COUNCIL OF GOVERNORS MEETING To be held THURSDAY 22 NOVEMBER, 10AM AT ABBEY HOUSE HOTEL, DUDDON SUITE, BARROW IN FURNESS A G E N D A

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1 COUNCIL OF GOVERNORS MEETING To be held THURSDAY 22 NOVEMBER, 10AM AT ABBEY HOUSE HOTEL, DUDDON SUITE, BARROW IN FURNESS A G E N D A 14 APOLOGIES FOR ABSENCE To receive any apologies for absence 15 MINUTES OF THE MEETING HELD ON 20 JULY 2012 To receive and approve the minutes of the meeting held on 20 July MATTERS ARISING To consider any matters arising from the minutes, that are not covered elsewhere in the agenda Lead Chair Chair Chair Paper Attached 17 CHAIR S REPORT Chair Verbal To note and discuss items raised by the Chair 18 MEDICAL RECORDS UPDATE Claire Alexander Verbal 19 ELECTION OUTCOME To receive an update following the election procedure 20 LEAD GOVERNOR APPOINTMENT PROCESS To agree the process for the appointment of Vice Chair/Lead Governor 21 LEAD GOVERNOR UPDATE To note and discuss items raised by the Lead Governor 22 PROGRESS REPORT ON THE REVIEW OF THE COUNCIL S SUB-GROUPS AND CONSTITUTION To review and approve the report 23 REVIEW OF EXPENSES POLICY To review and approve the policy Chair Chair Lead Governor Chair Chair Attached Attached To follow Attached Attached

2 FOR INFORMATION 24 MONITOR QUARTERLY DECLARATION To receive and note 25 INTEGRATED PERFORMANCE REPORT To receive and note 26 PATIENT EXPERIENCE SUB GROUP MINUTES - 16 AUGUST 2012 To receive and note 27 FT MEMBERSHIP AND COMMUNICATIONS SUB GROUP MINUTES - 7 SEPTEMBER 2012 To receive and note 28 MOTIONS OR QUESTIONS ON NOTICE Constitution Ref, Annex 7, Items 7 & 10: The Company Secretary should be advised of any motions or questions at least 14 days prior to the meeting. The notice of every motion must be signed or transmitted by at least two Governors 29 URGENT MOTIONS OR QUESTIONS Constitution Ref: Annex 7, Item 12: Items are to be submitted in writing before the commencement of the meeting. The Chair shall decide whether the motion or question should be tabled Attached Attached Attached Attached 30 ANY OTHER BUSINESS Chair 31 DATE, TIME AND PLACE OF NEXT MEETING 31 January, 2013, Boardrooms,10am, County Hall, Kendal

3 AGENDA ITEM NO: 2012/13 Minutes of the Council of Governor meeting held on Friday 20 July 2012 at 10am at Lancaster House Hotel, Lancaster. PRESENT: Sir David Henshaw Interim Chair Shahnaz Ashgar Professor P Brown Councillor A Burns Cllr S Fishwick Professor P Hodge Janet Higgs Stan Hill Canon J.G. Hunter Mr J Kaye Mrs K Knipe Mr G Nicholson Mr G Ozuzu Ms D Partington Mrs M Radice Mr R Short Mr Roy Slack Mr I Soane Mr J Wood Public Governor, Barrow and Copeland Public Governor, South Lakes and Eden Partner Governor, Cumbria County Council Partner Governor, Lancashire County Council Public Governor, Lancaster, Craven and Wyre Public Governor, Lancaster, Craven and Wyre Public Governor, Barrow and Copeland Public Governor, Lancaster, Craven and Wyre Public Governor, South Lakes and Eden Public Governor, Lancaster, Craven and Wyre Staff Governor, Nurses, Midwives and Operating Department Practitioners Staff Governor, Medical and Dental Partner Governor, Voluntary sector Public Governor, South Lakes and Eden Public Governor, Barrow and Copeland Public Governor, South Lakes and Eden Partner Governor, Voluntary Sector, Cumbria Public Governor, Lancaster, Craven and Wyre IN ATTENDANCE: Jackie Daniel Chief Executive Rachael Whitaker Minute taker Patrick McGahon Director of Service and Commercial Development Allan Mowat Interim Company Secretary Jackie Bellard Engagement Lead (Audit Commission) Gareth Kelly Engagement Manager (Audit Commission) Jane Stanley Head of Financial Services 1 APOLOGIES FOR ABSENCE Peter Clarke, Michael Porter, Sharon Granville, Karen Halbert, Glyn Davies, Derek Lyon, Michael Holder 2 MINUTES OF THE MEETING HELD ON 13 MARCH 2012 Mrs Hamid queried accuracy of item 4.10 in which Sir David Henshaw mentioned the Trust Board is currently quorate. Sir David Henshaw confirmed this minute was correct. The minutes were agreed as an accurate record. Minutes of the Council of Governors meeting 20 July 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 - Council of Governors meeting

4 AGENDA ITEM NO: 2012/13 3 MATTERS ARISING There were no matters arising from the minutes. Sir David Henshaw introduced Ms Jackie Daniel, who has been appointed as the Trust s new Chief Executive. Governors formally approved Ms Daniel s position. 4 CHAIR S ITEMS 4.1 Sir David Henshaw mentioned staff briefings were held recently in which staff were updated on progress with Interim 2, Outpatients and Maternity. Sir David Henshaw stated part 2 of the recovery plan would be submitted in September. This would include all the options available in relation to delivering services in the future 4.2 Sir David Henshaw mentioned work has been ongoing with Clinical Commissioning Groups and in January, a range of options will be put to public consultation. Experts will be used to help handle the consultation process. He added no decisions have been made regarding priorities although it is important to state the Trust can t carry on delivering services as it does. All options must be safe and sustainable. 5 LEAD GOVERNOR UPDATE 5.1 Mr Ozuzu proposed Governors should have a conversation regarding the way forward and look at how the Council function for them to work more effectively. Mr Ozuzu added that previously Governors have dealt with issues alone and moving forward this needs to change, to function strongly they should be working together as a unit. 5.2 Mr Ozuzu mentioned the Council would be looking at the Monitor best practice guide in more detail during their workshop session and Mr Ozuzu would then take any proposals of new working arrangements to the Trust Board for approval. 5.3 Mr Kaye mentioned that previous problems occurred while the majority of the current council were in place; he added the complete interaction is essential moving forward. Sir David Henshaw mentioned even if Governors had been shadowing the Board, they would still not have stopped the problems that occurred. He added Governors should have been more challenging and it took Monitors intervention to highlight the problems. 5.4 Mrs Radice mentioned she feels she couldn t have challenged more than she did. Mr Soane mentioned the in trying to hold the Board to account Governors are faced with the operational/strategic debate. He added that Governors need enough information to be able to hold the Board to account effectively. 5.5 Sir David mentioned that in future, it may be appropriate for a Governance review to be undertaken. Mr Wood mentioned that it is important any decisions made in the Governors Workshop sessions are shared with the public. 6 ANNUAL REPORT AND ACCOUNTS 6.1 Mrs Stanley detailed contents of the Annual report, quality report and annual account, including the process and timetable. She mentioned a summary sheet would be produced next year for the accounts, following a suggestion from Governors. Minutes of the Council of Governors meeting 20 July 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 - Council of Governors meeting

5 AGENDA ITEM NO: 2012/ Professor Brown queried where in the accounts you would find cost benefits compared to the previous year s accounts. He asked what the benefit to the Trust was from outsourcing PCAS and the Langdale units. Mr McGahon informed Professor Brown that the decision was made in 2008 following approval from the Overview and Scrutiny Committee. Mr McGahon added that any cost benefit would not be detailed in the account but would be documented in Trust Board papers of Cumbria Primary Care Trust. 6.3 Governors noted the contents of the report. 7 AUDIT COMMISSION REPORTS 7.1 Mrs Bellard presented the Annual Governance report, which includes messages arising from the audit of the Trust s financial statements. She mentioned the financial statements presented were of a good standard and the audit commission did not identify any material errors. 7.2 Due to the Trust s breaches of its authorisation, they were unable to conclude that proper arrangements were made to secure the economy, efficiency and effectiveness of the Trust s resources during 2011/12. Sir David Henshaw mentioned a proposal for PricewaterhouseCoopers to carry out a review of corporate governance. 7.3 Mr Kelly presented the external assurance report on the Trust s Quality Report. He mentioned the assurance work consisted of the content of the Quality report, two indicators mandated by Monitor 62 day waiting times from urgent GP referral to first treatment for Cancer and MRSA and the third indicator, mortality, as selected by Governors. 7.4 Mr Kelly mentioned the content of the Quality Report is compliant although there remains scope for improvement of the timeliness of its completion. 7.5 Mr Kelly found the Trust had a range of controls in place in relation to 62 day waiting times and MRSA, however scope was identified to further enhance the accuracy of the 62 day cancer wait indicator. 7.6 Mr Kelly s testing of the mortality indicator provided assurance; however the Trust was unable to provide complete case notes for three cases out of the initial sample of 20, which did highlight weaknesses in record management. 7.7 Governors received and noted the contents of the reports. Sir David Henshaw commented he was encouraged by the reports and thanked Mrs Stanley and her team for their hard work with the accounts. 8 EXTERNAL AUDIT APPOINTMENT UPDATE 8.1 Mrs Stanley presented the report which provided an update on progress towards the appointment of the external auditor for 2012/13. Mrs Stanley explained the process relating to the tender documentation and evaluation. Six completed responses were received and it was recommended that the top four are invited for supplier interviews in the first week of September. Mr Stanley mentioned members of the Governors finance subcommittee would be contacted regarding their involvement in the interview process. Minutes of the Council of Governors meeting 20 July 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 - Council of Governors meeting

6 AGENDA ITEM NO: 2012/ Mrs Stanley presented Governors with a letter from the Audit Commission which details the Audit Commission s intention to resign as the Trust s auditors, no later than 30 September The Council of Governors noted the contents of the paper and formally acknowledged receipt of the Auditors letter. 9 ELECTIONS 9.1 Mr Mowat provided an update on the forthcoming election process. Mr Mowat mentioned there are 12 vacancies including five of the six staff Governors who are up for election. Mr Mowat mentioned members will be written to informing them of the election and detailed the timetable for the process which includes nominations opening on 28 August and the results being available on 23 October. 10 CLINICAL STRATEGY PROCESS 10.1 Mr McGahon provided and update on the clinical strategy process and informed Governors of the shared values and the principles to build upon. These included the quality of patient care being placed at the centre and top of the joint agenda and Care being shared wherever appropriate between organisations and between primary and secondary Care with care in the community as the default position Mr McGahon detailed the structure of the review groups and mentioned that Governors will be asked to play a role within the review groups and engagement process. 11 ISSUES RAISED BY GOVERNORS 11 Governors were presented with responses to issues raised in advance of the meeting Mrs Radice requested a review is undertaken of all issues raised by Governors over the past two years. Sir David Henshaw suggested it would be appropriate for this to be picked up by the Patient Experience sub group. 12. MOTIONS OR QUESTIONS ON NOTICE 12.1 Mr Soane raised two motions which were received at least 14 days prior to the meeting and had been transmitted by two Governors. Mr Soane s first motion asked Governors to commit to a revision of how Governors business is carried out and mentioned they would report back on progress in public. This motion was carried Mr Soane s second motion linked to Mr McGahon s presentation regarding the Clinical Strategy process and requested for Governors to be more participative moving forward. The motion was carried It was requested details of any motions raised are included in the agenda packs in the future. 13. DATE, TIME AND PLACE OF NEXT MEETING 6 November 2012, 10am, Forum 28, Barrow-in-Furness Minutes of the Council of Governors meeting 20 July 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 - Council of Governors meeting

7 AGENDA ITEM NO: 2012/13/19 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST COUNCIL OF GOVERNORS MEETING Date of meeting: Thursday 22 November 2012 Title / Subject: Governor Election results October 2012 Status Purpose: Report of: Prepared by: Contact for queries: Action required / recommendation: Public To advise the Council on the governors elected to council in the recent round of elections Phil Woodford Deputy Director of Corporate Affairs Claire Lea Interim Company Secretary Claire Lea (claire.lea@mbht.nhs.uk) The Council is asked to accept the election results and endorse the next steps to be taken. Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 - Council of Governors Meeting (22 November 2012)

8 AGENDA ITEM NO: 2012/13/19 Supporting Information Background papers/ supporting agenda items (if applicabe): Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s business plan: Link to UHMB s Assurance Framework: None N/a Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Yes Yes Yes Yes Yes Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): Compliance with the Trust s constitution and the Department of Health s Model Election Rules Elections are held across the trust membership to support public accountability Not applicable Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 - Council of Governors Meeting (22 November 2012)

9 AGENDA ITEM NO: 2012/13/19 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST GOVERNOR ELECTION RESULTS OCTOBER 2012 INTRODUCTION Paragraph 10 of the Trust s constitution sets out that an election for elected members of the Council of Governors shall be conducted in accordance with the Model Rules for Elections as published from time to time by the Department of Health. It also sets out that an election, if contested, shall be by secret ballot Upon authorisation as a foundation trust, the Trust was established with a council of governors with staggered terms of office. This was to ensure that there was some continuity amongst the elected governors as time went on. In practice this meant that initially some governors were elected on a three year term, others on a two year term and others on a one year term. After this initial appointment all terms of office would be for a three year term. The terms of office were set to run concurrently with the date of authorisation as a foundation trust (1 October 2010), i.e. the two year term of office came to an end on 30 September 2012 at the second anniversary of the Trust s authorisation and the three year term of office will conclude at the third anniversary (30 September 2013). In addition the Constitution sets out that where any vacancy arises as a result of early resignation or termination of office then the Trust must call an election to fill the seat for the remainder of that governor s term of office. As a result, elections were required in respect of those governors who, initially, had been given a two year term office and also in respect of vacancies that had arisen. The constituencies affected were as follows: Barrow and West Cumbria (2 vacancies) (2x 3 year term of office) Lancashire and North Yorkshire (1 vacancy) (1 year term of office) South Lakeland and North Cumbria (5 vacancies) (4 x3 year term of office, 1x 1 year term of office) 2 Staff Governors - Estates and Ancillary (1 vacancy) (3 year term of office) & Allied Health Professionals (1 vacancy) (3 year term of office) THE ELECTION PROCESS Electoral Reform Services are the Trust s Independent Scrutineer and are responsible for the election process and ensuring that is in line with the Department of Health Election Rules. The deadline for nominations closed on Wednesday 12th September Ballot papers were distributed to qualifying Members on Tuesday 2nd October Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 - Council of Governors Meeting (22 November 2012)

10 AGENDA ITEM NO: 2012/13/19 Completed ballot papers were received by the Independent Scrutineer by 12 noon on Monday 22nd October THE RESULTS The following constituencies were uncontested and the candidates elected unopposed. This meant that the election process had not clearly determined who would receive the 1 year term of office that was available within the South Lakeland and North Cumbria constituency. (It would normally be based on the number of votes cast). As a result a meeting was then held between the Chairman and the South Lakeland and North Cumbria governors to determine how this matter might be addressed. Electoral Reform Services had advised that, if there were no volunteers, then the most appropriate process to reach that determination would be for the 4 newly elected Governors to draw lots at the next Council of Governors meeting. (Mr Kaye had been returned for a second term of office and would automatically receive a three year term). At the meeting with the Chairman on Wednesday 7 th November, Ms Acheson volunteered to take the one year term, thus removing the need to draw lots. Public: South Lakeland and North Cumbria Joan Acheson (1 year term of office = 1 October September 2013) Michael Burke (3 year term of office = 1 October September 2015) John Kaye (3 year term of office = 1 October September 2015) John Sellar (3 year term of office = 1 October September 2015) Roger Titcombe (3 year term of office = 1 October September 2015) Staff: Estates and Ancillary Glyn Davies (3 year term of office = 1 October September 2015) The remaining constituencies went out to a full ballot process. The results were as follows: Barrow and West Cumbria public constituency Shahnaz Asghar (3 year term of office = 1 October September 2015) Dave Waddington (3 year term of office = 1 October September 2015) Lancashire and North Yorkshire public constituency Val Richards (1 year term of office = 1 October September 2013) Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 - Council of Governors Meeting (22 November 2012)

11 AGENDA ITEM NO: 2012/13/19 NEXT STEPS There remains one outstanding vacancy for a staff governor - Allied Health Professionals (3 year term of office) which will go back out to election in the next three months. A further set of elections will be held in the summer of 2013 to cover those governors whose three year term of office will expire in September A full list of governors and their terms of office are set out in Appendix 1 for information. A comprehensive induction programme is being established for the newly elected governors and existing governors will also invited to participate in the programme. ACTION REQUIRED / RECOMMENDATION The Council is asked to accept the election results and endorse the next steps to be taken. Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 5 - Council of Governors Meeting (22 November 2012)

12 AGENDA ITEM NO: 2012/13/19 Appendix 1 Register of Members of the Council of Governors October 2012 Elected Governors Public Governors (17 seats) Barrow & West Cumbria Stan Hill 3 years 30 September 2014 Derek Lyon 3 years 30 September 2013 Shahnaz Asghar 3 years 30 September 2015 Dave Waddington 3 years 30 September 2015 Lancashire & North Yorkshire Mike Porter 3 years 30 September 2014 Janet Hamid 3 years 30 September 2014 Philip Hodge 3 years 30 September 2014 Kathleen Knipe 3 years 30 September 2013 Jim Wood 3 years 30 September 2013 Val Richards 1 year 30 September 2013 John Hunter 3 years 30 September 2014 South Lakeland & North Cumbria Maria Radice 3 years 30 September 2013 Joan Acheson 1 year 30 September 2013 Michael Burke 3 years 30 September 2015 John Kaye 3 years 30 September 2015 John Sellar 3 years 30 September 2015 Roger Titcombe 3 years 30 September 2015 Staff Governors (6 seats) Sharon Granville (Management & Admin 3 years 30 September 2014 Gilbert Ozuzu (Medical & Dental) 3 years 30 September 2014 Graeme Nicholson (Registered Nurses, 3 years 30 September 2013 Midwives & Operating Department Practitioners) Karen Halbert (Registered Nurses, 2 years 30 September 2013 Midwives & Operating Department Practitioners) Vacant (AHPs) 3 years 30 September 2015 Glyn Davies (Estates & Ancillary) 3 years 30 September 2015 Appointed Governors (7 seats) Michael Holder, North Lancs PCT 3 years 30 September 2013 Peter Clarke, Cumbria PCT 3 years 30 September 2013 Cllr Anne Burns, Cumbria County Council 3 years 30 September 2013 Cllr Sarah Fishwick, Lancashire County 3 years 30 September 2013 Council Mr Ian Soane, Voluntary Sector, Cumbria 3 years 30 September 2013 Ms Denise Partington, Voluntary Sector, 3 years 30 September 2013 Lancashire Professor John Goodacre, Lancaster University 3 years 30 September 2013 Election results October 2012 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 6 - Council of Governors Meeting (22 November 2012)

13 AGENDA ITEM NO: 2012/13/20 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST COUNCIL OF GOVERNORS MEETING Date of meeting: Thursday 22 November 2012 Title / Subject: Status Purpose: Report of: Prepared by: Contact for queries: Action required / recommendation: Lead Governor Appointment Process Public To consider the process for the appointment of the Vice Chair/lead Governor of the Council of Governors Phil Woodford Deputy Director of Corporate Affairs Claire Lea Interim Company Secretary Claire Lea (claire.lea@mbht.nhs.uk) The Council of Governors is asked to agree the process for the appointment of Vice Chair/Lead Governor Appointment of Lead Governor University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 - Council of Governors Meeting (22 November 2012)

14 AGENDA ITEM NO: 2012/13/20 Supporting Information Background papers/ supporting agenda items (if applicable): Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s Assurance Framework: Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): N/a Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Yes Yes Yes Yes Yes Supports the delivery of a robust governance and risk management framework Compliance with the Trust s constitution Not applicable Not applicable Appointment of Lead Governor University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 - Council of Governors Meeting (22 November 2012)

15 AGENDA ITEM NO: 2012/13/20 PROCESS FOR THE APPOINTMENT OF THE VICE CHAIR/LEAD GOVERNOR OF THE COUNCIL OF GOVERNORS 1. Introduction 1. The Trust s Constitution, Paragraph 6, Annex 5, details the requirement for the Council of Governors to appoint one of the Governors to be Vice Chair of the Council of Governors. 2. Gilbert Ozuzu was appointed as Lead Governor in November The appointment was for a one year term of office. A ballot process is therefore required to appoint a Vice Chair/Lead Governor for the period December 2012 November Appointment Process All elected governors are invited to express interest in seeking appointment as Vice Chairman/Lead Governor. Governors who express an interest in being appointed should provide a brief account (using the attached pro-forma) about why they wish to be appointed and, in line with the role specification (also attached), what strengths they would bring to the role. Members of the Council of Governors are asked to submit Expressions of Interest in the role of a Vice Chairman/Lead Governor by 5pm on Monday 3 December 2012, using the attached pro-forma. A closed ballot process will be held between 4 and 5 December, the outcome of which will be announced on Friday 7 December The full Council of Governors will be entitled to vote. Following circulation of the ballot papers, candidates may be questioned by other members of the Council of Governors. Where there is just one candidate, that Governor will be elected unopposed on the basis that they fulfil the role specification. The period of office will be one year from the date of appointment. 3. Action/recommendations The Council of Governors is asked to review and agree the process of appointment. Appointment of Lead Governor University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 - Council of Governors Meeting (22 November 2012)

16 AGENDA ITEM NO: 2012/13/20 ROLE SPECIFICATION VICE CHAIR/LEAD GOVERNOR OF THE COUNCIL OF GOVERNORS The role- The Lead Governor will: a) In accordance with Monitor s Code of Governance, facilitate direct communication between Monitor and the Council of Governors. This will be in a limited number of circumstances and in particular where it may not be appropriate to communicate through the normal channels, which in most cases will be via the Chairman or the Trust Secretary. b) Work with the Chair of the Board of Directors to ensure the Council of Governors (CoG) is working effectively. c) Chair such parts of the meetings of the Council of Governors (CoG) which cannot be chaired by the Chair or the Deputy Chair of the Trust due to a conflict of interest in relation to the business being discussed. d) To meet with the Senior Independent Director and to provide input to the Chair s annual appraisal on behalf of the Council of Governors. e) Be appointed from amongst the Governors. f) Be appointed for a one year period. g) Meet routinely with the Chair and Company Secretary to set the agenda for meetings and development events of the Council of Governors, and to prepare for meetings with the Board of Directors. h) Prepare a Lead Governor report for the Trust Board meetings/engagement events held in public on the work of the Council of Governors and attend to present the paper i) Contribute to the induction and training of Governors. j) Work with individual Governors who need advice or support to fulfil their role as a Governor. k) Represent the Council of Governors when appropriate and necessary, including at Trust or other events. The person - To be able to fulfil this role effectively the Lead Governor will: a) Have the confidence of Governor colleagues and of members of the Board of Directors. b) Have the ability to influence and negotiate with positive outcome. c) Be able to present well-reasoned argument. d) Be committed to the success of the University Hospitals of Morecambe Bay NHS Foundation Trust. e) Be able to commit the time necessary, which is envisaged to be approximately 1.5 days per month in addition to the time already spent in the role of Governor. f) Be able to demonstrate experience of chairing both large and small meetings effectively. g) Demonstrate an understanding of the Trust s Constitution, key FT governor guidance and how the Trust is influenced by other organisations. Appointment of Lead Governor University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 - Council of Governors Meeting (22 November 2012)

17 AGENDA ITEM NO: 2012/13/20 Council of Governors Vice Chairman/Lead Governor Expressions of Interest Governors are invited to express interest in the role of a Vice Chairman/Lead Governor. Expressions of Interest Form I would like to be express interest in the role of Vice Chairman/Lead Governor Name: Signature: Please provide a brief account about why you wish to be appointed and, in line with the role specification, what strengths you would bring to the role (NB this information will be circulated as part of the ballot process): Please return this form to Claire Lea Interim Company Secretary, by 5pm Monday 3 December Appointment of Lead Governor University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 5 - Council of Governors Meeting (22 November 2012)

18 AGENDA ITEM NO: 2012/13/22 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST COUNCIL OF GOVERNORS Date of meeting: Thursday 22 November 2012 Title / Subject: Status Purpose: Report of: Prepared by: Contact for queries: Action required / recommendation: Progress report on the review of the Council s sub-groups and constitution Public To set out the progress made on progress and to identify the next steps in the review Claire Lea Interim Company Secretary Claire Lea Interim Company Secretary Claire Lea Interim Company Secretary (claire.lea@mbht.nhs.uk) The Committee is asked to accept the report and to endorse the next steps in the review Progress report on the review of the Council s sub-groups and constitution University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 - Council of Governors Meeting (22 November 2012)

19 AGENDA ITEM NO: 2012/13/22 Supporting Information Background papers/ supporting agenda items (if applicabe): Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s business plan: Link to UHMB s Assurance Framework: Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): Workshop minutes 20 July 2012 Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Development of a robust governance and risk management framework All standards Not applicable at this stage Not applicable Yes Yes Yes Yes Yes Progress report on the review of the Council s sub-groups and constitution University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 - Council of Governors Meeting (22 November 2012)

20 AGENDA ITEM NO: 2012/13/22 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST Progress report on the review of the Council s sub-groups and constitution INTRODUCTION 1. The Council has previously agreed at its workshop in July 2012 that a review of its sub-groups and constitution were now required. It agreed that a group of governors should be established to carry out this review. 2. The Trust has now obtained additional resources in the form of an Interim Company Secretary, Claire Lea, who has met with Phil Woodford, Ian Soane and John Kaye individually to consider the initial steps that have been taken in this regard. THE REVIEW 3. It is proposed that the review will include the amendment of the Constitution in the light of the Health and Social Care Act 2012, the removal of any duplication, and will improve the clarity and consistency within the current constitution. The review will also consider whether the current sub-group structure is fit for purpose and consider possible refinements to improve communication between the Trust Board and the Council and to provide greater assurance to the Council in its role of holding the Board to account. Any amendments to the Terms of Reference for the Council s subgroups that may be required will also be considered. NEXT STEPS 4. An invitation will be set out to all governors inviting them to participate in the review before the end of November and the two meetings scheduled before the end of the year. 5. The group will then establish a timetable for the review and report back on progress to the next meeting of Council. ACTION REQUIRED / RECOMMENDATION The Committee is asked to accept the report and to endorse the next steps in the review. Progress report on the review of the Council s sub-groups and constitution University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 - Council of Governors Meeting (22 November 2012)

21 AGENDA ITEM NO : 2012/13/23 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST COUNCIL OF GOVERNORS MEETING Date of meeting: Thursday 22 November 2012 Title / Subject: Status Purpose: Report of: Prepared by: Contact for queries: Action required / recommendation: Governor Expenses Policy annual review Public The Board approved the Policy for reimbursement of Governors Expenses in October The Council of Governors reviews the policy annually, with a view to making recommendations for any changes to the Board of Directors. Phil Woodford Deputy Director of Corporate Affairs Claire Lea Interim Company Secretary Claire Lea (claire.lea@mbht.nhs.uk) The Council of Governors is asked to:- 1. Review the document. 2. Make recommendations for any changes to the Board of Directors. Governor Expenses Policy annual review University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 - Council of Governors Meeting (22November 2012)

22 AGENDA ITEM NO : 2012/13/23 Supporting Information Background papers/ supporting agenda items (if applicable): Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s Assurance Framework: Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): Not applicable Not applicable Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Yes Yes Yes Yes Yes Supports the delivery of a robust governance and risk management framework Outcome 26 Compliance with the Trust s constitution Not applicable Not applicable Governor Expenses Policy annual review University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 - Council of Governors Meeting (22November 2012)

23 AGENDA ITEM NO : 2012/13/23 POLICY FOR REIMBURSEMENT OF GOVERNORS EXPENSES 1. Introduction The Trust s FT Constitution, paragraph 16, states The Foundation Trust may pay travelling and other expenses to members of the Council of Governors at rates determined by the Foundation Trust. This policy sets out the guidelines under which Governors and prospective Governors may be reimbursed for legitimate expenses incurred in the course of their duties as a UHMB Foundation Trust Governor. The policy was approved in October 2011 and is now due for review. The only amendment required is to bring the mileage rate for expenses in line with the latest Inland Revenue recommendation of 45p/mile. There are no other amendments to the policy. 2. Principles The post of Governor of a Foundation Trust is voluntary, and it is a fundamental principle that no Governor shall receive any form of salary for being a Governor. However, it is not the intention that Governors should find the cost of reasonable expenses incurred as a result of their duties. Expenses will be reimbursed for the following expenditure:- a. Travel expenses to attend Council, members and local constituency meetings arranged by the Trust, and any other meetings specified by the Trust for attendance in a Governor capacity. Mileage rate, where authorised, will be paid at a rate of 45p/mile for all eligible mileage. The rate paid to Governors is in line with those paid to other staff and volunteer groups, that accepted nationally within private and public organisations and is also the rate which the Inland Revenue accepts as being the maximum before tax is payable. There is no tax liability for the Governors to declare or the Trust to collect. Travel by bus or train will be reimbursed as per the ticket amount (the ticket should be retained and attached to the claim form for payment). Reimbursed travel by taxi is not permitted unless prior agreement has been received by the Company Secretary. Governors are asked that they attempt to arrange transport to meetings by the cheapest means. b. Parking and toll charges incurred as a direct result of attending the above meetings. Governor Expenses Policy annual review University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 - Council of Governors Meeting (22November 2012)

24 AGENDA ITEM NO : 2012/13/23 c. Subsistence allowance where the Governor is away from home either, between 5 and 10 hours at 5 maximum, or over 10 hours 15 maximum where no refreshment is provided. Periods away from home are calculated from the times of leaving and returning home. Only in exceptional circumstances, and with the prior agreement of the Company Secretary, will overnight expenses or conference fees be paid. The rate paid to Governors is in line with those paid under Agenda for Change Terms and Conditions. d. Expenses arising because a Governor is required to employ a carer to look after a dependent relative whilst the Governor is on Trust business as described above. Costs must be agreed with the Company Secretary in advance and will only be payable on production of evidence of expenditure for the services and may be liable to deductions for tax and national insurance. (Governors requiring assistance in arranging transport must contact the Company Secretary or FT Membership Services Officer well in advance of the planned meeting to enable the necessary time to arrange). 3. Submission of Claims Governors remain wholly responsible for the compilation and accuracy of their claims (assistance is available if required). Claims forms are available from the FT Membership Services Officer. When completed they should be passed to the Company Secretary for authorisation, who will forward them for payment. Forms should be submitted in line with Trust policy (as detailed in the New Claimant Travel Expenses information supplied to Governors at induction). Claims will normally be reimbursed directly to a nominated bank or building society account in accordance with the Trust s accounting timetable. If urgent payment is required, the Governor should raise the matter with the Company Secretary. 4. Review The Council of Governors will review this policy annually and any changes required will be recommended to the Board of Directors. 5. Action/recommendations The Council of Governors is asked to:- 1. Review the document. 2. Make recommendations for any changes to the Board of Directors. Governor Expenses Policy annual review University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 - Council of Governors Meeting (22November 2012)

25 AGENDA ITEM NO: /13 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST BOARD OF DIRECTORS Date of meeting: 31 st October 2012 Title / Subject: Monitor Governance Statement Quarter 2 Status Public Purpose: To provide information to consider in order to agree the Monitor Governance Statement responses for Quarter 2. Report of: Prepared by: Contact for queries: Action required / recommendation: Tim Bennett Director of Finance and Information Janet Higgs Deputy Director of Finance Janet Higgs Deputy Director of Finance (janet.higgs@mbht.nhs.uk) The Board of Directors are asked to: 1. Confirm the responses to the 3 statements on the Governance Statement for Quarter 2; 2. authorise submission of these responses to Monitor by 31 October Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 1 -

26 AGENDA ITEM NO: /13 Supporting Information Background papers/ supporting agenda items (if applicabe): Monitor Governance Statement Quarter 1 TrustBoard meeting Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s business plan: Link to UHMB s Assurance Framework: Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): Not Applicable Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community All Standards Monitor Compliance Framework 2012/13 Not Applicable Not Assessed Yes Yes Yes No Yes Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 2 -

27 AGENDA ITEM NO: /13 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST Monitor Compliance Declarations for Quarter 2 INTRODUCTION 1. This paper provides the information required for the Trust Board to confirm its responses to be included in the Quarter 2 Monitor Governance Statement. GOVERNANCE STATEMENT 2. The Governance Statement requires the board to respond confirmed or not confirmed to 3 statements in respect of Finance, Governance and Exception reporting: Finance 3. The board anticipates that the Trust will continue to maintain a financial risk rating of at least 3 over the next 12 months. Governance 4. 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 B of the Compliance Framework; and a commitment to comply with all known targets going forwards. (An extract from Appendix B of the Compliance Framework is attached as Appendix 1 to this report.) Exception reporting 5. The board confirms that there are no matters arising in the quarter requiring an exception report to Monitor (per compliance Framework page 17 Diagram 8 and page 63) which have not already been reported. 6. Diagram 8 of the Compliance Framework 2012/13 identifies the following examples of exception reports: a) Finance i. Unplanned significant reductions in income or significant increases in costs ii. iii. Requirements for additional working capital facilities beyond those incorporated in the prudential borrowing limit ( PBL ) Failure to comply with the NHS Foundation Trust Annual Reporting Manual Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 3 -

28 AGENDA ITEM NO: /13 iv. Discussions with external auditors which may lead to a qualified audit report v. Transactions potentially affecting the financial risk rating and/or resulting in an investment adjustment vi. Proposed disposals of protected assets (or removal of protected status see Protection of Assets: Guidance for NHS Foundation Trusts) b) Governance i. Removal of director (s) for significant contractual or non-contractual dispute with another NHS body ii. iii. Adverse reporting from internal auditors Risk of a failure to maintain registration with the Care Quality Commission iv. Significant third party investigations that suggest material issues with governance e.g. fraud, Care Quality Commission reports of significant failings, National Patient Safety Agency reports, Health Protection Agency reports of important or significant C. difficile outbreaks. v. Care Quality Commission responsive or planned reviews vi. Outcomes or findings of Care Quality Commission responsive or planned reviews vii. Proposals to vary the Authorisation viii. Other patient safety issues which may impact the Authorisation (e.g. serious incidents) ix. Proposals to vary mandatory service provision or dispose of assets, including: cessation or suspension of mandatory service(s) variation of Authorisation or asset protection processes x. Loss of accreditation of a mandatory service xi. xii. Reporting of breaches in information governance (including data losses) Performance penalties to commissioners c) Other Risks Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 4 -

29 AGENDA ITEM NO: /13 i. Enforcement notices from other bodies implying potential or actual significant breach of any other requirement in the Authorisation, e.g: Health and Safety Executive or fire authority notices Material issues impacting the Trust s reputation Adverse reports from overview and scrutiny committees Patient group concerns RESPONSES Finance 7. The Trust s plan for 2012/13 does not achieve a risk rating of 3 and Quarter 2 actuals are in line with plan and show a Financial Risk Rating of 1. The Board must therefore respond NOT CONFIRMED to this statement. Governance 8. The Trust has not met the required targets in respect of :- a) A&E 4 hour wait b) Maximum time of 18 weeks from point of referral to treatment in aggregate, admitted patients c) Clostridium Difficile The Board must therefore respond NOT CONFIRMED to this statement. Exception reports 9. The board needs to consider whether there are any areas where an exception report is required in order to confirm the answer to this statement. RECOMMENDATION 10. The Board of Directors are asked to confirm the responses to the three statements on the Governance Statement for Quarter 2 and to authorise submission of these responses in line with the deadlines for Quarter 2, 31 October 2012 Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 5 -

30 AGENDA ITEM NO: /13 Appendix 1 Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 6 -

31 AGENDA ITEM NO: /13 Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 7 -

32 AGENDA ITEM NO: /13 Monitor Governance Statement Q2 University Hospitals of Morecambe Bay Hospitals NHS Foundation Trust - Page 8 -

33 AGENDA ITEM NO: /13 UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST BOARD OF DIRECTORS Date of meeting: 31 October 2012 Title / Subject: Status Public INTEGRATED PERFORMANCE REPORT Purpose: The aim of the Integrated Performance Report report is to clearly communicate compliance with key standards and indicators and links to Trust Objectives Report of: Prepared by: Contact for queries: Action required / recommendation: Tim Bennett, Director of Finance, Information & Supplies and Juliet Walters, Chief Operating Officer Julie Buckley, Head of Information Rhiannon Tinson, Head of Operational Performance Robin Woods, Head of Financial Management Paula Roles, Deputy Director of HR & OD Julie Buckley, Head of Information (julie.buckley@mbht.nhs.uk) Or Rhiannon Tinson,Head of Operational Performance (rhiannon.tinson@mbht.nhs.uk) Or Robin Woods, Head of Financial Management (robin.woods@mbht.nhs.uk) Or Paula Roles, Deputy Director of HR & OD (Paula.Roles@mbht.nhs.uk) The Group are asked to: 1. comment on the contents of this paper and provide feedback. Integrated Performance Report Page 1

34 AGENDA ITEM NO: /13 Supporting Information Background papers/ supporting agenda items (if applicabe): Previously considered by (if applicable): Link to UHMB s objectives (select those objectives this paper supports): Link to UHMB s business plan: Link to UHMB s Assurance Framework: none - Continuously improve the patient experience - becoming the provider of choice for excellence with safe and effective patient care Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works Encourage staff to be innovative when delivering and planning high quality and sustainable services - achieving long term financial sustainability Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including to specialist services wherever that is feasible Positively contribute to the well-being of the local community Strategic Objective- 2 Principle Objective 2.1 a Yes Yes Yes No Yes Link to a Care Quality Commission standard(s): Identification of any statutory / regulatory implications for UHMB: Public and patient engagement: Equality Impact Assessed (if applicable): Integrated Performance Report Page 2

35 AGENDA ITEM NO: /13 EXECUTIVE OVERVIEW INTRODUCTION This report outlines the Trust s performance against the key performance, financial and workforce management standards and indicators. The report has been developed to sit alongside the Quality Account which outlines the compliance with quality standards and indicators in detail. O verall UHMB compliance with the quality standards and indicators is included in the dashboard of key standards, section 2 of this report. The Trust Corporate Objectives are presented across 5 K ey performance areas: 1. Continuously improve the pat ient experience - Becoming the provider of choice for excellence with safe and effective patient care 2. Support and develop all staff to take responsibility for what they do and help them to do their best - getting staff truly engaged in how the trust works 3. Encourage staff to be innovative when delivering and planning high quality and sustainable services - Achieving long term financial sustainability 4. Work with our partners to provide an integrated health service that meets the needs of the local population providing local access, including t o specialist services wherever that is feasible 5. Positively contribute to the well-being of the local community Report Format 1. The report is divided into eight sections. a) Section 1, this section, provides an executive overview including: summarized performance for the year, brief exception reports for standards/targets breached in the period against the Monitor Compliance Framework, the Operating Framework and contractual quality standards and finally recommendations to the Board of Directors. b) Section 2 is a dashboard of key standards, which gives an overview of the trust s critical indicators for the year, divided into three categories indicating performance against; Monitor s 2012/13 Compliance Framework 2012/13 Operating Framework Standards Contractual Quality Standards, including the CQUIN Scheme. i) In the page number column on the dashboard of key indicators; QA indicates that the detail for the period can be found in the Quality Account, and Where a p age number appears in the column, further details of performance are included within this report. Integrated Performance Report Page 3

36 AGENDA ITEM NO: /13 ii) The Lead column indicates the member of the Executive Team with lead responsibility for delivery of the standard. iii) Within the dashboard of key indicators, performance for the period is categorised in four levels of achievement: Achieving/Achieved On plan to achieve Under achieving Of concern iv) The first category of achievement, Achieving indicates that the trust is consistently operating at the required standard or in some cases has already Achieved the standard for the year. v) The second category, On plan to achieve indicates that the trust is delivering the standard for the period, which will ensure successful delivery of the standard by the target date. vi) The third category, Under achieving demonstrates it is unlikely that the standard will be ac hieved by the quarter end, but there are no financial or serious external regulatory consequences for failure to achieve. vii) The final category, Of concern indicates that the trust is not currently delivering this standard for the period and is unlikely to do so by the quarter end. There will be as sociated financial or regulatory consequences as a result. viii) The last column within the dashboard, entitled movement indicates the position compared to the previous month as follows: Improved Position No Change Position deteriorated c) Section 3a provides a tabulated overview of the trust s performance assessed against Monitor s service performance element of the 2012/13 Compliance Framework. It details the weightings and t hresholds for each target together with current performance, score for the period and risk rating. Section 3b provides a tabulated overview of the declaration of performance against the financial risk rating. d) Section 4 details financial performance in month and the cumulative to date. e) Section 5 provides graphic detail of each of the indicators included within Monitor s Compliance Framework for 2012/13 and monthly performance in Integrated Performance Report Page 4

37 AGENDA ITEM NO: / /13. There is also an assessment of our achievement level, together with other monitoring data related to the objective. f) Section 6 provides a description of the Operating Framework standards for the period, plus graphic detail of each standard. It also demonstrates our performance throughout 2010/11 and 2011/12 where available, monthly performance in 2012/13, and where appropriate our cumulative performance for the year. In addition, an assessment of our achievement level is provided, together with other monitoring data related to the objective. g) Section 7 describes performance against those contractual standards included within the Quality Schedule of the trust s 2012/13 contract with commissioners. Where appropriate a graphic comparison of previous years performance is included together with an as sessment of our achievement level. h) Section 8 details workforce metrics. i) Appendix 1 CQUIN schemes Recommendation The Board of Directors is asked to receive the report for the period, and consider the Trust s performance against Monitor s 2012/13 Compliance Framework, the 2012/13 Operating Framework standards, 2012/13 Contractual standards and the 2012/13 Annual Plan. Integrated Performance Report Page 5

38 AGENDA ITEM NO: /13 Monitor s compliance framework Operating framework standards 2012/13 Contractual Standards Page No Executive Lead Clinical/Operational leads ( see Glossary of Initials) Achieving On Plan to achieve Under achieving Of Concern Movement Quality Standards & Risk Rating for September 2012 ( Cancer data One month behind) Clostridium Difficile -no more than 40 within 2012/13. ( 1,3) 27 JH KW/LP MRSA - no more than 3 within 2012/13 ( 1,3) 27 JH KW/LP MRSA Screening- proportion of admissions screened for MRSA ( 1,3) JH KW/LP Cancer 31 day wait for second or subsequent treatment - surgery. % of patients receiving second or subsequent surgery within a maximum waiting time of 31 days within a given period. Standard=94% ( 1,3) GN CD's/DGM's Cancer 31 day wait for second or subsequent treatment - drug treatments. % of patients receiving a subsequent/ adjavant anti-cancer drug regime within a maximum waiting time of 31 days within a given period. Standard=94% ( 1,3) GN CD's/DGM's Cancer 31 day wait from diagnosis to first treatment. Standard=96%. ( 1,3,4) GN CD's/DGM's Cancer 62 Day Waits for first treatment (from urgent GP referral). % of patients receiving first definitive treatment for cancer within 62 days following referral from an NHS Cancer Screening Service within a given period. Standard=90% ( 1,3) GN CD's/DGM's Cancer 62 Day Waits for first treatment (from Consultant led screening service referral) 28 Standard=90%. ( 1,3) GN CD's/DGM's Cancer 2 week (all cancers). % of patients urgently referred by a GP/GDP who were first seen within 14 calendar days. Standard=93%. ( 1,3,4) GN CD's/DGM's Cancer 2 week (breast symptoms). % of patients urgently referred for investigation of breast symptoms by a primary or secondary care clinician, who were seen within 14 calendar days. Standard=93%( 1,3,4) GN CD's/DGM's Referral to treatment time, admitted patients. Standard= 90% of completed patient pathways 30 where the patient waited <18 weeks ( 1,3,4) JW CD's/DGM's Referral to treatment time, non-admitted patients. Standard= 95% of completed non-admitted patient pathways where the patient waited <18 weeks ( 1,3,4) JW CD's/DGM's Referral to treatment time- Incomplete. Standard=92 % of completed patient pathways were completed in less than 18 weeks. ( 1,3,4) JW CD's/DGM's RTT specialties with failed delivery - new Count of number of specialties that failed the non-admitted, admitted and incomplete standards in month. Standard=0. ( 1,3,4) 30 JW CD's/DGM's % patients waiting > 6 weeks for a diagnostic test. Standard= <1%. ( 1,3,4) JW CD's/DGM's Percentage of patients seen within 18 weeks for direct access audiology treatment. Standard=95%. 91,5) JW JSA/JB Achieve at least one of these: (1,4,5) JW PG/JC Total time in A&E <4 hours. % of patients admitted, discharged or transferred with 4 hours. 28 Standard=95%. JW PG/JC Time to initial assessment within 15 minutes (95th percentile) 34 JW PG/JC Time to treatment in department within 60 minutes (median) JW PG/JC Achieve at least one of these ( 1,4,5) JW PG/JC -unplanned re-attendance rate to be within 5% JW PG/JC -left department without being seen within 5% JW PG/JC Satisfaction of the Provider s obligations under each Ambulance Services Handover Plan - ( 32 Penalties in place from 1st October 2012) JW PG/JC Ambulance handover compliance= the measurement of clinical handover at which the receiving staff complete their element of data entry, taking responsibility for the patient from ambulance 32 staff. Standard= 95% JW PG/JC Delayed transfers of care to be maintained at a minimal level. Standard <=3.5% ( 1,3,4) JW JM/MM Mixed Sex Accommodation Breach. Count of unjustified breaches. Standard=0. ( 1,3,4) JH JM/MM VTE Risk assessment. % of adult admissions reported as having had a vte assessment on admission using the clinical criteria of the national tool. Standard= 90% (1) GN NB Compliance with requirements regarding access to healthcare for people with a learning disability. Local standard- to be agreed.( 4,5) JH PR/DW Ethnicity recording standard minimum 85% recorded(4,5) JW CD's/DGM's Provider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission. Less than or equal to 0.8% of elective admissions cancelled on the day or 31 after admission JW CD's/DGM's Breach of Clause 40.5 of the Core Legal Clauses (cancelled operations) - Standard = 0 31 JW CD's/DGM's Provider failure to ensure that sufficient appointment slots are made available on the Choose 33 and Book system. Standard=<4%. JW CD's/DGM's Integrated Performance Report Page 6

39 AGENDA ITEM NO: /13 Monitor s compliance framework Operating framework standards 2012/13 Contractual Standards Quality Standards & Risk Rating for September 2012 ( Cancer data One month behind) Page No Executive Lead Clinical/Operational leads ( see Glossary of Initials) Achieving On Plan to achieve Under achieving Of Concern Movement Percentage of SUS data altered in period between (a) 5 Operational Days after month-end, and (b) the Inclusion Point for the month in question. 99% Clinical coding completed by inclusion. (3) TB JAB/JC Failure to agree the EMSA Plan in accordance with Clause 30.2 of the Core Legal Clauses JH KG Breach of an EMSA Plan milestone. Standard= 100% compliance with agreed EMSA plan. JH KG HSMR - Mortality - see the Quality Account ( I) QA GN CD's Never Events. Standard=0. (1) GN CD's/DGM's Serious Untoward Incidents - Trust to implement all actions arising from SUI's (1) JH JM/MM CQUIN = position at Q1 only VTE prevention- reduce avoidable death, disability and chronic ill health from Venousthromboembolism (VTE). % of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool. Threshold 90%. Patient Experience- Improve responsiveness to personal needs of patients. Adult inpatient survey conducted October- January 2012/13 for patients who had an inpatient episode July-August Patient Safety Themometer- Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those with a catheter, and VTE. Three consecutive quarterly submissions of monthly survey data will trigger full payment of the CQUIN. QA QA QA JH NB JH HJ JH LW Dementia- Improve awareness and diagnosis of dementia in acute hospital setting. % of patients aged 75+ who are screened on admission. % of patients aged 75 and over, who have a dementia risk assessment within 72 hours of admission to hospital. % of patients aged 75 and over, identified as at risk of having dementia who are referred for specialist diagnosis. Threshold 90%. Advancing Quality- Regionally led quality incentive scheme for Pneumonia, Hip and Knee Replacement, Acute Myocardial Infarction, Heart Failure and Stroke. Improving the standard of End of Life Care- implement Gold standards framework (GSF), establish project group, creation of a Bereavement centres, audit use of Liverpool Care Pathway (LCP) and advanced care planning and agreement of required actions. Delivery of the Diabetes NSF- Early referral and review for patients assessed as RED on the Think Glucose patient assessment tool. Assessment by a trained nurse within 24 hours of admission, education programme throughout the hospital, development of robust links to the community. Acute Stroke Admissions- Acute stroke beds in appropriate environments on clinical sites. Stroke steering group to implement agreed stroke strategies. Visit to Northumbria NHS Foundation Trust. Share existing stroke skills with CCG, development of ESD in community. Best Practice Dementia- Improved quality, experience and safety for all patients (and their carers) by avoiding unnecessary admissions, reducing length of stay, reducing admission rates. MDT Process (Across Organisational Boundaries)- Development of a complex discharge pathway across the whole health economy. Compliance with NICE MDT Guidance. Neck Of Femur at RLI- Improve the management and delivery of care for patients with fractured neck of femur at RLI Maternity- To ensure that all women using maternity services across Morecambe Bay have the opportunity to feedback on their experiences, improve the patient experience and act as an advisory group as part of the development of the clinical strategy for maternity. QA QA QA QA QA QA QA QA QA JH DMcG JH AQ Steering group JH JM JH PS JH PK JH JH? JH DMcG JSA/DMcG JH FC/SW Cardiology- One stop Cardiology clinics, plan to produce a business case for additional cardiology capacity, provide a 2 & 6 week turn around in Echocardiography for high risk patients. Heart QA Failure data collection and visit best practice site. JH AB/JAL Workforce Sickness absence rate ( in month, cumulative, and trust target = 3.5%) 35 PJ CD's/DGM's Turnover rates 35 PJ CD's/DGM's Appraisal completion - Target 100% By 30th September 35 PJ CD's/DGM's Mandatory training completion - Target 100% by end of December PJ CD's/DGM's Integrated Performance Report Page 7

40 AGENDA ITEM NO: /13 Monitor s compliance framework Operating framework standards 2012/13 Contractual Standards Page No Executive Lead Quality Standards & Risk Rating for September 2012 ( Cancer data One month behind) Other Priorities Stroke: 80% patients to spend 90% time in hospital on stroke unit 33 JW PK/JC Stroke: High risk TIA patients assessed and treated in 24 hours - standard = 60% JW PK/JC Clinical/Operational leads ( see Glossary of Initials) Achieving On Plan to achieve Under achieving Of Concern Movement Maternity cases seen under 13 weeks - Target = 90%. JW FC/SW Length of stay JW CD's/DGM's Day Case rates- targets to be defined. JW CD's/DGM's Guaranteed Appointment date - backlog 34 JW CD's/DGM's Day of Surgery on Admission - plan to be developed for all Divisions JW CD's/DGM's Out-patient DNA- targets to be defined. JW CD's/DGM's Out-patient new to follow up ratio- targets to be defined. JW CD's/DGM's % unplanned readmissions to hospital - targets to be defined. GN CD's/DGM's Glossary of Initials AB = Adrian Brodison CD = Clinical Directors DGM = Divisional General manager DMcG = Don McGowan FC = Fraser Cant GN = George Nasmyth HJ = Helen Jarram JA = John Coleman JAB = Julie Buckley JAL = Julian Auckland-Lewis JB = John Bannister JH = Jackie Holt JM = Joann Morse JSA = John Abraham JW = Juliet Walters KG = Kay Gilbey KW = Kim Wilson LP = Lorna Pritt LW = Lynne Wyre MM = Mary Moore NB = Nadeem Baquai PG = Paul Grout PJ = Paul Jones PK = Pradeep Kumar PS = Paul Smith TB = Tim Bennett Integrated Performance Report Page 8

41 Section 3a Declaration of performance against healthcare targets and indicators for Q3 & & Q1 part Q2 Target or Indicator (per Compliance Framework) Threshol d Weighti ng Annual Plan At Risk Q3 Met/Not Met Q4 Met/Not Met Clostridium Difficile -meeting the C.Diff objective as agreed 1.0 No Achieved Achieved MRSA - meeting the MRSA objective as agreed 1.0 No Achieved De Minimus 4 cases for the year Q1 Met/Not Met Failed to Meet 2 over in Q1 Achieved ( 1 case) July 2012 Failed to Meet Achieved AGENDA ITEM NO: /13 August 2012 Sept 2012 I in month but over YTD trajectory Achieved ( but one case in month) 3 in month but 1over YTD trajectory Achieved Q2 Met/Not Met Cancer 31 day wait for second or subsequent Achieved Not Not >94% 1.0 No Achieved Achieved Achieved Achieved treatment surgery available available Cancer 31 day wait for second or subsequent Achieved Not Not >98% 1.0 No Achieved Achieved Achieved Achieved treatment - drug treatments available available Cancer 31 day wait for second or subsequent Not Not Not Not >94% 1.0 No Not applicable Not applicable Not applicable treatment radiotherapy applicable applicable applicable applicable Cancer 62 Day Waits for first treatment (from urgent Achieved Not Not >85% 1.0 No Achieved Achieved Achieved Achieved GP referral) available available Cancer 62 Day Waits for first treatment (from Achieved Not Not >90% 1.0 No Achieved Achieved Achieved Failed to Meet Consultant led screening service referral) available available Referral to treatment time, 95th percentile, admitted patients <23Wks Achieved Failed to Failed to Failed to 1.0 No Achieved Achieved Achieved target - Maximum time of 18 weeks 90% Meet Meet Meet from referral to treatment - admitted Referral to treatment time, 95th percentile, nonadmitted patients <18.3Wk Achieved Achieved 1.0 No target - Maximum time of 18 weeks from s 95% Achieved Achieved Achieved Achieved Achieved referral to treatment non-admitted target - Maximum time of 18 weeks from Not Not referral to treatment patients on an incomplete 92% No applicable applicable pathway Achieved Achieved Achieved Achieved Achieved 31 Days from decision to treat to start of first Not Not >96% 0.5 No Achieved Achieved Achieved Achieved Achieved treatment: All Cancers available available Cancer 2 week (all cancers) >93% 0.5 No Achieved Achieved Achieved Achieved Achieved Not Not available available Cancer 2 week (breast symptoms) Not Not >93% 0.5 No Achieved Achieved Achieved Achieved Achieved available available A&E Clinical Quality- Total Time in A&E <4Hrs 0.5 No Failed to Failed to Failed to Failed to Failed to Meet Failed to Meet Failed to Meet Meet Meet Meet Meet Compliance with requirements regarding access to healthcare for people with a learning disability N/A 0.5 No Achieved Achieved Achieved Achieved Achieved Achieved Achieved Total Score Q1 1.5 Not available Achieved ( 1 case) Integrated Performance Report Page 9

42 Risk rating for 2012/13 Less than 1.0 Green AGENDA ITEM NO: /13 Q1 = 1.5 but overridden to Red due to CQC override From 1.0 to <2.0 Amber - Green Q2 data not complete yet, but July would have scored 1.5 but overridden to Red, From 2.0 to <4.0 Amber - Red August not yet complete 4.0 or higher Red Section 3b Declaration of Performance against Finance risk ratings Historic Year to 31 March 12 Plan YTD to 30 September 12 Underlying performance (EBITDA Margin) Achievement of plan (EBITDA % of plan achieved rating) Financial Efficiency Net return after financing rating IS Surplus margin rating Financial Efficiency rating Liquidity rating Actual YTD to 30 September 12 Weighted Average Rating The following overriding rule applies Two financial criteria at '1' highest achievable rating is "1" Limit due to overriding rules 1 1 Financial Risk Rating The table above shows the Trust s planned and actual Financial Risk Ratings for the six months ended 30 th September and the comparative figures for Performance is in line with the Annual Plan and Part 1 of the Recovery Plan submitted to Monitor. Part 2 of the Recovery Plan was submitted to Monitor as planned and includes further CIPs for 2012/13. However, the Trust s FRR will remain at 1 for the remainder of 2012/13. Integrated Performance Report Page 10

43 AGENDA ITEM NO: /13 Financial Performance For the period ending 30 September 2012 Narrative 1. Attached are tables and graphs showing the Trust's financial performance for the period ended 30th September The planned deficit for the first six months of the year was 15.6m against which actual performance was a deficit of 16.1m. 3. The main points to note for the six months ended 30th September are: * NHS Patient care income for the period was 1.26m better than planned (see IPR 1) ; Whilst income is over recovered for year to date, the commissioners have a limited amount of funds with which to pay for contract performance and to provide additional support to the Trust. An agreement on the amount of extra support the PCTs will provide in has not yet been reached but any over achievement against plans may result in a lower level of support being available. * The income figure includes an assessment of potential penalties which may be incurred as a result of the Trust's failure to achieve certain targets. These total 998k but have not yet been agreed with the Trust's commissioners. Where penalties can be identified to divisons they have been allocated against divisional income performance. The assessment of penalties is mixed sex accommodation [ 13k], 18 week referral to treatment [ 369k], A&E waiting times & ambulance handover [ 116k] and communications[ 500k]. * The Trust had three cases of Clostridium Dificile in September, taking the total for the year to date to 21, one more than the trajectory allowed. Failure to meet this target for the year will trigger further penalties, the amount of which would depend on the percentage by which the Trust exceeds its target of 40 cases. The current failure rate of 5% could incur a penalty of up to 2m. * A further provision of 741k has been made to take account of failure to meet CQUIN targets in full. * Pay budgets were 1.076m overspent; this includes overspendings on medical staffing budgets of 2.0m because of the use of agency locums, further details of which are included in IPR1b. These are partly offset by underspendings on other staff. * Non-pay budgets were overspent by 370k, detailed analysis is shown in IPR1a. 4. Divisional income & expenditure performance is shown in IPR 2, with supporting detail provided for each division in IPRs 2a - 2g. 5. Savings of 1.279m have been delivered against the target of 1.440m for the year to date (see IPR 2). The main changes have occurred in Surgery and Estates & Facilities divisions which are both reporting significant shortfalls against their targets in September (see IPR 2c & 2f). 6. The Trust had cash balances of 12.22m. The planned and actual cash flow to date for is shown in IPR Financial Appendix 2 7. Capital expenditure of 2.4m has been incurred to 30th September, 1m less than planned, details are shown in IPR Fin App 3 8. The FRR for September including the Trust's working capital facility is 1. Integrated Performance Report Page 11

44 AGENDA ITEM NO: /13 IPR Finance Table 1 - Income and Expenditure For the period ending 30 September 2012 Income and Expenditure September 2012 Cumulative to 30 Sep 2012 Trend Actual Plan Variance Actual Plan Variance '000 '000 '000 '000 '000 '000 Income NHS Clinical Income 17,924 17, , ,864 1,262 Non-NHS Clinical Income (26) Levies ,394 2,395 (1) Training and Education (13) 1,992 1,998 (6) Research and Development ,826 18, , ,456 1,290 Non-Clinical Income 1,410 1,586 (176) 8,151 8,236 (85) Total Income 20,236 19, , ,692 1,205 Expenditure Pay Costs 15,456 14,922 (534) 91,365 90,289 (1,076) Non-Pay Costs 6,278 6, ,873 38,503 (370) Total Expenditure 21,734 21,336 (398) 130, ,792 (1,446) EBITDA (1,498) (1,395) (103) (8,341) (8,100) (241) Technical Items Profit and Loss on Asset Disposal Depreciation and Amortisation ,313 5, Transfer from Morecambe Bay Hospitals Charity for the Purchase of Donated Assets Dividends and Other Finance Charges ,261 2, Interest Receivable (20) (5) 15 (135) (93) 42 Net Surplus / (Deficit) Before Asset Impairments and Severance Payments (2,742) (2,688) (54) (15,717) (15,634) (83) Impairment Value of Fixed Assets Cost of Severance Payments 16 0 (16) (381) Net Surplus / (Deficit) After Asset Impairments and Severance Payments (2,758) (2,688) (70) (16,098) (15,634) (464) The Trust has achieved an EBITDA for the period ended 30 September 2012 of (8,341) The Trust has achieved an EBITDA for the period ended 30 September 2011 of 6,225 The Trust recorded a surplus / (deficit) for the period ended 30 September 2012 of (16,098) The Trust recorded a surplus / (deficit) for the period ended 30 September 2011 of (1,153) Narrative 1. Non-elective activity reduced to the planned level in September but remains above plan for the year to date. Should activity return to the higher levels seen between April and August there remains the risk that activity will be above the emergency rate threshold, meaning that activity above this level will be paid at 30% of tariff price. Daycase and Elective activity was better than planned in September but income is still less than budgeted for the year to date. This is because the casemix of activity has less been than planned. The specialties which are over-performing are Gastroenterology, General Medicine, ENT and Oral Surgery. Outpatient activity across the Trust is above plan, although by less than in earlier months. 2. Pay overspendings because of the use of agency staff have continued, details are provided in IPR 1b. 3. Non-pay budgets underspent in the September; the main variances are explained in IPR 1a. Integrated Performance Report Page 12

45 AGENDA ITEM NO: /13 IPR Finance Table 1a - Analysis of Pay and Non-Pay Costs For the period ending 30 September 2012 Expenditure Sep 2012 September 2012 Cumulative to 30 Sep 2012 Trend Estab Worked Actual Plan Variance Actual Plan Variance WTE WTE '000 '000 '000 '000 '000 '000 Pay Costs Medical Staffing ,912 3, ,083 23, Agency Locums (Medical) (572) 3,728 1,244 (2,484) Nurse Staffing 1,895 1,721 5,143 5, ,340 33,560 2,220 Bank & Agency Nurses (491) 2, (2,176) Other Staff 2,064 1,916 5,124 5, ,486 31, Total Pay Costs 4,460 4,214 15,456 14,922 (534) 91,365 90,289 (1,076) Non-Pay Costs Drugs 1,404 1, ,019 9, Clinical Supplies and Services 2,080 2, ,097 13, General Supplies and Services ,181 2, Establishment Expenditure (10) 2,279 2, Premises and Fixed Plant 1,029 1, ,201 4,950 (251) NHS Ambulance Services 5 0 (5) (23) Other Non-Pay Costs 1, (206) 7,053 6,006 (1,047) Total Non-Pay Costs 6,278 6, ,873 38,503 (370) Total Expenditure 4,460 4,214 21,734 21,336 (398) 130, ,792 (1,446) Narrative 1. Medical staffing budgets continue to overspend because of the use of agency locums. IPR 1b provides detail on agency expenditure by division The has been a further small underspending on nursing and other staff, in line with that seen in August. Worked wtes have reduced slightly compared to August but remain higher than in the first four months of the year. Sickness for August was 4.4%, higher than in the earlier part of the year and is reflected in the use of bank staff (paid one month in arrears), which at 143 wte is the highest number of bank staff used in any month in 2012/13. The underspending on drugs was mainly in the two Medicine divisions and has continued the trend seen previously. However, the rate of underspending was higher in September because of refunds received from suppliers in September; these are not expected to recur. Clinical supplies underspendings are because of lower elective activity than planned in Surgery, particularly in Trauma & Orthopaedics, where the use of expensive prostheses has been less than budgeted. Expenditure on premises remains overspent but both energy ( 33k) and maintenance ( 11k) expenditure were less than budgeted in September. However the overspending arising from the cost of accommodation for agency staff continued, altogh at a slightly lower rate. The causes of the overspending in Other Expenditure continue to be those previously noted: the cost of the purchase of healthcare from other organisations to assist in the delivery of the 18 week target ( 490k), legal fees ( 150k) and consultancy fees ( 225k). Integrated Performance Report Page 13

46 AGENDA ITEM NO: /13 IPR Finance Table 1b - Trust Agency Expenditure For the period ending 30 September , , , , , , ,000 Agency Medical Staff 11/12 Agency Medical Staff 12/13 Other Agency Staff 11/12 Other Agency Staff 12/13 Payments at WLI Rate 11/12 Payments at WLI Rate 12/13 100,000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Narrative 1. Agency Medical Staff - This shows the Trust's monthly expenditure on agency medical staffing. Total expenditure for the year to date is 3.73m. Expenditure in the month was 753k compared to 594k in August, with the increase accounted for in Elective Medicine ( 152k) in both consultant and junior medical staff. The main areas of expenditure are ; Acute and Emergency Medicine Division - Progress has been made in filling the previously reported long standing vacancies in the RLI Emergency Department. All training grade posts are now filled and the middle grade vacancy has been appointed to with the appointee expected to take up post in mid-october. The remaining consultant vacancy is currently advertised. Expenditure on agency medical staff will therefore reduce in the coming months (IPR 2a). Elective Medicine Division - Additional activity in Dermatology and Gastroenterology and the covering of substantive consultant vacancies, in particular in Dermatology, continues to be provided by agency locums. The increased expenditure is due to the recruitment of an additional agency consultant in Rheumatology (there are now two in post) and the use of agency staff in General Medicine. There are also currently four agency locum consultants in Dermatology. Expenditure on locum consultants is anticipated to continue at the current levels for the remainder of the financial year in order to meet activity demands. Women's and Children's Services - Agency expenditure has reduced to 47k in September from an average for the first four months of 62k. As previously reported a paediatric consultant took up post at FGH at the beginning of August. Vacancies on the junior rotas at RLI previously covered by agency staff have now been filled on the new rotation of training grade doctors. Surgery and Critical Care Division - The use of agency locums has continued covering 11WTE junior and middle grade vacancies mainly in Trauma & Orthopaedics, General Surgery and Anaesthetics. Actual agency costs for the month were approx 20k lower than previous month, with reduced requirement for leave cover. Active recruitment for vacancies is ongoing within Employment Services and alternative options are being considered by Clinical Service Managers and Senior Management Team. Other Agency Staff - This is the cost incurred on all other agency staff excluding doctors. Additional expenditure for agency midwives is 125k in September. This is higher than planned as the division have retained agency midwives above approved levels. A large part of additional spend is as a result of HR issues. As reported last month, hearings have been scheduled with some completed in September producing resolutions with further hearings scheduled in the coming month. It is expected that once these hearings are concluded it will enable the division to reduce agency use. The division will be presenting the rationale for the need for increased staffing levels to executives in October. Payments at WLI Rate - This refers to all expenditure incurred by the Trust for waiting list payments made to medical staff and any other additional payments made at the Waiting List rate i.e. additional sessions, or for staff covering sickness, annual leave etc. Integrated Performance Report Page 14

47 AGENDA ITEM NO: /13 IPR Finance Table 1c - Monthly Surplus/Deficit Monitoring For the period ending 30 September 2012 'm (0.500) Planned Monthly Surplus / (Deficit) Actual Monthly Surplus / (Deficit) Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 (1.000) (1.500) (2.000) (2.500) (3.000) (3.500) Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 'm 'm 'm 'm 'm 'm 'm 'm 'm 'm 'm 'm Planned Monthly Surplus / (Deficit) (3.035) (2.199) (3.197) (2.289) (2.227) (2.687) (1.431) (1.702) (2.902) (1.682) (2.235) (1.682) Planned Cumulative Surplus / (Deficit) (3.035) (5.234) (8.431) (10.720) (12.947) (15.634) (17.065) (18.767) (21.669) (23.351) (25.586) (27.268) Actual Monthly Surplus / (Deficit) (3.109) (1.935) (2.862) (2.643) (2.792) (2.758) Narrative The graph above shows actual financial performance compared to plan for the period ended 30 September The surplus/deficit shown in the graph includes the cost of severance payments. Integrated Performance Report Page 15

48 AGENDA ITEM NO: /13 IPR Finance Table 2 - Divisional Financial Performance For the period ending 30 September 2012 Income & Expenditure Performance Income from Activity Net Expenditure Total Actual Plan Variance Actual Plan Variance Actual Plan Variance '000 '000 '000 '000 '000 '000 '000 '000 '000 Acute and Emergency Medicine Division IPR 2a 25,521 25, ,626 15, ,895 9, Elective Medicine Division IPR 2b 10,111 9, ,271 15,433 (838) (6,160) (6,202) 42 Surgery and Critical Care Division IPR 2c 40,605 41,738 (1,133) 34,894 34,678 (216) 5,711 7,060 (1,349) Women's & Children's Services IPR 2d 12,583 12, ,294 11,447 (847) (479) Core Clinical Services IPR 2e 5,953 5, ,890 19, (12,937) (13,340) 403 Estates & Facilities IPR 2f ,889 9,767 (122) (9,889) (9,767) (122) Corporate Services IPR 2g ,358 12,124 (234) (12,358) (12,124) (234) Total Divisions 94,773 94, , ,387 (1,835) (25,449) (24,235) (1,214) Savings Performance Annual Cumulative to 30 Sep 2012 Plan Plan Achieved Variance '000 '000 '000 '000 Acute and Emergency Medicine Division* IPR 2a Elective Medicine Division* IPR 2b Surgery and Critical Care Division IPR 2c 1, (58) Women's & Children's Services IPR 2d Core Clinical Services IPR 2e Estates & Facilities IPR 2f (39) Corporate Services IPR 2g Trust-Wide IPR 2h (203) Total 5,399 1,440 1,279 (161) * The Acute and Emergency Medicine Division currently hold the shared savings plan in 2012/13 for both Medical Services divisions. Narrative See individual divisional financial performance tables for further details. Integrated Performance Report Page 16

49 AGENDA ITEM NO: /13 IPR Finance Table 2a - Divisional Performance Acute Medicine Division For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity 25,521 25, Income 432k over-recovered YTD against plan. Income is over-recovered for the year to date with extra activity in Net Expenditure 15,626 15, General Medicine, following the year to date trend. There have been 9,895 9, an additional 409 non-elective spells above plan in the first six months of the financial year. Income ( 102k) for a particularly long patient spell recently completed has also been included in this month's income figure. Pay 10k over YTD budget. Medical staffing remains the key area of concern with six vacancies currently experienced and a 205k year to date overspend. In the emergency department at the RLI, all training posts have been filled for the first time in a number of years, the last middle grade vacancy is appointed to with effect from mid-october and the consultant vacancy is currently advertised. These changes will see the overspend on locum cover reduce in the coming months. The exact amount will depend on which current cover methods are able to be replaced (ie our own consultants or middle grades working fewer extra hours or agency bookings being reduced). Nurse staffing is 202k underspent, with a large proportion of this relating to CIP (ie vacancies where posts will be removed from November). Non Pay 91k under YTD budget. The main reason for the non-pay underspending is drugs. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Year to date CIP Savings 16k ahead of YTD Plan. The savings shown now relate solely to the Acute Medicine Division, with agreement of the allocation of savings between Acute and Elective Medicine finalised in September. Overall, the savings are ahead of plan at this point and work is continuing to develop plans to deliver further savings. Integrated Performance Report Page 17

50 AGENDA ITEM NO: /13 IPR Finance Table 2a - Divisional Performance Elective Medicine Division For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity (10,111) (9,231) 880 Income 880k over YTD budget. Net Expenditure 16,271 15,433 (838) 6,161 6, Over performance on Day Case and Elective work has continued in line with the trend of the first five months. Increased activity in Gastroenterology, Dermatology and General Medicine has resulted in over-recovery of income by 521k year to date. In the first six months of the year there have been 986 additional spells. This additional demand, which the division forecast to continue for the remainder of the financial year, has carried cost in premium capacity sessions and locum usage. Potential income penalties of 68k have been deducted in respect of 18 week breaches. Pay 973k over YTD budget. The staffing of activity at premium rates has resulted in overspending on agency medical staff at all levels of seniority. The majority of this is directly related to additional capacity provided to meet increasing demand (see above). Following the completion of the Division's capacity and demand review, work towards the provision of sustainable services utilising permanently employed staff is in progress. However, given the timescales involved in the recruitment of consultants the division do not anticiapte substantive staff being in post before 1st April Non-pay & non-clinical income 135k under YTD budget. The underspend on non-pay relates to drugs ( 177k under year to date) where in September a number of refunds have been received from suppliers. All other budgets are largely in line with plan. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity Savings on YTD Plan. Savings are now shown in respect of the Elective Medicine Division following agreement between Acute and Elective Medicine on the split of the majority of schemes. Elective Medicine is slightly ahead of its savings plan and work to ensure delivery of remaining savings is continuing. Integrated Performance Report Page 18

51 AGENDA ITEM NO: /13 IPR Finance Table 2c - Divisional Performance Surgery and Critical Care Division For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity 40,605 41,738 (1,133) Income 1.1m under YTD budget. Net Expenditure 34,894 34,678 (216) 5,711 7,060 (1,349) Daycase and elective activity is down by 535 spells year to date which equates to a reduction in income of 958k. As in previous months, the main area affected continues to be Trauma & Orthopaedics which accounts for 832k of this shortfall. A demand and capacity review for Trauma & Orthopaedics has now been completed and indentified the capacity shortfall across the Trust. The Divisional General Manager and Service Managers are preparing plans to provide additional capacity as a long term solution to addressing shortfalls. It is anticipated that current working arrangements will continue until the end of Theatre utilisation work is also taking place, through which it is intended to increase efficiency. Non elective and non elective excess bed days income has underachieved by 162k year to date. General Surgery continues to account for the majority of this underachievement. Outpatient activity continues to overachieve by 330k for year to date. Pay 618k over YTD budget. The pay overspend is due to medical staffing expenditure, which is 928k over spent for the year to date. Locum and agency spend has continued, covering substantive vacancies in Trauma & Orthopaedics, General Surgery at RLI and Anaesthetics. Agency spend is monitored constantly to ensure that costs are kept to a minimum. We are also actively working to fill key vacancies, and have successfully recruited to a key Consultant post at FGH, which should result in a reduction in agency spend of approximately 20k per month in coming months. The Surgical division has continued to provide a large number of additional sessions at premium rates, in particular for Trauma & Orthopaedics, Ophthalmology and Urology. The division is continuing to work towards increasing baseline capacity where needed to reduce future waiting list costs and address the current demand and capacity issues across the specialities. Non Pay 272k under YTD budget. Non pay expenditure remains underspent year to date, predominantly as a result of activity levels remaining below plan, and therefore reduced usage of supplies. All non-pay budgets are currently being reviewed, supplies budgets in particular, in order to establish the extent to which in year expenditure can be reduced. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Year to Date CIP (58) Savings 57k under YTD Plan. The division has achieved 178k of savings for the year to date. There had been some slippage relating to the best practice tariff schemes in earlier months. Issues have been identified and work is ongoing with both service managers and clinicians, which is now leading to an improvement in performance. 37k of the year to date under-achievement is because of a later than planned implementaion to changes in the procurement of prostheses, the savings for which will now begin in October. Further savings initiatives are under consideration to complement the current plan. These include additional best practice tariff measures. Integrated Performance Report Page 19

52 AGENDA ITEM NO: /13 IPR Finance Table 2d - Divisional Performance Women's and Children's Services For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity 12,583 12, Income 368k over YTD budget. Net Expenditure 12,294 11,447 (847) Children & Young People's income is 12k behind plan for the year to date, there is an over-recovery in non-elective work offset by an under-recovery on outpatients. The entirety of the over-performance can be attributed to volume. Women's Health is ahead of plan by 379k, the majority ( 223k) of which is additional non-elective activity, with a further 106k of the over performance attributable to Gynaecology Outpatients (479) Pay 629k over YTD budget. The main area of overspend is the continued requirement to employ agency doctors and midwives. The use of agency doctors is primarily to cover vacant posts and gaps in the rota, whilst midwives are being employed to cover for sickness and other staff absences. The spending on agency midwives is 125k in month. The division has completed its rationale for additional midwives and this is to be presented to executives on 24th October. Non Pay 218k over YTD budget. The use of agency staff in Women's Health is causing a pressure on non-pay budgets, as the division is required to pay for accommodation and travel. There is also an increased cost being seen in drugs and clinical supplies and services, though with the over performance in income, this is not totally unexpected. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity Savings 39k ahead YTD Plan. Following a period of investment in services the division did not find savings in the first part of the year. Work has been undertaken to identify efficiency improvements and these will in future reduce the cost of running the service. There are now plans in place to deliver 180k of schemes in this financial year and further opportunities are being prepared potentially to add to this total. Integrated Performance Report Page 20

53 AGENDA ITEM NO: /13 IPR Finance Table 2e Core Clinical Services For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity 5,953 5, Income 75k over YTD budget. Net Expenditure 18,890 19, Direct Access Radiology income is 109k ahead of plan year to date, (12,937) (13,340) 403 with Interventional Radiology income lower than plan by 31k year to date. Pay 503k under YTD budget. The year to date underspend results from the phasing of funds issued to support additional activity in the early part of the year. This month has seen the reversal of the trend of pay underspending for the Division, with an overspend of 29k in month. This arises primarily from medical staffing and the use of agency locums. The use of medical agency staff in Radiology has stopped at RLI, as a result of the recruitment of three new consultants. Agency use continues at FGH, to provide cover for further vacancies and to support additional activity. The recruitment process is underway for these posts and these should be filled in the New Year. Expenditure on agency pharmacists continues as a significant pressure at RLI and FGH, resulting from Band 6 retention problems and high levels of maternity leave. There are currently eight staff on maternity leave with only two expected to return this financial year. Non Pay 151k over YTD budget. External reporting within Radiology accounts for 135k of this variance, but has reduced significantly this month as consultant vacancies have been filled. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Year to date CIP Savings 47k ahead of YTD Plan. CIPs have been delivered year to date but work continues to put in place additional CIP schemes to realise recurrent savings by quarter 4. At present 1.079M, 2.8% of net budgeted expenditure, has been identified. Budget holder sessions have been held at each site to extend engagement with this process and to generate further ideas. Amnesty ideas are currently being gathered, some of which relate to Trustwide potential schemes. Integrated Performance Report Page 21

54 AGENDA ITEM NO: /13 IPR Finance Table 2f - Divisional Performance (Estates and Facilities) Estates and Facilities For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity 0 Pay 7k over YTD budget. Net Expenditure 9,889 9,767 (122) Pay is slightly overspent for the year to date. Although there are vacancies within the division these are currently below the numbers needed to meet the divisional vacancy factor target. 9,889 (9,767) (122) Non Pay 95k over YTD budget. The use of additional ambulances, including internal transfers on the RLI site, has continued with an overspending of 88k for the year to date. The division has placed an order to lease an ambulance for internal site use at the RLI, delivery is expected by 31 January Annual savings will be in the region of 13k. Electricity budgets remain overspent ( 67k for the year to date) but were underspent in September. The invoices received so far for September 2012 show a fall in consumption. The Division continues to publish articles in the Weekly News to educate staff about reducing energy consumption. Investment of approximately 15k in energy efficient lighting and motion sensor lighting has been installed in some areas of the Trust to reduce consumption. This expenditure will pay back in 2.5 years. The Trust has identified a preferred energy partner to assist in identifying potential energy savings. The procurement process is in the final stages and is due to end on 23rd October. Income 21k under-recovered YTD Budget The decision to provide updated T3 screens in Interim 2 had associated installation costs of 60k. The Divisional General Manager contracted with the supplier to install the screens free of charge in exchange for the cancellation of outstanding energy recharges ( 16k) and nil future energy recharges for RLI ( 4k per year) as this was the cheaper option. Ramsay income at WGH will cease in November 2012 which will reduce income by 39k per month. An additional 13k income per month will be received as a consequence of the Renal Service transferring to Lancashire Teaching Hospitals. 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Year to Date CIP (39) Savings 38k behind YTD Plan. The division has a cost improvement target of 4.5%. The division expects not to achieve the Hospedia energy CIP due to the new contract. However, the division does expect to deliver the full savings target through the identification of further schemes. There has been a delay in implementing changes to rotas resulting in an under achievement of cost improvement plans of 74k for the year to date. These schemes are now due to be implemented in November. Integrated Performance Report Page 22

55 AGENDA ITEM NO: /13 IPR Finance Table 2g - Divisional Performance Corporate Services For the period ending 30 September Year To Date Income & Expenditure Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Income from Activity Net Expenditure 12,358 12,124 (234) Pay is 181k under budget YTD. 12,358 12,124 (234) The major underspending has been against vacant posts, many of which have been covered by interim appointments which are included in the consultancy fees below. Non Pay 424k over YTD budget. The main overspent budgets are: Legal fees ( 142k), arising mainly from advice relating to maternity and other governance concerns. Consultancy fees ( 203k) This is due to later than planned appointments to permanent posts and the need for additional support to complete the Trust's Recovery Plan. In addition divisional expenditure includes severance payments of 33k 2. Year To Date Savings Performance Actual Plan Variance Main variances, proposed actions, estimated effect of actions '000 '000 '000 actions (including start date) and accountable person Integrated Performance Report Page 23

56 AGENDA ITEM NO: /13 IPR Finance Table 5 - Financial Risk Rating For the period ending 30 September 2012 Metric Weighting Annual Plan 2012/13 September 2012 Plan September 2012 Actual % Ratio Risk Rating % Ratio Risk Rating % Ratio Risk Rating A. EBITDA Margin 25.00% -6.20% % % 1 B. EBITDA % Achieved 10.00% 84.70% % % 5 C. Return on Assets 20.00% % % % 1 D. I&E Surplus Margin 20.00% % % % 1 E. Liquid Ratio 25.00% Weighted Average Rating Narrative The Trust's Financial Risk Rating is 1 (more than one component of the FRR is 1). This is as expected based on the Trust's financial plan for the year. Integrated Performance Report Page 24

57 AGENDA ITEM NO: /13 IPR Finance Appendix 1 - Statement of Financial Position Opening Prev Mth Curr Mth Balance Balance Balance 01 Apr Aug Sep 12 '000 '000 '000 NON CURRENT ASSETS Property Plant & Equipment 136, , ,572 Intangible Assets Other Assets 1,667 1,805 1,789 Total Non Current Assets 138, , ,003 CURRENT ASSETS Inventories 2,241 2,163 2,347 Trade & Receivables 7,522 6,901 7,515 Cash & Cash Equivalents - GBS 18, Cash & Cash Equivalents - Commercial Cash 12 15,040 12,029 Total Cash & Cash Equivalents 18,296 15,312 12,221 Total Current Assets 28,059 24,376 22,083 TOTAL ASSETS 166, , ,086 CURRENT LIABILITIES Trade & Other Payables (16,072) (16,208) (15,356) Provisions (266) (166) (147) Tax Payable (3,434) (3,484) (3,377) Other Liabilities (1,513) (8,759) (9,662) Total Current Liabilities (21,285) (28,617) (28,542) Net Current Assets/(Liabilities) 6,774 (4,241) (6,459) Total Assets less Current Liabilities 145, , ,544 NON CURRENT LIABILITIES Borrowings - Provisions (1,968) (2,062) (2,078) Total Non Current Liabilities (1,968) (2,062) (2,078) TOTAL ASSETS EMPLOYED 143, , ,466 TAXPAYERS EQUITY: Public Dividend Capital 126, , ,145 Revaluation Reserve 26,095 26,095 26,095 Donated Asset Reserve Retained Earnings (Brought Forward) (8,675) (8,675) (8,675) Retained Earnings (In Period) - (13,341) (16,099) TOTAL TAXPAYERS EQUITY 143, , ,466 Better Payment Practice Code Trade - % by number 92% Trade - % by value 95% NHS - % by number 78% NHS - % by value 94% Narrative The Trust has signed up to the Prompt Payment Code which is a government initiative to tackle late payment issues and help small businesses in the challenging financial climate. Surplus cash balances continue to be invested and this is reflected in the cash balances shown in commercial accounts. Cash is 3.0m above planned levels due to: recovery of receivables outstanding 1.2m; increased payables of 2.3m; this is offset by a worsening I & E position 0.5m. Other liabilities includes 8.2m of deferred income received in cash from the Trust's main commissioners in line with the agreed profile for contract payments. Integrated Performance Report Page 25

58 AGENDA ITEM NO: /13 IPR Finance Appendix 2 - Cash Flow Forecast For the period ending 30 September 2012 '000 25,000 20,000 15,000 Forecast Actual 10,000 5,000 0 (5,000) Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 (10,000) (15,000) (20,000) Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Feb 13 Mar 13 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 Forecast 22,564 22,130 19,411 16,565 14,137 9,221 7,147 3, (3,738) (8,723) (15,770) Actual 22,782 22,285 22,877 20,340 15,312 12,221 Variance ,466 3,775 1,175 3,000 Variance % 1.00% 0.70% 17.86% 22.79% 8.31% 32.53% Narrative 1. The Trust's cash balances as at 30th Sep amounted to 12.2m, 3m better than planned due to: Outstanding invoices have been settled sooner than anticipated to the value of 1.2m - The Trust's I & E position is 0.5m worse than planned - Payables are 2.3m higher than planned Integrated Performance Report Page 26

59 AGENDA ITEM NO: /13 IPR Finance Appendix 3 - Capital Expenditure Scheme Annual Cumulative to 30 September 2012 Plan Plan Variance Actual '000 '000 '000 '000 Estate Schemes 3,000 1, IT Strategy (64) 233 Medical Equipment 2, Emergency Department RLI 1, (126) 996 Oncology RLI Other capital schemes 1, Total 9,080 3, ,434 Narrative 1. Charitably funded capital to 30 September totalled 63k A number of schemes within the Estate Schemes category are behind plan where these relate to MU1. Replacement of boilers at WGH is also behind schedule. Expenditure on the Emergency Department scheme remains ahead of plan in line with the earlier completion of this scheme. Medical equipment priorities have been assessed and expenditure is expected to increase in line with the plan from October onwards. Depreciation on fixed assets in September amounted to 892k. Integrated Performance Report Page 27

60 AGENDA ITEM NO: /13 IPR Finance Appendix 4 - Comparison of Planned and Actual Activity For the period ending 30 September 2012 Daycase & Elective Non Elective Spells 3600 Spells DC & EL Actual Activity 10/ DC & EL Actual Activity 11/ DC & EL Planned Activity 12/ DC & EL Actual Activity 12/ NEL Actual Activity 10/ NEL Actual Activity 11/ NEL Planned Activity 12/ NEL Actual Activity 12/ Accident & Emergency 3700 Non Elective Excess Bed Days Attendances Excess Bed Days A&E Actual Activity 10/ A&E Actual Activity 11/ A&E Planned Activity 12/ A&E Actual Activity 12/ NEL XBD Actual Activity 10/ NEL XBD Actual Activity 11/ NEL XBD Planned Activity 12/ NEL XBD Actual Activity 12/ Attendances All Outpatient Attendances OP Actual Activity 10/ OP Actual Activity 11/ OP Planned Activity 12/ OP Actual Activity 12/ Attendances Outpatient Procedures OP Proc Actual Activity 10/ OP Proc Actual Activity 11/ OP Proc Planned Activity 12/ OP Proc Actual Activity 12/ Outpatient First Attendances Outpatient Follow Up Attendances Attendances Attendances OP FA Actual Activity 10/ OP FA Actual Activity 11/ OP FA Planned Activity 12/ OP FA Actual Activity 12/ OP FUP Actual Activity 10/11 OP FUP Actual Activity 11/ OP FUP Planned Activity 12/ OP FUP Actual Activity 12/ Integrated Performance Report Page 28

61 Section 5 Indicator details - Assessment against Monitor s compliance framework AGENDA ITEM NO: /13 MRSA Bacteraemia (Patient Experience) Incidence of MRSA bacteraemia bloodstream infections Standard= 3 cases in year September = 0 case Year to date= 2 cases The trust has a target of 3 c ases of MRSA bacteraemia for this financial year with one case in April in the Acute Medicine Division resulting from a device related incident. The second case took place with the Surgical and Critical Care Division in August. The root cause analysis will be complete by the end of September. All staff should be t rained annually in hand hygiene and t he training recorded on the TMS system. All relevant staff will shortly receive ANTT training, with a new e learning package available on the TMS system for all staff. Clostridium Difficile (Patient Experience) Standard= 40 cases in year September = 3 cases Year to date= 21 cases Antimicrobial prescribing audits continue quarterly with additional audits taking place on wards with cases of C difficile infection. Further work is required around antimicrobial stewardship in partnership with pharmacy and medical teams. A C difficile action plan has been developed and is reviewed monthly current actions include; training for ward staff in cleaning practices in collaboration with hotel services and monthly commode inspections undertaken by the Infection Prevention team. Integrated Performance Report Page 29

62 Cancer 62 Day Waits for first treatment (from Consultant led screening service referral) Standard=90%. (1, 3) AGENDA ITEM NO: /13 Percentage of cases % % 80.00% 60.00% 40.00% 20.00% 0.00% Cancer 62 Day Waits for first treatment (from Consultant led screening service referral) Performance Period Standard Standard = 90% August= 87.90% 2 patients waited longer than 62 days for treatment after referral from a screening service in August The first breach patient was on holiday during their pathway for 8 weeks and the second patient was unfit for their cancer treatment as they needed other conditions to be resolved before treatment could commence. Unfortunately there are no waiting time adjustments that can be made for these patients, and were not due to any unnecessary. CCG colleagues have been asked to ensure that patients are only referred into the Trust when they are ready and available to attend, to help limit the number of patient choice breaches A&E Clinical Quality- Total Time in A&E <4 hours (1, 3, 4) Integrated Performance Report Page 30

63 4 Hour Standard=95% Trust=92.47% RLI= 91.76% FGH= 93.59% Action On track to achieve 95% at Trust level by 25/11/12 and by site; RLI- from 14/10/12, FGH- from early December. Actions during September have included; FGH: - Appointment of 1 acute physician. -Conversion of eye cubicle into additional minor/additional triage area. RLI: -Refurbishment completed in Emergency Department clinical areas. -Consultant weekend work trialled -proving successful. AGENDA ITEM NO: /13 Actions to take place in October include FGH -Second acute physician starts end of October. -Review of Primary Care Access Service/Clinical Delivery Unit/Single Point of Access pilot. RLI -Advert for 5 th Emergency Department consultant, to start in the New Year. -Medical Unit one wards move to interim 2. Integrated Performance Report Page 31

64 AGENDA ITEM NO: /13 Section 6 Indicator details - Summarised performance against 2011/12 Operating framework standards (If not shown above) Referral to treatment time, admitted patients. Standard= 90% of completed patient pathways where the patient waited <18 weeks Standard = 90% Trust = 87.95% The Trust failed the admitted RTT standard in September due to high numbers of patients in General Surgery, Ophthalmology and Trauma & Orthopaedics waiting longer than 18 weeks for their treatment. General Surgery is on trajectory to achieve the 18 week standard from 01/12/12 and Ophthalmology from 01/11/12.Detailed action plans to increase capacity include re-designing Consultant job plans, additional in-house and independent sector theatre lists and improving efficiency of theatre lists. RTT specialties with failed delivery - new (1, 3, 4) - Number of treatment functions where standards are not delivered (admitted, nonadmitted and incomplete pathways) The aggregate non-admitted and incomplete Trust standards were both achieved in September; however the Trust failed the admitted RTT standard. 13 specialties failed to deliver the RTT standards in September. The 13 specialties were made up of; 5 Incomplete pathways (General Surgery, Trauma & Orthopaedics, Gastroenterology, Geriatric Medicine, Respiratory Medicine) 3 Admitted (General Surgery, Ophthalmology and Trauma & Orthopaedics) 5 Non- admitted (General Surgery, Urology, Cardiology, Gastroenterology, and Respiratory Medicine). Detailed plans and trajectories to achieve 95% in failing specialties by 01/01/13 are currently in the process of being finalised. Integrated Performance Report Page 32

65 Section 7 Indicator details 2012/13 Contractual Standards Quality Requirements AGENDA ITEM NO: /13 Provider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission This standard relates to the total number of elective care operations cancelled after admission in September Standard= 0.8% September = 1.23% - Q2 level at 1.43% 46 on-day cancellations in theatre for the month of September: 19 emergencies took priority 7 admin error 7 lack of time in theatre 4 no bed 8 no case-notes available 1 no anaesthetist Actions: - Performance has improved in month. A review of the admin errors is to take place with corrective actions to be taken. Cancelled operations- Not offered guaranteed new date within 28 days This standard relates to the number of patients with a previous cancellation who were not rebooked within the guaranteed 28 day period. Standard= 0 September position = 9 Of the 9 patients, 4 were treated in September, 3 in October, 1 patient has deferred treatment and 1 to be seen in outpatients for a further discussion. The escalation process to ensure that all patients are rebooked within 28 days will be reviewed and implemented by 31 st October. Integrated Performance Report Page 33

66 Provider failure to ensure that sufficient appointment slots are made available on the Choose and Book system (4) AGENDA ITEM NO: /13 Standard: <= 4% September position= 6% The position has improved in month however there were 169 appointment slot issues, mainly in Children s services, cardiology, Neurology, GI & Liver. Additional capacity is being sought within the relevant specialties to ensure that slots are available to book >96% of patients directly through the Choose and Book system. Ambulance handover compliance The standard relates to the percentage compliance of entering arrivals data into the hospital arrivals screens. Standard= 95% September RLI= 48.33% September FGH= 42.56% FGH performance has substantially improved, with a decline in month at the RLI -All triage screens have been installed at each site to improve the efficiency of data entry. -The ambulance services handover plan is in the process of review in order to maximise compliance. -An NWAS Sector Manager is in post for 3 months with the objectives of reducing ambulance turnaround times and training/raising awareness of arrivals compliance via the HAS screens. Integrated Performance Report Page 34

67 Stroke: 80% patients to spend 90% time in hospital on stroke unit Percentage of patients % 80.00% 60.00% 40.00% 20.00% 0.00% Stroke: 80% patients to spend 90% time in hospital on stroke unit Period FGH RLI Performance Standard AGENDA ITEM NO: /13 Standard: 80% of patients to spend 90% of time on an acute stroke unit. August Snapshot view of Trust = 68.97% - The RLI position has improved substantially in month, whereas the decline in performance at FGH is under review. 3 additional stroke beds will be available at the RLI following opening of Interim 2 and the service is on trajectory to achieve 80% in November as planned. Standard 80% Q1 July August Trust position 66.89% 62.50% 68.97% FGH position 80.00% 88.24% 76.19% RLI position 57.95% 45.45% 64.86% A&E Clinical Quality- Time to Initial Assessment (95 th percentile) A&E Clinical Quality-Time to initial assessment 15 minute Standard= 95% RLI= 15 minutes The RLI has achieved the 15 minute standard. The data collection for this standard at FGH is under review. Integrated Performance Report Page 35