=656) in the same period. The Trust is currently working with the commissioners to understand this significantly outlying position. However, this continued increase in referrals has had a significant impact on the outpatient and diagnostic services, as each 2 week wait referral has to be seen and diagnosed within the required timescales, which can include multiple appointments and diagnostic tests. The Trust has managed the increases in demand through additional outpatient and diagnostic clinics, however due to a number of underlying issues, some outside the Trust s control, there has been pressure points in the system leading to the under performance against the 62 day cancer standard. The following section outlines performance to date, the underlying issues and the mitigating actions that have been implemented to manage the position going forward. 2

209 Appendix 7c 3.2 Cancer 62 Day Standard The Trust has struggled to consistently achieve the 62 day standard during 2015/16, despite the significant resource and clinical over sight that has been applied to review pathway delivery. The Trust initiated a recovery plan in 2014, covering pathway management, governance structures and tracking processes (see section 4), with an independent review from the Department of Health Intensive Support Team also commissioned. This was reviewed in 2015 in line with the NHS Tripartite Eight Key Priorities cancer recovery programme. The following section provides an overview of the current position and the key issues associated with the under-achievement against the standard. As outlined in Chart 2, the Trust has seen sporadic performance against the 62 day standard during 2015/16, recovering the overall position in Q3, reporting a marginal achievement at 85.1%. However, the Trust under-achieved in the months of January (77.88%) and February (82.80%), therefore despite an improved position of 86% being achieved in March, the overall Q4 position reporting below the required 85% standard at 82.19%. 3

210 Chart 2: Performance against the Cancer 62 Day Standard (April March 2016) Appendix 7c The Trust reported a total of 15 full breaches (accountable to NT&HFT) and 13.5 shared breaches (0.5 of each breach accountable to NT&HFT and 0.5 accountable to tertiary trusts). Table 1 shows the overall breakdown by month throughout 2015/16 including median, maximum and minimum waiting times and Table 2 showing the comparative position by Quarter 2015/16. Table 3 shows the breakdown of breaches by tumour group. Table 1: 62 Day Standard Performance including waiting times by month 2015/16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total Number of accountable patients Number of patients who breached Median (days) - All Minimum Wait (days) - All Maximum Wait (days) - All Number of full accountable breaches Median (days) - Full accountable breaches Minimum Wait (days) - Full accountable breaches Maximum Wait (days) - Full accountable breaches Number of shared accountable breaches Median (days) - Shared accountable breaches Minimum Wait (days) - Shared accountable breaches Maximum Wait (days) - Shared accountable breaches Performance 85.84% 88.04% 83.06% 85.71% 83.33% 80.00% 85.42% 81.31% 88.00% 77.88% 82.80% 85.96% 4