DUDLEY CLINICAL COMMISSIONING GROUP BOARD AGENDA

Transcription

1 DUDLEY CLINICAL COMMISSIONING GROUP BOARD AGENDA Monday 30 March pm 4.00pm Boardroom, Brierley Hill Health and Social Care Centre, Venture Way, Brierley Hill, DY5 1RU QUORACY Meetings will be quorate when four elected GP clinical members and one other Board member are present, (one of whom shall be the CCG Chair, Chief Officer or Chief Finance Officer) Time Agenda Item Attachment Presented By 1.00pm 1. Apologies 1.00pm 2. Declarations of Interest To request members to disclose any interest they have, direct or indirect, in any items to be considered during the course of the meeting and to note that those members declaring an interest would not be allowed to take part in the consideration for discussion or vote on any questions relating to that item. 1.05pm 3. Budget Book 2015/16 Enclosed Mr M Hartland 1.35pm 1.50pm 4. Dudley Group Foundation Trust Draft Annual Quality Account 5. Primary Care Co Commissioning Approval for Delegated Arrangements Enclosed Enclosed Ms T Curran Mr P Maubach 2.10pm 6. Revised Conflicts of Interest Enclosed Mr S Wellings 2.25pm 7. Use of Dudley CCG Seal Enclosed Mr M Hartland 2.35pm 8. Five Year Forward View/Vanguard System Enclosed Mr P Maubach 2.50pm 9. NHS 111 West Midlands Procurement Update Enclosed Mr N Bucktin 3.00pm 10. Unannounced Visit Report Dudley Group Foundation Trust Enclosed Ms T Curran 3.20pm 11. EPRR Core Standards Checklist Action Plan Enclosed Ms T Curran 3.35pm 12. Equality and Diversity/Health Inequalities Enclosed Mr N Bucktin 4.00pm Close 13. For Information 13.1 Glossary Enclosed Date and Time of Next Meeting Thursday 14 May pm 4pm Boardroom, Brierley Hill Health and Social Care Centre

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3 DUDLEY CLINICAL COMMISSIONING GROUP Date of Board: 30 March 2015 Report: CCG Financial Budgets for 2015/16 Agenda item No: 3 TITLE OF REPORT: CCG Financial Budgets for 2015/16 PURPOSE OF REPORT: To present baseline budgets for the financial year 2015/16 AUTHOR OF REPORT: MANAGEMENT LEAD: CLINICAL LEAD: KEY POINTS: Mr J Smith, Head of Financial Management Corporate Mr M Gamage, Head of Financial Management Commissioning Mr M Hartland, Chief Operating and Finance Officer Mr M Hartland, Chief Operating and Finance Officer Dr J Rathore, Clinical Executive for Finance and Performance Planned Revenue Surplus 6,295,000 QIPP/savings programme of 7,190,000 in 2015/16 Financial risk of up to 5m across the portfolio of CCG managed budgets New financial governance framework for 2015/16 The Committee is requested to approve: RECOMMENDATION: FINANCIAL IMPLICATIONS: ACTION REQUIRED: the budgets for the CCG as set out in this paper the adoption of the new financial governance framework for 2015/16 See key points Decision Approval Assurance Page 1 of 12

4 DUDLEY CCG FINANCIAL BUDGETS FOR THE PERIOD 1 ST APRIL 2015 TO 31 ST MARCH 2016 CONTENTS 1. Introduction 2. Financial Overview 3. Financial Plan 2015/ Sources of funding 3.2 Financial structure 3.3 Planned Expenditure Acute Services Mental Health Primary Care Development Drugs and GP Prescribing Continuing Healthcare Community Services Other Commissioning and Reserves Corporate Services 4. Better Care Fund 5. Integration 6. Quality, Innovation, Productivity, Prevention (QIPP) 7. New Financial and Governance Framework 8. Risk Management 9. Contingency/1% Non-Recurrent Expenditure Planning 10. Capital 11. Statement of Financial Position - Balance Sheet 12. Cash Limit 13. Summary/Conclusion 14. Recommendation APPENDICES 1. Resource Limit 2. Financial Summary 2a Financial Detail 3. Savings Plan / QIPP 4. Sources & Applications 5. Statement of Financial Position 6. Cash Plan 7. Budgets by Budget Holder 8. Contract Lead Commissioners 9. Services within Integration Model 10. Better Care Fund Services Page 2 of 12

5 1. INTRODUCTION This paper sets out the proposed budgets of Dudley CCG for 2015/16. It provides an overview of the resource environment for the NHS and outlines key financial targets the CCG must achieve, together with an assessment of the financial risks to the CCG. The CCG has three financial statutory targets:- to achieve revenue breakeven or better to achieve capital breakeven against the capital resource limit to achieve a breakeven on the cash limit. The CCG is also expected to comply with the Public Sector Payment Policy (also known as the Better Payment Practice Code) which requires the CCG to pay 95% of valid invoices within 30 days of their receipt or the receipt of goods or services (whichever is the later) unless other payment terms have been agreed. The CCG is also required to ensure that cash balances at month-end are within 1.25% of the cash requested and drawn down from NHS England. The budget book builds upon the NHS Forward View into Action: Planning for 2015/16 and additional supporting technical guidance issued by NHS England. 2. FINANCIAL OVERVIEW The CCG s revenue baseline in 2015/16 is 403.3m. This excludes the funding that will transfer to the CCG as a result of the delegation of primary care commissioning. The Budget Book presented to the Board identifies a balanced financial plan for 2015/16, with plans to achieve a surplus of 6.3m in 2015/16. This is in line with the control total set by the NHS West Midlands Sub-Regional team. It also reflects NHS England requirements in respect of key planning assumptions and business rules. The context within which the CCG will need to operate financially will be challenging, requiring effective reinvestment, caution and prudence. Stringent controls on expenditure and performance management will be required in order to ensure the CCG resources are directed to services providing maximum quality and value. For this reason a new financial framework for 2015/16 will be adopted and will embed a focus on the financial impact of all decisions made throughout the organisation. This will be done by empowering commissioners and budget holders to take responsibility for facilitating service change in a more efficient way than the current system allows. The commissioners will be accountable for their overall portfolio within a revised financial and governance framework. This approach is described further in section 7 of this paper. 3. FINANCIAL PLAN 2015/ Sources of Funding The CCG will receive the majority of its funding from NHS England in the form of a resource limit. Appendix 1 provides a summary regarding the composition of the total resource limit the CCG is planning on receiving in 2015/16 and is summarised in the following table. 2015/16 will be a more challenging year financially for the CCG than experienced in recent history (including the predecessor PCT), and will therefore require a shift in focus on financial performance at all levels of the organisation to ensure we achieve our statutory financial duties. Page 3 of 12

6 Item Total Budget ( 000's) CCG Startpoint 2014/15 Programme Resource Allocation 370, % Growth 15/16 10,130 Winter Resilience 2,016 BCF Funding 7, /15 Surplus 6,295 Total 2015/16 Programme Allocation 396,402 Total 2015/16 Running Cost Allocation 6,851 CCG Resource Allocation 2015/16 403,253 Planned Expenditure 396,958 Surplus / (Deficit) 6,295 This can be explained as follows: m 10.1m 2.0m 7.2m 6.3m 6.9m National resource allocation set by NHS England for programme (commissioning) expenditure. 2015/16 growth at 2.7% on the programme resource allocation Inclusion of recurrent winter funding, received non-recurrently in 2014/15. Direct allocation from NHS England for the Better Care Fund Projected surplus carried forward from 2014/15 National resource allocation set by NHS England for administration (running cost) expenditure m Total Funding 2015/16 The allocation above excludes funding the CCG will receive as a consequence of accepting the delegation of budgets for primary care commissioning. Due diligence on the proposed value to be transferred is ongoing, but is expected to be in the region of 300m. The financial plan submitted has been prepared taking into account NHS England specific business rules and assumptions around growth and inflation for 2015/16 and these are summarised in the table below: NHS ENGLAND PLANNING ASSUMPTIONS & BUSINESS RULES CCG PLAN AS SUBMITTED Minimum 0.5% Contingency Fund Held 0.50% Business Rules 1% Surplus Carry Forward 1.60% 2% Underlying Surplus 2.00% 1% Non-Recurrent Spend 15/ % Demographic Growth-local determination based on ONS age profiled 1.5% range Growth & Inflation Assumptions Prescribing Inflation-expected range 4%-7% 6.50% Continuing Care inflation - 2.5% 3.20% Net QIPP Savings- no greater than 2% 1.78% Running Costs 10% reduction from 2014/15 Achieved per head of population Page 4 of 12

7 NHS England has approved the financial plan for 2015/16, upon which this Budget Book is based, declaring the plan strong and assured. 3.2 Financial Structure 2015/16 Financial management and reporting within the CCG is currently based on key financial drivers described below:- 1. Acute Services to reflect expenditure on Acute Commissioning, Planned and Urgent care, mostly with NHS and independent providers. 2. Mental Health to reflect the commissioning of Mental Health; Learning Difficulties; and Dementia services 3. Primary Care Development to reflect investment in membership support of Dudley GP member practices. 4. Drugs & GP Prescribing to reflect GP prescribing and drugs spend; and medicines management and support. 5. Continuing Care - to reflect expenditure on continuing healthcare and intermediate care services. This includes both personal health budgets and payments to independent providers. 6. Community Health - to reflect the commissioning of Community and Children s Services 7. Other to reflect Safeguarding expenditure; property costs for commissioned services; Better Care Fund (BCF) transfer for Social Care Services and Reserves & Investments such as the contingency reserve, 1% Non-Recurrent spend and target surplus for 2015/ Corporate Services this represents the running costs of the CCG and contains the majority of CCG staff and establishment costs plus charges from the Commissioning Support Unit (CSU). Subject to approval of the new financial governance framework in section 7, which has already been approved by the Finance and Performance Committee, the disaggregation and reporting mechanism for financial performance is likely to change to that identified above. Financial performance reports to Board in year will reflect the new structures from May Planned Expenditure The budgets contained in this paper represent planned expenditure to maintain services and invest in agreed priorities set out in the CCG s Strategic Plan. Detailed budgets are shown in Appendices 2a A budget summary is shown below. Page 5 of 12

8 WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) Acute Services , ,918 Mental Health ,573-37,573 Primary Care Development Drugs & GP Prescribing ,669 (194) 55,475 Continuing Care ,053-14,776 Community Health ,078-30,078 Other ,195-30,357 Surplus Target - - 6,295-6,295 TOTAL PROGRAMME , ,593 (194) 396,402 Corporate Services ,584 2,284 (17) 6,851 TOTAL ADMIN ,584 2,284 (17) 6,851 TOTAL , ,877 (212) 403, Acute Services Activity plans are based upon agreed activity trajectories, costed to reflect 2015/16 Payment by Results rules and tariffs. The contract values for the CCG s main providers including Dudley Group Foundation Trust (DGFT) are based on the latest offers received with negotiations due to conclude in advance of the Board. Contract negotiations with other non-dudley providers, led by other CCGs are still in their final stages and therefore the latest contract offer has been used or an estimate based on the forecast outturn in 2014/15, adjusted for growth and net inflation. The final deadline for signing contracts has been extended to the 31 st March due to a revised national tariff proposal being issued by Monitor in February as a result of challenge from provider organisations during the consultation phase. The revised tariff will result in an additional cost pressure of approximately 900,000 which is not currently identified with the financial plans. Funding has been made available nationally; however it is not certain at this stage how it will be allocated to CCGs and therefore represents a risk. We have informed our main providers that we cannot sign contracts until this issue is resolved. Contracts for 2015/16 include, where possible, the application of the CCG s commissioning intentions, which are intended to achieve the CCG s strategic goals whilst providing improved efficiency and form part of the 2015/16 QIPP programme. These are described later in the paper. Appendix 8 identifies indicative contract values for main providers Mental Health Services Mental Health contracts are expected to be agreed before 31 March and the Budget Book reflects the latest contract offers. In 2015/16 the contract with Dudley and Walsall Mental Health Partnership NHS Trust will be a cost and volume contract based upon the mental health PbR clusters. Page 6 of 12

9 3.3.3 Primary Care Development The CCG intends to continue to invest in primary care initiatives within its control to ensure national and local initiatives are delivered. Training, support and mentorship schemes were established in 2014/15 with further investment in GPs with specialist interest being planned in 2015/ Drugs and GP Prescribing Forecast PPA prescribing data at month 10 has been used as the basis for 2015/16 baseline. Net inflation of 3.5% and ONS growth of 1.5% has been applied with a further 1.5m identified as a QIPP target. The medicines management team have produced a work plan to ensure the target is achieved. The Prescribing of EPO drugs for the management of renal anaemia are in the process of being repatriated from primary to secondary care. A budget variation will be required to reflect the impact of this transfer as the costs materialise during 2015/ Continuing/Intermediate Healthcare Continuing healthcare providers will receive an inflationary uplift of 2% in 2015/16, an increase that is reflected in budget book figures. The CCG will also continue to roll out Personal Health Budgets, with new clients expected to come on stream in addition to the full year effect of clients who started receiving their budgets in 2014/ Community Services The tariff deflator has been applied to the community NHS contracts where appropriate. The Dudley Group Foundation Trust contracted activity is based on a similar level to last year s contract. This is higher than the forecast outturn for 2014/15 and reflects the additional activity anticipated as a result of the full establishment of the rapid response team and other services aligned to the integration model Other Commissioning and Reserves In support of the financial planning assumptions made in the CCG s financial plan, a 1% nonrecurrent spend reserve and a 0.5% contingency reserve have been created to invest in nonrecurrent initiatives and also mitigate against any future risks the CCG may have to manage. This is in line with national guidance. Further analysis of other spend can be found in Appendix 2a, which includes the charge the CCG will receive from NHS Property Services for the premises costs associated with commissioned services that are owned and maintained by NHS Property Services and Community Health Partnerships (in relation to LIFT buildings). Planned Surplus/Deficit - the planned surplus for 2015/16 is 6.3m, equating to 1.6% of recurrent revenue resource Corporate Services This reflects corporate functions managed within the running cost allowance given to CCGs of per head of population reflecting the 10% reduction from last year. Running costs include any costs incurred that are not a direct payment for the provision of healthcare or healthcare related services, including all costs associated with the corporate and operational management of the CCG. These costs will be closely monitored against target. Appendix 2a illustrates the planned running costs for the CCG for 2015/16 and have been are based on current structures, adjusted for the impact of organisational change already incurred where appropriate. The agreed contract value for services to be purchased from NHS Midland & Lancashire Commissioning Support Unit is also included in full. Page 7 of 12

10 In order for the CCG to achieve its running cost allowance in 2015/16 it has been necessary to apply a 3% cost improvement plan across all departments, this is in the main due to required structure changes following the CCG taking full delegated responsibility for primary care commissioning services. 4. BETTER CARE FUND The BCF was announced in June 2013 to drive the transformation of local services to ensure that people receive better and more integrated care and support. A pooled commissioning budget will be established in 2015/16 to the value of 69.5m: the CCG will transfer commissioned services to the value of 36.5m and Dudley MBC 33.0m. A section 75 agreement will be agreed between the two participants and the pooled budget will be managed by the newly established Integrated Commissioning Executive. A schedule of services, with associated values, can be found in Appendix 10. The BCF requires the CCG to transfer funding to the Local Authority to protect social care. This equates to 3m in 2015/16. A further 1.6m performance element will be transferred to the Local Authority if the emergency admissions savings target of 2.5m is achieved. The sum of 7.1m has been received from NHS England to transfer to Dudley MBC in addition to the sums outlined above, resulting in a potential total transfer of resource to the Local Authority of 11.9m 5. INTEGRATION In the autumn of 2014 the CCG undertook to commission a review of the long term financial plans of health bodies in the Dudley Health Economy in order to understand the financial pressures facing us over the next 5 years. A summit organised by the CCG including key health and social care partners was held in January 2015 to review the long-term sustainability of our system; and to agree how we should be working together to continue to secure safe and sustainable services for our population for the foreseeable future. The summit received the output of the long-term financial analysis which identified a significant financial gap in our long-term position, over and above existing plans, which would be realised if we do not make further changes to our plans and the way we work together to drive efficiency improvements across the system. The summit concluded that we need to establish more formalised integrated working; ensure that we all work to a common vision and model of care for the system; and put in place collaborative arrangements in some key areas in order to be able to make the significant changes that are required. The summit also recognised there will still be areas, where providers will expect to operate independently (particularly on some planned care services); and also where there will be both a benefit and a need in some services to work collaboratively on a scale greater than the Dudley area. It was proposed that we should establish a Partnership Board, involving all parties at the summit, to oversee the implementation of the model of care and five key enabling programmes of work. A concern expressed and shared by all concerned at the summit was the pace of change which is needed to meet the challenges that we face and our capacity and capability to enact these changes this despite the significant progress that has already been made. Subsequently, therefore, we submitted a proposal, based upon the agreements reached at the summit, for the Dudley Health and Social Care system to become a Five Year Forward View vanguard site for the new models of care. The proposal has since been approved by NHS England, Monitor and the TDA and Dudley is now one of 29 national vanguard sites which will be supported by a 200m transformation fund to deliver these new models of care. The value of services commissioned by the CCG currently identified to be part of the integration model can be found in Appendix 9. A financial modelling workstream is being established that will co-ordinate the whole-system demand modelling, financial and activity planning. It will also provide the forum for determining our evaluation methodology and ensuring that we have the capability to Page 8 of 12

11 track the necessary performance measures as a system to determine whether service changes are delivering the necessary improvements. The value of the services within the model may change over time. A supplementary workstream will manage the financial risk and governance of the overall programme. A bid to NHS England for support with the programme will be submitted early in the new financial year. 6. QUALITY, INNOVATION, PRODUCTIVITY AND PREVENTION A programme of service change has been established which will deliver the CCG s QIPP target in 2015/16. The sum of 7.2m is the value required to meet the funding gap and create headroom for the transfer of resources to the BCF in 2015/16. The main QIPP schemes in 2015/16 are the establishment of an Urgent Care Centre and the expansion of the current Rapid Response Team service. A schedule of all schemes for 2015/16 can be found in Appendix 3. The QIPP Plan equates to 1.8% of total commissioning resource in 2015/16 and are all recurrent and cash releasing. In 2015/16 there is an additional requirement to reduce running costs by 10%. This target has already been achieved during 2014/15 and the current running cost budget reflects the reduced allocation received. The CCG s QIPP initiatives have been shared with providers and included within the Service Delivery Improvement Plan section within 2015/16 contracts. This provides the CCG with the contractual leverage required to ensure that the schemes are implemented and delivered. There are a number of schemes which started during 2014/15 that will deliver a financial benefit in 2015/16. These will form part of a contingency programme to be used in the event that there is a shortfall against the main QIPP programme. It is imperative, however, that the QIPP target is delivered in full by responsible leads. The CCG will have less flexibility in 2015/16 to contribute non-recurrent savings to the programme so a greater focus on QIPP delivery will be implemented. This is explained further in the following section. 7. NEW FINANCIAL GOVERNANCE FRAMEWORK The 2015/16 financial year will be more challenging for the CCG due to the transfer of funding to Dudley MBC for the BCF; increasing pressure of acute services; risks relating to QIPP delivery and pressures on running costs due to new structures and co-commissioning. The Finance and Performance Committee/Clinical Development Committee have agreed a number of actions to reduce the financial risk moving forward, such as return to invest to save principles for developments and service change; the development of an investment/disinvestment prioritisation tool for all services and the adoption of some financial recovery techniques. However it is also proposed to fundamentally amend the financial framework in which we operate as an organisation. The intention, therefore, is to embed a focus on the financial impact of all decisions we make throughout the organisation by empowering commissioners and budget holders to be fully responsible for the deployment of resources approved by the Governing Body in this Budget Book. A key factor in implementing this model is the redefinition of the framework in which we operate and the streamlining of approval processes to enable commissioners/budget holders to commit resources and make the required service changes as efficiently as possible. This will result in a refresh of our Scheme of Delegation to empower commissioners/budget holders to take full responsibility for their portfolio. Budgets by Budget Holder can found in Appendix 7 (budget holders may change when the framework is implemented). It is important for the Board to recognise, however, that with responsibility comes accountability. Management of a portfolio s total financial position will be delegated to the commissioner/budget holder and where appropriate responsible clinical lead. In addition, commissioners/budget holders will be responsible for the delivery of all QIPP and service change initiatives within their portfolio, Page 9 of 12

12 and all performance and KPI s metrics for such services. A list of contracts by lead commissioner has been constructed and can be found in Appendix 8 We will align commissioners/budget holders with finance staff and other CCG staff who provide an enabling function. This approach will require a change in behaviour in ways of working between staff across teams within the CCG and a development programme is being established. In order to enable the scheme of delegation to be amended, appropriate Committees will be required to approve plans for the forthcoming year for each portfolio. This should include detailed budget plans and spend profiles; QIPP/service change programme for the year; Investment/disinvestment/decommissioning plans; plans for improvements in Constitution requirements and quality improvements. When these are approved, the implementation of schemes to deliver the plan will be approved with a significantly reduced process as long as the proposal is within predetermined tolerances. This should increase the speed with which service change can happen. The new framework will require increased focus on QIPP delivery. Commissioners and budget holders will be responsible, and held to account for the delivery of all QIPP schemes. The scope of the current QIPP challenge day is to be expanded. It is proposed to utilise the day to challenge commissioners and linked finance staff collectively on all financial, QIPP, performance (and potentially quality issues) within their portfolio. The new framework will be applicable from 1 April 2015 and budgets are currently being devolved to appropriate commissioners. This will be ratified by the Finance and Performance Committee in April. 8. RISK MANAGEMENT The CCG will need to plan appropriately to manage in-year financial risk. A key determinant of this is the ability to obtain early indications of adverse variations within budgets. The diagram below illustrates the sensitivity of the main risks facing the CCG and the impact on the CCG s 6.3m surplus if the probability of those risks occurring increases or decreases from the base case level of the potential risk. Non Return of surplus Acute SLAs QIPP Under-Delivery BCF Prescribing PBR Tariff 8,000 7,000 Reduced Probability of Risk Increased Probability of Risk 6,000 5,000 4,000 3,000 Total Impact on Surplus / (Deficit) ( ) 2,000 1,000 Outlined below are some of the key risks identified to date for 2015/16:- PbR tariff the initial PbR tariff was withdrawn and republished on 19 February. This resulted in contracts not being agreed by the proposed date of 20 February. The financial consequences of Page 10 of 12

13 the revised tariff are being modelled, but will present a cost pressure in the region of 900,000. We are expecting such funding from NHS England, but this is yet to be confirmed. QIPP Schemes - delays to the introduction of service changes from commissioning intentions may result in subsequent savings not being realised. An integral part of the QIPP for 2015/16 is the reduction of spend on emergency admissions which is required to fund the recurrent transfer to the Better Care Fund in 2015/16. Prescribing budgets are historically volatile. 2014/15 Surplus the associated risk of the surplus from 2014/15 not being returned to the CCG but instead being retained to support centrally commissioned services. Continued increases in acute and non-acute activity in excess of growth estimates and over performance reserves Better Care Fund the current plan includes an efficiency target of 2.8m, the CCG and Dudley MBC have agreed to share the risk equally between both parties for the non-achievement of this target. The plan also includes a savings target of 2.5m in relation to a reduction in emergency admissions. To mitigate the above risks the following actions will be implemented:- New financial governance framework, as described in section 7. Savings/QIPP Challenge enhancement of the QIPP challenge model, potentially expanding to other key performance indicators. Acceleration of savings schemes originally identified for implementation in 2015/16. Contingency reserve to remain unallocated until October 2015 to mitigate pressures outlined above. Delay and reduce non-recurrent investment plans Further disinvestment and potential decommissioning of existing services if required. The CCG and Dudley MBC have agreed to share the risk equally between both parties for the non-achievement of the BCF efficiency target. The financial plan includes a pay for performance element of 1.625m to be paid to Dudley MBC on achievement of the required reduction in emergency admissions. If this target is not achieved the CCG will use this funding to pay for the cost of the admissions incurred. This leaves a net risk of approximately 900, CONTINGENCY/1% NON-RECURRENT EXPENDITURE In line with planning guidance a 0.5% contingency reserve has been established within the plan and is, as in prior years, prudently entirely uncommitted and is expected to fund any unforeseen pressures that the CCG may face or be required to fund during 2015/16. This will remain uncommitted in the first six months of the year and will only be released for investment in the second half of the year if it is not required to meet statutory financial targets or to mitigate risks. The CCG has also been required to identify 1% of its recurrent resource limit to spend nonrecurrently. A number of issues have already been identified as potential items for funding from the 1% non-recurrent investment reserve. The West Midlands Sub-Region is required to approve such expenditure and have indicated items for utilisation. The CCG Financial Plan, therefore, identifies the full allocation of the 1% reserve, and is to be utilised on pump-priming QIPP initiatives, Page 11 of 12

14 improving performance against contractual/quality targets, transitional support for providers and other relevant non-recurrent expenditure. This may need to be reduced however to mitigate risks. 10. CAPITAL The CCG has submitted capital bids in 2015/16 equating to 216,000 for the provision of purchasing mobile devices, as outlined in the CCG s IT Strategy. 11. STATEMENT OF FINANCIAL POSITION Appendix 5 shows the forecast balance sheet position for 2015/ CASH LIMIT The detailed forecast cash plan is shown in Appendix 6 and is based on the NHS England notified cash limit adjusted for expected receipts and anticipated revenue resource allocations. 13. SUMMARY/CONCLUSION This paper presents a final budget for 2015/16 to Dudley CCG Board for approval. Delivery of the proposed budget will be challenging but its delivery will support the CCG in meeting its goals and outcomes as outlined in our Strategic and Operational Plans. Anticipated within the plan is a net savings target of 7.190m for which robust performance management will be required. A number of risks remain evident for which contingencies will need to be established to meet the CCG s financial target of 6.3m surplus and other financial statutory duties. 14. RECOMMENDATION The Committee is requested to approve: the budgets for the CCG as set out in this paper the adoption of the new financial/governance framework for 2015/16 Matthew Hartland Chief Operating and Finance Officer March 2015 Page 12 of 12

15 Appendix 1 Dudley CCG Resource Limit Period : Baseline 2015/16 Recurring ( 000's) Non Recurring ( 000's) Total ( 000's) CCG Recurrent Funding 2013/14 : Programme 360, ,311 Notified Resource Allocation Adjustments Specialised Services Tranche 1 1,074 1,074 Specialised Services Tranche 2 1,146 1,146 Interpreting Services Total Notified Allocation Adjustments 2, ,250 Total Notified Resource Allocation 13/14 362, , % Growth 14/15 7,759 7,759 Specialised Services Risk Share Paediatric Insulin Pumps 14/15 (112) (112) TOTAL 14/15 NOTIFIED RESOURCE ALLOCATION 370, , % Growth 15/16 10,130 10,130 Winter Resilience 2,016 2,016 BCF Funding 7,157 7,157 TOTAL 15/16 NOTIFIED RESOURCE ALLOCATION 390, ,107 Anticipated Resource Adjustments 14/15 Surplus 6,295 6,295 Total Anticipated Resource Allocation 0 6,295 6,295 CCG RESOURCE LIMIT 2015/16 : PROGRAMME 390,107 6, ,402 ADMIN : Running Costs 2013/14 7, ,710 Notified Resource Allocation Adjustments Running Cost Reduction (63) (63) TOTAL 14/15 NOTIFIED RESOURCE ALLOCATION 7, ,647 Running Cost Reduction (796) (796) CCG RESOURCE LIMIT 2015/16 : ADMIN 6, ,851 TOTAL CCG RESOURCE LIMIT 2015/16 396,958 6, ,253

16 Appendix 2 Dudley CCG Financial Summary Report 2015/16 Period: Baseline WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) Acute Services , ,918 Mental Health ,573-37,573 Primary Care Development Drugs & GP Prescribing ,669 (194) 55,475 Continuing Care ,053-14,776 Community Health ,078-30,078 Other ,195-30,357 Surplus Target - - 6,295-6,295 TOTAL PROGRAMME , ,593 (194) 396,402 Corporate Services ,584 2,284 (17) 6,851 TOTAL ADMIN ,584 2,284 (17) 6,851 TOTAL , ,877 (212) 403,253

17 Appendix 2a Dudley CCG Financial Detail Report Period: Baseline WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) ACUTE SERVICES Acute Contracts , ,112 Ambulance Services - - 8,623-8,623 NCAs - - 2,381-2,381 Planned Care - - 1,939-1,939 Urgent Care Centre & NHS ,847-3,847 Winter Resilience - - 2,016-2,016 TOTAL ACUTE SERVICES , ,918 MENTAL HEALTH SERVICES Mental Health Contracts ,834-33,834 Dementia Learning Difficulties - - 1,419-1,419 Other Mental Health Services - - 2,202-2,202 TOTAL MENTAL HEALTH SERVICES ,573-37,573 PRIMARY CARE DEVELOPMENT Primary Care Training Nurse Mentors and EVTS Practice Engagement LIS TOTAL PRIMARY CARE DEVELOPMENT DRUGS & GP PRESCRIBING Central Drugs - - 2,354 (194) 2,160 Medicines Management - Clinical Oxygen Prescribing ,097-52,097 TOTAL DRUGS & GP PRESCRIBING ,669 (194) 55,475 INTERMEDIATE AND CONTINUING HEALTHCARE CHC Adult Fully Funded - - 6,815-6,815 Continuing Healthcare Assessment & Support Funded Nursing Care - - 2,773-2,773 CHC Adult Fully Funded Personal Health Budgets Intermediate Care - - 4,081-4,081 TOTAL INTERMEDIATE AND CONTINUING HEALTHCARE ,053-14,776 COMMUNITY SERVICES Community Services ,135-28,135 Childrens Services - - 1,943-1,943 TOTAL COMMUNITY HEALTHCARE ,078-30,078 OTHER COMMISSIONING Statutory Reserves - - 6,609-6,609 Non Recurrent Reserve - - 3,830-3,830 BCF Transfer for Social Care Services ,782-11,782 Local Enhanced Services - - 1,593-1,593 NHS Property Services and CHP Charges - - 3,585-3,585 Safeguarding Other - - 2,672-2,672 TOTAL OTHER COMMISSIONING ,195-30,357

18 Appendix 2a Dudley CCG Financial Detail Report Period: Baseline WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) CORPORATE Clinical Management (17) 682 Other Board CCG Management Communications & Engagement Finance and Performance , ,186 Administration Team Commissioning Quality Membership Development and Primary Care IT Contracting Estates NHS Midland & Lancashire CSU - - 1,187-1,187 Other Corporate Costs TOTAL CORPORATE ,584 2,284 (17) 6,851 SURPLUS Surplus Target - - 6,295-6,295 TOTAL SURPLUS - - 6,295-6,295 OVERALL TOTAL , ,877 (212) 403,253

19 Appendix 3 Dudley CCG Savings Plan / QIPP Schemes 2015/16 Period: Baseline Main QIPP Programme Commissioning Lead 2015/16 000's Rapid Response Team Andrew Hindle (1,500) Remaining Emergency Admissions - BCF Neill Bucktin (1,000) Urgent Care Centre Jason Evans (2,000) Delayed Transfers of Care Jenny Cale (600) Intermediate Care 7 day working * Jenny Cale 0 Primary Care Mental Health * Trish Taylor 0 Elective Pathways Mark Curran (590) Better Prescribing Clair Huckerby/Duncan Jenkins (1,500) TOTAL (7,190) * Schemes providing a quality improvement but no financial impact in 2015/16 Schemes under development Falls Care Homes Diabetes Model of Care Commissioning Lead Tapiwa Mtemachani Andrew Hindle Joanne Gutteridge Contingency QIPP Schemes Commissioning Lead 2015/16 000's Mental Health Grants Trish Taylor (393) Non Emergency Patient Transport Mark Curran (400) Palliative Care Services Andrew Hindle (300) Respiratory Service Redesign Andrew Hindle (200) TOTAL (1,293)

20 Appendix 4 Financial Plan 2015/16 Summary Sources and Applications Statement Recurring Non Recurring TOTAL '000 '000 '000 Baseline Commissioning Allocation 370, ,805 Baseline Running Cost Allocation 6,851 6,851 Total Baseline Allocation 377, ,656 New Sources / Reduction of Funds Surplus c/f 6,295 6,295 DH Growth 10,130 10,130 Notified Allocations 2, ,016 Anticipated Allocations Better Care Fund 0 7,157 7,157 Total Income 12,146 13,452 25,598 Application of Funds Acute Commissioning Growth / Demographics / HRG 4 4,965 4,965 PTS / CQUIN 0 Acute Cost pressures / transformation 3,000 2,000 5,000 Pressures/Committed Contract Inflation 12,645 12,645 Community Services Continuing Care 0 Mental Health ,078 Transforming care for over 75's 0 Better Care Fund Transfer For Social Care 4,625 7,157 11,782 Diagnostic Activity 0 Integration 0 Estates Strategy 0 IT Strategy Winter 2,016 2,016 Primary Care Strategy 0 Other Total Expenditure 28,075 10,987 39,062 Gap -15,929 2,465-13,464 QIPP Schemes -7,190-7,190 Price Efficiencies -12,569-12,569 Total Expenditure 8,316 10,987 19,303 Surplus / (Deficit) 3,830 2,465 6,295

21 Dudley CCG Statement of Financial Position for 2014/15 & 2015/16 Period : Baseline 2014/15 Appendix /14 Outturn ( 000) 2014/15 Plan ( 000) 2015/16 Plan ( 000) SoFP March Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Assets Non Current Assets Opening Balance Depreciation Additions Long Term Receivables Total Non Current Assets Current Assets Inventories 0 NHS Trade and Other Receivables Non NHS Trade and Other Receivables 279 1, ,300 1,500 1,500 1,500 2,100 2,200 2,400 2,500 2,600 2,600 2,700 Cash and Cash Equivalents Total Current Assets 439 1,429 1,379 1,329 1,279 1,229 1,179 1,129 1,079 1, ,241 1,498 1,759 1,923 1,903 2,482 2,546 2,708 2,870 2,884 2,846 2,815 Total Assets 439 1,429 1,379 1,329 1,279 1,229 1,179 1,129 1,079 1, ,241 1,498 1,759 1,923 1,903 2,482 2,546 2,708 2,870 2,884 2,846 2,815 Liabilities Non Current Liabilities Borrowings Deferred Income (non current) Provisions (non current) Trade and Other Payables (non current) Finance Leases (non current) Total Non Current Liabilities Current Liabilities Borrowings Deferred Income (current) Provisions (current) (500) (1,500) (1,500) (1,250) (950) (900) (850) (800) (750) (700) (650) (750) (700) (647) (627) (607) (587) (577) (567) (567) (567) (267) (167) (67) (400) Trade and Other Payables (current) (23,452) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (22,000) (21,885) (21,585) (20,660) (20,555) (19,450) (21,380) (20,970) (22,559) (23,670) (22,440) (21,850) (22,700) Finance Leases (current) Total Current Liabilities (23,952) (23,500) (23,500) (23,250) (22,950) (22,900) (22,850) (22,800) (22,750) (22,700) (22,650) (22,750) (22,700) (22,532) (22,212) (21,267) (21,142) (20,027) (21,947) (21,537) (23,126) (23,937) (22,607) (21,917) (23,100) Total Liabilities (23,952) (23,500) (23,500) (23,250) (22,950) (22,900) (22,850) (22,800) (22,750) (22,700) (22,650) (22,750) (22,700) (22,532) (22,212) (21,267) (21,142) (20,027) (21,947) (21,537) (23,126) (23,937) (22,607) (21,917) (23,100) TOTAL ASSETS EMPLOYED (23,513) (22,071) (22,121) (21,921) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,971) (22,206) (21,291) (20,714) (19,508) (19,219) (18,124) (19,465) (18,991) (20,418) (21,067) (19,723) (19,071) (20,285) Taxpayers' Equity General Fund (23,513) (22,071) (22,121) (21,921) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,971) (22,206) (21,291) (20,714) (19,508) (19,219) (18,124) (19,465) (18,991) (20,418) (21,067) (19,723) (19,071) (20,285) Retained Earnings (Accumulated Losses) Revaluation Reserve Other Reserves TOTAL ASSETS EMPLOYED (23,513) (22,071) (22,121) (21,921) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,671) (21,971) (22,206) (21,291) (20,714) (19,508) (19,219) (18,124) (19,465) (18,991) (20,418) (21,067) (19,723) (19,071) (20,285)

22 Appendix 6 Dudley CCG Cashflow for 2014/15 & 2015/16 Period : Baseline 2014/ / Subcode Blank2 Blank3 Blank4 Blank5 Blank6 Blank7 Blank8 Blank9 Blank10 Blank11 Blank12 CCG Cash Requirement 379, Less T01 Prescription Pricing Authority 50, Other Central / BSA payments 104 B01 Remaining Cash limit 329,270 TT1 Receipts 2014/15 April May June July August September October Nov Dec January February March Total Balance b/fwd BACS CHAPS CCG-Drawdown 26,594 24,997 24,947 25,186 24,997 24,947 29,168 28,965 28,915 29,154 28,965 32, ,270 CCG-Drawdown additional Other PCS Payments Reimbursements VAT Capital Receipts Total Receipts 26,632 25,275 25,275 25,464 25,275 25,275 29,446 29,243 29,243 29,432 29,243 32, ,806 Payments Creditors NHS 22,398 22,398 22,398 22,398 22,398 22,398 22,398 22,398 22,398 22,398 22,398 24, ,318 Creditors CHAPS 3,714 2,357 2,357 2,545 2,357 2,357 6,528 6,325 6,325 6,513 6,325 7,538 55,243 Salary CHAPS ,800 Pensions Tax & NI Standing Orders /Direct Debits PCS Payments Other Capital Payments Total -Expenditure 26,382 25,025 25,025 25,213 25,025 25,025 29,196 28,993 28,993 29,181 28,993 32, ,801 Balance c/fwd / Subcode CCG Cash Requirement 396, Less T01 Prescription Pricing Authority 54, Other Central / BSA payments 104 B01 Remaining Cash limit 342,700 TT1 Receipts 2015/16 April May June July August September October Nov Dec January February March Total Balance b/fwd BACS CHAPS - CCG-Drawdown 28,000 30,700 29,000 28,000 27,200 27,500 27,600 27,800 26,800 28,900 29,200 32, ,700 CCG-Drawdown additional - Other PCS Payments Reimbursements - VAT Capital Receipts Total Receipts 28,132 31,053 29,130 28,276 27,555 27,835 27,998 28,078 27,040 29,287 29,416 32, ,424 Payments Creditors NHS 23,017 26,017 23,837 23,017 22,965 23,167 22,683 23,383 22,483 23,983 24,583 26, ,118 Creditors CHAPS 4,451 4,590 4,778 4,351 3,920 4,020 4,651 4,120 3,920 4,751 4,320 4,814 52,686 Salary CHAPS ,310 Pensions Tax & NI ,048 Standing Orders /Direct Debits PCS Payments - Other Capital Payments Total -Expenditure 27,811 30,955 28,971 27,953 27,252 27,554 27,753 27,870 26,770 29,103 29,270 32, ,424 Balance c/fwd

23 Appendix 7 Dudley CCG Financial Budget Summary: Budgets by Budget Holder (at total contract value) Period: Baseline WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) Laura Broster Communications & Engagement TOTAL Neill Bucktin Acute Commissioning , ,112 Better Care Fund ,782-11,782 Central Drugs - - 2,354 (194) 2,160 Collaborative Commissioning Commissioning Learning Difficulties - - 1,419-1,419 Medicines Management - Clinical NCAs - - 2,381-2,381 Other Commissioning Oxygen Prescribing ,097-52,097 TOTAL ,466 (194) 273,999 Jenny Cale CHC Adult Fully Funded - - 6,815-6,815 CHC Adult Fully Funded Personal Health Budgets Continuing Healthcare Assessment & Support Funded Nursing Care - - 2,773-2,773 Intermediate Care - - 4,081-4,081 Palliative Care Reablement TOTAL ,694-15,417 Steph Cartwright Administration Team Organisational Development TOTAL Linda Cropper Acute Childrens Services CHC Children - - 1,391-1,391 CHC Children Personal Health Budgets TOTAL - - 1,943-1,943 Mark Curran Local Enhanced Services Patient Transport Planned Care - - 1,939-1,939 TOTAL - - 2,294-2,294 Trisha Curran Quality Safeguarding TOTAL Jason Evans Ambulance Services - - 8,623-8,623 Out of Hours - - 1,379-1,379 Urgent Care - - 2,468-2,468 Winter Resilience - - 2,016-2,016 TOTAL ,486-14,486

24 Appendix 7 Dudley CCG Financial Budget Summary: Budgets by Budget Holder (at total contract value) Period: Baseline WTE Budget Pay Budget ( 000's) Non Pay Budget ( 000's) Income Budget ( 000's) Total Budget ( 000's) Joanne Gutteridge Local Enhanced Services - - 1,409-1,409 TOTAL - - 1,409-1,409 Matthew Hartland Finance and Performance , ,186 IT (0) 217 Non Recurrent Reserve - - 3,830-3,830 NHS Midland & Lancashire CSU - - 1,187-1,187 NHS Property Services and CHP Charges - - 3,585-3,585 Other Corporate Costs & Services Statutory Reserves - - 6,609-6,609 Surplus Target - - 6,295-6,295 TOTAL ,267 21,856 (0) 23,123 David Hegarty Clinical Management (17) 682 Other Board TOTAL (17) 762 Andrew Hindle Community Services ,135-28,135 Dementia Hospices Long Term Conditions TOTAL ,040-30,040 Daniel King Membership Development & Primary Care Local Enhanced Services Nurse Mentors and EVTS Primary Care Training TOTAL ,021 Paul Maubach CCG Management TOTAL Anthony Nicholls Contract Management TOTAL Trish Taylor Child and Adolescent Mental Health Mental Health Contracts ,834-33,834 Mental Health Services Adults Mental Health Services - Collaborative Commissioning Mental Health Services - NCAs Mental Health Services Not Contracted Activity Mental Health Services Other Mental Health Services - Specialist Services TOTAL ,036-36,036 TOTAL , ,877 (212) 403,253

25 Appendix 8 Dudley CCG Contract Lead Commissioners Period: Baseline CONTRACT LEAD COMMISSIONER INDICATIVE VALUE ACUTE The Dudley Group NHSFT Neill Bucktin 169,305,588 Univerity Hospital Birmingham Mark Curran 7,024,983 The Royal Wolverhampton Mark Curran 6,371,364 West Midlands Hospital Mark Curran 6,278,503 Sandwell & West Birmingham Jason Evans 4,721,333 Royal Orthopaedic Mark Curran 3,592,669 Birmingham Children's Hospital Linda Cropper 1,292,575 Birmingham Women's Hospital Neill Bucktin 1,052,819 * Worcestershire Acute Neill Bucktin 940,540 * Heart of England FT Neill Bucktin 380,397 * Walsall Healthcare Neill Bucktin 269,686 * University Hospital North Midlands Neill Bucktin 245,082 * Shrewsbury & Telford Neill Bucktin 235,229 * Robert Jones & Agnes Hunt Neill Bucktin 212,227 * TOTAL 201,922,995 COMMUNITY The Dudley Group NHSFT Andrew Hindle 22,389,156 Black Country Partnerships NHS Foundation Trust Linda Cropper 4,911,116 Royal Wolverhampton Hospital NHS Trust Andrew Hindle 619,686 Birmingham Community NHS Trust Andrew Hindle 190,517 Sandwell and West Birmingham Andrew Hindle 155,288 Worcestershire Health and Care NHS Trust Andrew Hindle 40,440 Walsall Healthcare Andrew Hindle 3,781 TOTAL 28,309,984 MENTAL HEALTH Dudley and Walsall Mental Health Trish Taylor 26,473,286 Black Country Partnerships NHS Foundation Trust Neill Bucktin 6,359,654 South Staffordshire and Shropshire Mental Health Trish Taylor 506,205 Birmingham and Solihull Mental Health Trish Taylor 280,939 Worcestershire Health and Care NHS Trust Trish Taylor 152,579 TOTAL (1,500) URGENT CARE West Midlands Ambulance Jason Evans 8,434,545 Urgent Care Centre Jason Evans 2,763,049 NHS 111 Jason Evans 987,000 TOTAL 12,184,594 GRAND TOTAL 242,416,073 * To be confirmed

26 Appendix 9 Dudley CCG Services Within Integration Model Period: Baseline Dudley Group NHS FT Dudley & Walsall Mental Health Black Country Partnerships AREA TEAMS WITHOUT WALLS District Nursing 7,805,129 Primary Care Mental Heatlth 2,016,594 Virtual Ward 1,595,641 TOTAL 9,400,770 2,016,594 0 ALIGNED SPECIALIST SERVICES Adult Consultant Services 11,285 Anti-Coagulation & Phlebotomy 198,677 Audiology 817,251 CAMHS Services 2,774,780 Care Home ANPs 154,958 Child Protection Service 482,590 Childrens Asthma, Allergy & Eczema 70,537 Childrens Development Team 175,276 Childrens Haemoglobin Team 51,926 Childrens Occupational Therapy 485,249 Childrens Orthotics 81,464 Childrens Palliative Care 499,719 Childrens Physical Health Service 312,868 Childrens Physiotherapy 615,127 Childrens Speech & Language Therapy 1,697,256 Community Recovery Service 2,707,671 Continence Services 1,141,486 Criminal Justine Liaison 82,606 Crisis Resolution/Home Treatment 2,937,526 Dematology - Communtiy 230,463 Diabetic Community Nursing 529,966 Dietetics Community 232,322 Early Intervention in Psychosis 90,299 Eating Disorders Community Team 74,354 Employment Services 68,035 End of Life Nurse Educator 42,053 ENT - Community 286,376 Heart Failure Nursing 564,488 Hospital Liason Team 126,306 IAPT 290,980 Integrated Living Team 126,331 Intermediate Care Support 804,277 LD Behavioral Psychology Services 726,221 LD Community Team 245,307 LD Dysphagia 201,905 LD Health Access 521,505 LD Occupational Therapy 380,764 LD Physiotherapy 72,666 LD Speech & Language Therapy 113,879 Leg Ulcer Service 316,298 Macmillan Specialist Team 460,103 Medicine Management Dietician 80,726 Older Adult Community Team 894,250 Older Adult Consultant Services 116,797 Older Adult Daycare 295,451 Oncology Outreach 320,925 Orthotic Outpatients 801,378 Palliative Care Nursing Team 405,548 Physiotherapy Community 852,526 Physiotherapy Outpatients 818,863 Podiatry 1,860,816 Podiatry - Diabetes 85,395 Primary Care Neurology Team 377,326 Primary Care Occupational Therapy 473,569 Psychological Therapies Hub 982,415 Rapid Response Team 503,318 Respiratory Community Nursing 73,554 Speech & Language Therapy 457,584 Stepdown Medical Cover 58,899 Stroke Rehabilitation - Community 551,596 Support to Nursing Homes 52,988 Tissue Viability 1,246,153 Virtual IV Service 250,587 Wheelchair Services 692,880 TOTAL 15,995,987 11,035,469 7,025,239

27 Appendix 9 Dudley CCG Services Within Integration Model Period: Baseline Dudley Group NHS FT Dudley & Walsall Mental Health Black Country Partnerships AREA COMMUNITY CARE LED RETRIEVAL Adult Consultant Services 1,196,327 Child Assessment Unit 275,521 Community Medical Officers 407,426 Dermatology Outpatients 1,361,406 Diabetic Medicine Outpatients 756,903 Dietetics Outpatients 125,133 General Medicine Outpatients 221,763 Geriatric Medicine Outpatients 636,943 LD Outpatients 305,094 Neurology Outpatients 600,434 Older Adult Consultant Services 213,381 Paediatric Outpatients 802,691 Pain Management Outpatients 295,813 Palliative Care Outpatients 124,782 Respiratory Medicine Outpatients 1,228,702 Respiratory Physiology Outpatients 51,867 Rheumatology Outpatients 1,409,693 Stroke Outpatients 143,675 TIA Outpatient Services 275,914 TOTAL 8,443,145 1,409, ,615 WHOLE PATHWAY CARE Action Heart 515,631 Adult Inpatients 5,397,245 Cardiology Diagnostics 157,513 Day Care Attenders 522,234 Direct Access Diagnostics 2,659,741 Early Access Service 905,855 Early Intervention in Psychosis 776,833 Excess Bed Days 2,624,485 High Cost Drugs 5,868,925 Inpatient Services 85,753,308 LD cost of Ridge Hill 1,342,303 LD External Placements 180,000 LD Inpatients 976,578 Maternity Care - Antenatal 5,496,348 Maternity Care - Postnatal 855,470 Older Adult Inpatients 4,152,695 Orthopaedic Assessment Unit 380,354 Other Outpatient Services 22,327,127 Pathology 4,253,609 Podiatric Surgery 434,479 Psychiatric Liaison 195,533 Other Rehabilitation 1,069,812 T&O Rehabilitation 1,768,212 Stroke Rehabilitation - Acute 1,304,100 Unbundled Diagnostics 3,738,674 TOTAL 139,730,022 11,428,161 2,498,881 GRAND TOTAL 173,569,923 25,889,932 10,104,735 Note :- Indicative, subject to final clarification

28 Appendix 10 Dudley CCG Better Care Fund Services Period: Baseline AREA Indicative Value ( ) Dudley Group Foundation Trust District Nursing 7,805,129 Rehab - T&O 1,768,212 Virtual Ward/Assertive Case Managers 1,423,412 Rehab - Stroke 1,304,100 Rehab - Other 1,069,812 Physiotherapy MSK 852,526 Locality Wide Continence Pass Through 809,569 Community Heart Failure 564,488 Community Stroke Rehabilitation 551,596 Specialist Nursing-Diabetes 529,966 Community Rapid Response Team 503,318 OT Primary Care 473,569 Intermediate Care Team - OT 462,713 Macmillan Specialist Team 460,103 Palliative Care Nursing Team 405,548 Primary Care Neurology Team 377,326 Locality Wide Continence Activity 331,917 District Nursing - Oncology Outreach 320,925 Leg Ulcer 316,298 Intermediate Care Team - Physio 229,380 District Nursing - VIV 201,145 Speech Therapy Adults 185,283 Advanced Nurse Practitioners/Care Homes 154,958 Intermediate Care Team - Nursing 112,184 Tissue Viability 78,682 Stepdown Medical Cover 58,899 District Nursing - OPAT Expansion 49,442 TOTAL 21,400,500 Dudley and Walsall Mental Health NHS Trust Crisis Resolution Home Treatment Team : Adult - Face To Face 2,581,179 CRS- Face To Face 2,577,829 Psychological Therapies Hub - Face To Face 939,851 Elderly Services Community Team - Face To Face 780,308 Early Intervention In Psychosis Service : Adult - Face To Face 757,389 EAS- Face To Face 721,411 Crisis Resolution Home Treatment Team : Adult - Non Face To Face 356,347 EAS- Non Face To Face 184,444 CRS- Non Face To Face 129,842 Elderly Services Community Team- Non Face To Face 113,942 Psychological Therapies Hub - Non Face To Face 42,564 Early Intervention In Psychosis Service : Adult - Non Face To Face 19,444 TOTAL 9,204,550 Other GP Over 75's 1,571,000 Intermediate Care - BUPA 1,448,580 Intermediate Care - Leyton Healthcare 733,621 Community Equipment Stores 478,090 Intermediate Care - Shaw 465,126 GP Respite Beds 392,972 Intermediate Care - Other Private Care Homes 43,951 Dementia Service 186,651 A&E Diversion 135,455 Intermediate Care Support - Dr Plant 62,827 TOTAL 5,518,272 Efficiency Requirement (Shared risk with DMBC) (2,892,848) TOTAL (2,892,848) GRAND TOTAL 33,230,475

29 DUDLEY CLINICAL COMMISSIONING GROUP BOARD Date of Board: 30 March 2015 Report: Dudley Group Foundation Trust Draft Annual Quality Account Agenda item No: 4 TITLE OF REPORT: PURPOSE OF REPORT: AUTHOR(s) OF REPORT: MANAGEMENT LEAD: CLINICAL LEAD: KEY POINTS: The Dudley Group NHS Foundation Trust DRAFT Annual Quality Account To discuss the DGFT Quality Account and agree they key aspects that the Board would like included in the CCG s feedback / stakeholder commentary Ms Trisha Curran, Interim Chief Nurse Ms Trisha Curran, Interim Chief Nurse Dr Ruth Edwards, Clinical Executive Lead for Quality FTs have to have their Annual Quality Accounts externally audited before submitting to Monitor this inevitably means that the timescale is short for stakeholders to provide feedback The Trust must provide a copy of the (draft) Quality Report; including stakeholder feedback and Statements of Directors Responsibilities for Deloitte to review against Monitor s criteria by 6 April The Trust will need to have received the CCGs feedback on their (draft) quality account by mid-day on 6 April 2015 in order to submit their account to the auditors The Board is asked to: RECOMMENDATION: FINANCIAL IMPLICATIONS: WHAT ENGAGEMENT HAS TAKEN PLACE: ACTION REQUIRED: 1. Discuss the attached draft quality account 2. Note the comments made last year by the CCG (see page 85) 3. Note the Deloitte timetable for reporting by the Trust to Monitor (see page 92) 4. Agree the key aspects that the Board would like to be included in the CCG s stakeholder comments back to the Trust 5. Note that the CCG s stakeholder comments must be received by the Trust by 12:00 hours on 6 April 2015 None to report None Assurance Page 1 of 1

30 THE DUDLEY GROUP NHS FOUNDATION TRUST QUALITY REPORT 2014/15 INITIAL DRAFT MAR

31 2

32 Contents Part 1: Chief Executive s statement 5 Page Part 2: Priorities for improvement and statements of assurance from the Board of Directors Quality improvement priorities Quality priorities summary Choosing our priorities for 2015/ Our priorities Statements of assurance from the Board of Directors Review of services Participation in national clinical audits and confidential enquiries Research and development Commissioning for Quality and Innovation Payment Framework (CQUIN) Care Quality Commission (CQC) registration and reviews Quality of data Core set of mandatory indicators 45 Part 3: Other quality information Introduction Patient Experience: Does the Trust provide a clean, friendly environment in which patients are satisfied with the personal care and treatment they receive? Introduction Trust-wide initiatives National survey results Examples of specific patient experience initiatives Complaints, concerns and compliments Patient-led assessments of the care environment (PLACE) Single sex accommodation Patient experience measures 65 3

33 3.3 Patient Safety: Are patients safe in our hands? Introduction Patient Safety Leadership Walkrounds Incident management Nursing Care Indicators (NCIs) Harm Free care and the NHS Safety Thermometer Examples of specific patient safety initiatives Patient safety measures Clinical Effectiveness: Do patients receive a good standard of clinical care? Introduction Examples of awards received related to improving the quality of care Examples of innovation Examples of specific clinical effectiveness initiatives Clinical effectiveness measures Our performance against key national priorities across the domains of the NHS Outcome Framework 3.6 Glossary of terms Annex Comment from Dudley Health Overview and Scrutiny Committee Comment from Dudley Health and Wellbeing Board Comment from Dudley Clinical Commissioning Group Comment from the Trust s Council of Governors Comment from Healthwatch Dudley Statement of directors responsibilities in respect of the Quality Report Independent assurance report to the Council of Governors of The Dudley Group NHS Foundation Trust on the Annual Quality Report Throughout this document there are a number of quotes from patients taken from online reviews posted on NHS Choices and Patient Opinion. 4

34 Part 1: Chief Executive s statement I am again pleased to introduce the annual Quality Report and Account, where we give a detailed picture of the quality of care provided by our hospitals and adult community services. This report covers the year from April 2014 to the end of March Our primary focus is to provide high quality treatment and care for all of our patients. By this we mean we strive to provide: A good patient experience Safe care and treatment A good and effective standard of care As in previous years, this report uses these three elements to describe the quality of care at the Trust over the year, providing an overall picture of what the organisation is achieving and where it still needs to improve. Following on from this introduction, in Part 2 we have outlined our priority quality measures and charted their progress throughout the year. A summary of current and previous priorities can be seen in the table on page 8 as can more details on each priority on the page numbers listed in that table. These details include progress made to date, as well as our new targets for 2015/16. This part of the report also includes sections required by law on such topics as clinical audit, research and development and data quality. In Part 3 we have included other key quality initiatives and measures, and specific examples of good practice on all of the three elements of quality which hopefully give a rounded view of what is occurring across the Trust as a whole. As we provide both acute and community care, you will see some parts of the report are divided into hospital and community sections for ease of reference. In terms of independent reviews of the quality of care at the Trust, the key event this year was the Care Quality Commission (CQC) inspection team of 40 people who assessed the Trust, visiting many wards and departments and talking with a wide variety of staff and patients. This report contains a section (Section 2.2.5) providing the details of that review but in summary we were pleased to note that Trust was rated Good in 30 out of the 38 core services inspected. The majority of the group categories (five out of eight) also received an overall rating of Good. Despite this, the overall rating for the Trust was Requires Improvement, which was a disappointment. The Chief Inspector of Hospitals, Professor Sir Mike Richards, believes we are not far off achieving an overall Good rating and he has confidence that we are addressing the issues highlighted by the inspection. It is a credit to all of the staff that the inspection team found much evidence of excellent practice and that patients see them as highly caring with many examples of staff going the extra mile. As well as the CQC, we are monitored by a variety of other external organisations and agencies (see Section 2.1.1) and, as this report indicates, we are constantly monitoring ourselves in many ways on the quality of our care in order both to assure patients and ourselves of where we are doing well and to learn where we need to change practice and improve our services. 5

35 Although there is much debate about the usefulness of mortality indicators, I am pleased to be able to report that the Trust has now been consistently within the expected range for the Standardised Hospital Mortality (SHMI) indicator the whole of this year and, in fact, constantly from the period commencing October Our quality priorities You will see in Section 2 that we have made excellent progress with the majority of our 2014/15 priorities. I am pleased to report reductions in both healthcare associated infections and pressure ulcers. We have met both our C. Difficile and MRSA targets with this being the first year we have had none of the latter. Whilst we unfortunately had a single Stage 4 avoidable pressure ulcer in the hospital, the Stage 3 avoidable pressure ulcers were reduced by more than fifty percent from last year. The community had no Stage 4 avoidable ulcers while Stage 3 avoidable ulcers remain at the low static number of four (up to Q3) throughout the year. Our Mortality Tracking Process includes clinical coding, validation, multidisciplinary specialist audit and where necessary senior medical and nursing review led by our Deputy Medical Director. This process is to ensure that each death occurring in hospital is understood and we are responsive to the information we gather from this process. We have met our new target in this regard. In addition, the assessments that nurses undertake means that we have met our nutrition and hydration targets and with regards to patients perceptions of receiving enough help to eat at meal times the survey results indicate that this target is also being met. As part of the same survey, we had a target that at least 90 per cent of patients would indicate that their call bells are always answered in a reasonable time but more work is still required to reach this as the final year figure is xx (86.75% to Q3). Finally, the results of our annual survey of community patients mean that we have not met the targets we set ourselves. With the recent introduction of the national Friends and Family Test into the community we have decided that it would be more useful to introduce this into our targets for next year as we will be able to compare ourselves to both other local providers and national averages. With regards to 2015/16, we have retained all of the topics from 2014/15 due to their importance from both a patient and organisational perspective and due to some of the targets not being met. Measuring quality The report includes a wide range of objective indicators of quality, and we have also included a few specific examples of the many quality initiatives from around the Trust and what patients have said about us. We could not include them all but hopefully the examples, together with awards, innovation and initiatives that Trust staff have achieved and implemented in the year, give a flavour of our quality of care. A fundamental part of improving quality at the Trust is listening to our patients experiences. I am especially pleased to report that the Trust is receiving positive feedback from our inpatients, mothers on the maternity unit and patients being seen in the Emergency Department in the national Friends and Family Test (Section 3.2.2). Our nurses continue to improve the quality of care they provide as measured by our detailed monthly Nursing Care Indicator assessments (Section 3.3.4). I am also particularly pleased to report that a number of our nurses and midwives from 6

36 both the hospital and community have won some prestigious national wards ranging across a number of specialties (Section 3.4.2). I hope you will find it helpful to see some of the information we use to monitor our quality of care creating a picture of quality across the Trust. We would appreciate any feedback you would like to give us on both the format and content of the report but also the priorities we have chosen. You can either telephone the communications team on (01384) or communications@dgh.nhs.uk In addition, we summarise this lengthy report in our annual summary, Your Trust, and publish quarterly updates on the progress with our quality priorities on our website. I can confirm that, to the best of my knowledge, the information contained in this document is accurate. Finally, 2015/16 will be challenging for the Trust as we enter the second year of austerity measures. We will continue to work with patients, commissioners and other stakeholders to deliver further improvements to quality in the context of growing demand for services and developments in healthcare provision generally. Signed Date: xxth of xx 2015 Paula Clark Chief Executive 7

37 Part 2: Priorities for improvement and statements of assurance from the Board of Directors 2.1 Quality improvement priorities Quality priorities summary The table below gives a summary of the history of our quality priorities and also those we will be working towards in 2015/16. Priority 2009/ / / / / / /16 Notes Patient experience Increase in the number of patients who report positively on their experience on a number of measures. Achieved We improved on one measure but had a slight decrease in another Pressure ulcers Improve systems of reporting and reduce the occurrence of avoidable pressure ulcers. N/A N/A Infection control Reduce our MRSA rate in line with national and local priorities. Reduce our Clostridium Difficile rate in line with local and national priorities. Nutrition Increase the number of patients who have a risk assessment regarding their nutritional status. Hydration Increase the number of patients who have their fluid balance charts monitored. Mortality Improve reviews of hospital deaths. Hip operations Increase the number of patients who undergo surgery for hip fracture within 36 hours from admission (where clinically appropriate to do so). Cardiac arrests Reduce the numbers of cardiac arrests. Achieved Achieved Hospital: Partially achieved Community: Achieved Hospital: Achieved Community: Partially achieved Achieved Not achieved 8 Hospital: Achieved Community: Partially achieved Hospital: Achieved Community: Achieved Achieved Achieved N/A N/A N/A Achieved N/A N/A N/A Achieved Hospital: Partially achieved Community: Not achieved Hospital: Partially achieved Community: Achieved Not achieved Not achieved Partially achieved Achieved Hospital: Partially achieved Community: Not achieved Hospital: Partially achieved Community: Partially achieved Achieved Achieved Achieved Achieved N/A N/A N/A N/A N/A Achieved N/A Achieved Achieved Achieved Achieved Priority 1 Priority 2 Priority 3 Priority 4 Priority 5 N/A N/A N/A N/A N/A N/A N/A N/A N/A See page 10 for more information New in 2011/12 See page 14 for more information See page 19 for more information New in 2012/13 See page 22 for more information New in 2012/13 See page 22 for more information New in 2014/15 See page 26 for more information As the target was achieved for two consecutive years this priority was replaced in 2012/13 With a decrease from 32 per month in 2008 to 13 per month by 2011 this no longer remained a challenge

38 2.1.2 Choosing our priorities for 2015/16 The Quality Account Priorities for 2014/15 covered the following five topics: Patient Experience Infection Control Pressure Ulcers Nutrition Hydration Mortality These topics were agreed by the Board of Directors due to their importance both from a local perspective (e.g. based on key issues from patient feedback, results from our Nursing Care Indicators (see Section 3.3.4)) and a national perspective (e.g. reports from national bodies such as Age UK, CQC etc.). The first five topics were initially endorsed by a Listening into Action event on the Quality Report, hosted by the Chief Executive and Director of Nursing, attended by staff, Governors, Foundation Trust members and others from the following organisations: Dudley LINK, Dudley Primary Care Trust, Dudley MBC, Dudley Stroke Association and Dudley Action for Disabled People and Carers (ADC). The sixth topic was added from the recommendation of an external review of the Trust. Following consultation with the Governors, with those who attended the Annual Members meeting, with the public generally via an online questionnaire and suggestions from our main commissioner it has been agreed that the same priority topics will be retained in 2015/16. All of the topics have a fundamental role in providing good quality patient care. Good patient experience of our services is a core purpose of the Trust. The Trust is committed to minimising healthcare acquired infection rates which is a key commissioner and patient expectation. There are national campaigns of zero tolerance to avoidable pressure ulcers and the need to focus on patients nutrition and hydration. Monitoring mortality indicators is seen as a useful device as they can act as a "warning sign" or "smoke-alarm" for potential quality issues. Outstanding doesn't come close to describing the level of care the midwives give. To all of them it was obvious its more than just a job and they are more than willing to go above and beyond to ensure that mom and baby are happy and safe. 9

39 2.1.3 Our priorities Priority 1 for 2014/15: Patient experience Hospital a) Maintain an average score of 8.5* or above throughout the year for patients who report receiving enough assistance to eat their meals. b) By the end of the year, at least 90 per cent of patients will report that their call bells are always answered in a reasonable time. Patient experience Community a) Equal or improve the score of patients who state they were informed who to contact if they were worried about their condition after treatment. (2013/14 was 8.8 out of 10) b) Equal or improve the score of patients who state they know how to raise a concern about their care and treatment if they so wished. (2013/14 was 8.3 out of 10) *Change of scoring system to be consistent with the national surveys. Now out of 10 rather than 100 How the Trust measures and records this priority Hospital This priority has been measured using our real-time survey system. A random sample of inpatients is asked to share their experiences by participating in the survey about their stay before they leave hospital. Responses to the surveys are entered directly into a hand-held computer and downloaded straight into our database to provide timely feedback. During 2014/15 (up to ), 1391 patients participated in the surveys. All surveys are anonymous and results are shared with individual wards enabling them to take action on patient comments. Community The community priority has been measured using an annual survey. A paper questionnaire was distributed to community patients who were also provided with a freepost envelope to ensure an anonymous response; 541 responses to the survey were received, with question (a) answered by 513 respondents and (b) answered by

40 Developments that occurred in 2014/15 Changing and improving the food for our inpatients has been a focus this year with numerous interventions including:- new water jugs which are easier to handle; fresh fruit available every day; daily mealtime observations, refreshed training for housekeepers, increased availability of chips and jacket potatoes. There was also a complete new menu trial conducted on four wards which included tasting sessions and feedback from patients, staff and governors resulting in a menu Chosen by you, to be rolled out during Dedicated lead nurse on all wards for mealtimes to ensure enough nursing support during mealtimes.new well being workers developed and recruited across the trust to provide one to one care for our most vulnerable patients and in particular those living with dementia. Dementia Friends campaign and training launched across the Trust. Three wards have trialled a 30 second response time to answering call bells, including information posters displayed to advise patients of what can be expected. Improved highway signage on main roads leading to Guest. Card payment system on parking machines Environmental improvements to the admissions lounge and day case area, including daily newspapers, better signage and a review of seating arrangements. Establishment of the Patient Experience Group incorporating representatives from the Clinical Commissioning Group, Health watch Dudley and the Council of Governors. The group is chaired by the Chief Executive and reports into the Clinical Quality, Safety and Patient Experience Committee Development and agreement of new reporting style for CCG on patient experience Development of a patient experience app to be launched in 2015 to provide another platform for patients and the public to share their views. Business cards developed to advise patients how to raise a concern, compliment or complaint and posters refreshed across all sites. Reviewed appointment and discharge letters to ensure patients receive information on who to contact if they are worried after treatment and how to raise a concern Regular patient videos or letters presented to Trust Board each month. PICTURE 11

41 Current status: Hospital Quality priority hospital (a) Q1 Q2 Q3 Q4 2014/15 Maintain an average score of 8.5 or above throughout the year for patients who report receiving enough assistance to eat their meals. Number of patients who felt that they sometimes or never get the help that they needed (out of 400 surveyed) 2 (out of 440 surveyed) 2 (out of 300 surveyed) 9 (out of 1140 surveyed) Quality priority hospital (b) Q1 Q2 Q3 Q4 2014/15 By the end of the year at least 90 per cent of patients will report that their call bells are always answered in a reasonable time 85.5% 86% 89% 86.75% (Figures for 2014/15 are just up to the end of Dec 14) It can be seen that the Trust has met the target relating to patients perceptions of receiving enough assistance to eat their meals (target 8.5 with actual figure of 8.95). With regards to the call bell target, although the figures are an improvement on last year, this target has been narrowly missed. Current status: Community Quality priority community (a) 2013/ /15 Equal or improve the score of patients who state they were informed who to contact if they were worried about their condition after treatment. (2013/14 was 8.8 out of 10) Quality priority community (b) 2013/ /15 Equal or improve the score of patients who state they know how to raise a concern about their care and treatment if they so wished. (2013/14 was 8.3 out of 10) The Trust has achieved part (a) of the community priority achieving an equal score to the previous year for the number of people who felt they knew who to contact if they were worried about their condition after treatment in community services. However priority (b) has seen a slight decrease from 8.3 in 2013/14 to 8.0 in 2014/15 for patients who knew how to raise a concern about their care or treatment. 12

42 New priority 1 for 2015/16 Patient experience Hospital Achieve scores in the inpatient friends and family test that are at or above the national average each month Community Achieve scores in the community friends and family test that are at or above the national average each month. (First publication May 2015) Rationale for inclusion The hospital and community targets have changed this year to focus on the Friends and Family test. This is a national measure of patient experience and allows the trust to benchmark ourselves against trusts both regionally and nationally on a monthly basis. The Friends and Family Test aims to provide a simple headline metric to drive continuous improvements. It makes sure that staff providing the service and the Board of Directors receives regular feedback from patients on how the services are being received, what is working well and where improvements are needed. The simple survey asks patients if they would recommend the service to a friend or relative and to rate it from extremely likely to extremely unlikely to recommend. The hospital priority (a) target in 2014/15 was consistently achieved throughout the year and we are now looking for a priority where there are both local and national results published we can benchmark ourselves against aiming to be above the national average and ultimately aspire to be in the top 20% of trusts. Developments planned for 2015/16 Actions being undertaken to achieve the Trust target include: Continue the patient catering developments including the roll out of new menus. Refresh volunteer recruitment to target volunteers into the areas of greatest patient need including mealtime volunteers. Implement new call bell response time across the Trust and monitor progress. Review patient gowns Complete implementation of soft close bins to improve further quiet night time. Review appointment and discharge letters to ensure patients receive information on who to contact if they are worried after treatment and how to raise a concern Launch patient feedback app Provide patient and public wi-fi access across the three hospital sites. Board sponsor: Paula Clark, Chief Executive Operational lead: Liz Abbiss, Head of Communications and Patient Experience 13

43 Priority 2 for 2014/15: Pressure ulcers Pressure ulcers Hospital Ensure that there are no avoidable stage 4 hospital acquired pressure ulcers throughout the year. Ensure that the number of avoidable stage 3 hospital acquired pressure ulcers in 2014/15 does not increase from the number in 2013/14. Community Ensure that there are no avoidable stage 4 pressure ulcers acquired throughout the year on the district nurse caseload. Ensure that the number of avoidable stage 3 acquired pressure ulcers on the district nurse caseload in 2014/15 does not increase from the number in 2013/14. How we measure and record this priority Pressure ulcers, also called pressure sores and bed sores, are staged one to four with four being the most serious. When a patient is identified as having a pressure ulcer, the details are entered into the computer incident reporting system and are reviewed by the Tissue Viability team prior to reporting externally. If pressure damage is noted within 72 hours of admission to the hospital and the patient has not been under the care of the community teams or on the District Nurse Caseload, this is not considered to have developed whilst under the care of the Trust. This time frame is agreed regionally as it is recognised that pressure damage can occur but not be visible immediately. Developments that occurred in 2014/15 The Trust has updated the pressure ulcer prevention guidelines with all relevant recent developments. Standardised pressure ulcer prevention and management documents are now being used across the hospital and community. The prevention document includes a SKIN (Surface Keep moving Incontinence Nutrition) bundle (a standardised assessment and treatment record), which carers complete to ensure every aspect of pressure ulcer prevention is addressed at each patient care episode. The Trust has recognised the importance of continually updating community carers in pressure ulcer prevention and completion of the SKIN bundle document. SKIN bundle training sessions continue for this group of staff, which includes carers in the home and residential home settings, across the year on a rolling programme and all sessions are well attended. Each ward has tissue viability co-ordinating link nurses who complete on-going audits of these documents to ensure they are completed correctly. There has been an additional audit completed as part of a study programme that revealed some 14

44 changes are required to these documents to ensure a standard approach across the Trust. The Tissue viability team have started work to ensure these changes are carried out. The Trust introduced new Static Air mattresses to all inpatient beds (excluding maternity and children areas). This type of mattress is known as a hybid mattress and combines foam and air cells which makes them suitable for patients who are at very high risk of developing pressure ulcers. Plug-in specialist mattresses may still be required for a small number of patients but because this need has been reduced we are able to provide this further high risk equipment with no delays to patients. As a result of the switch the Trust has made significant cost savings and there was no increase in patients developing stage 3 and 4 pressure ulcers. The Tissue Viability team now see all patients that have been reported to develop stage 3 or 4 pressure ulcers. This assessment helps not only to verify that the correct type of wound has been reported but ensures that a specialist has seen the patient and can make sure that all the appropriate care is in place. The Trust have employed community tissue viability nurses to focus on the correct use of pressure relieving equipment in the community which of course involves education to community teams and carers. This team has implemented a new equipment selection flow chart which gives more guidance than before for nurses. This process involved roadshows to which all nurses were invited to collect their guidance and receive a short education session on all equipment available to them. The team have also developed a good relationship with the Dudley Council equipment service that supplies different types of pressure reduction equipment to patients at home and in care homes. They have been working with this service to ensure all equipment is tested correctly and fit for purpose and now hold regular meetings to ensure delivery and collection time frames are maintained. The Trust has representation at the national tissue viability group. This group works closely with NHS England to ensure standards are in place locally. This year they have worked together to develop a visual poster to help nurses with the identification of skin damage. PICTURE/QUOTE 15

45 Current status: Hospital The graph below shows the total number of avoidable stage 3 and 4 pressure ulcers that have developed in the hospital from 2011/12 to the present. It gives an indication of the dramatic fall in numbers due to the hard work of all staff involved. While there were 51 stage 3 and 4 ulcers in 2012/13 these have been reduced to 20 this year. 120 Total number of Avoidable Stage 3 and 4 Pressure Ulcers Developed in Hospital Number of Pressure Ulcers / / / /15 Year (Figures for 2014/15 are just up to the end of Feb 15) Specifically for avoidable stage 4 hospital acquired pressure ulcers, the target set was that there would not be any. This year there has unfortunately been a single avoidable stage 4 ulcer and so this target has not been achieved. No. of Pressure Ulcers Number of Avoidable Stage 4 Pressure Ulcers Developed in Hospital / /14 Apr - June 14 Jul - Sep 14 Oct - Dec 14 Jan - Mar 14 Period (Figures for 2014/15 are just up to the end of Feb 15) My sole experience of Russells Hall is that the community is fortunate to have such a dedicated and expert medical staff working with terminally patients in the Georgina Ward. 16

46 With regards to avoidable stage 3 hospital acquired pressure ulcers, the target set was that the number in 2014/15 would not increase from the number in 2013/14. In 2013/14 there were 41 avoidable stage 3 ulcers. It can be seen that so far this year there have been 19. It can be seen that the Trust is achieving this target up to the end of February Number of Avoidable Stage 3 Pressures Ulcers Developed in Hospital No. of Pressure Ulcers /14 Apr - June 14 Jul - Sep 14 Oct - Dec 14 Jan - Mar 15 Period (Figures for 2014/15 are just up to the end of Feb 15) Current status: Community No. Pressure Ulcers Total number of Avoidable Stage 3 Pressure Ulcers developed on District Nursing Caseload Q3 11/12 Q4 11/12 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Year/Quarter Q3 13/14 Q4 13/14 Q1 14/15 Q2 14/15 Q3 14/15 Q4 14/15 (Figures for 2014/15 are just up to the end of Feb 15) The target of there being no avoidable stage 4 pressure ulcers acquired throughout the year on the district nurse caseload has been achieved. With regard to the avoidable stage 3 acquired pressure ulcer numbers not increasing from the number in 2013/14, this was a difficult target to achieve as there were only 4 in 2013/14, a dramatic drop from the previous two years. So far this year there have been five although discussions are underway whether two of these were avoidable or unavoidable by the Trust. 17

47 New priority 2 for 2015/16 Pressure ulcers Hospital a) Ensure that there are no avoidable stage 4 hospital acquired pressure ulcers throughout the year b) Ensure that the number of avoidable stage 3 hospital acquired pressure ulcers in 2015/16 does not increase from the number in 2014/15. Community a) Ensure that there are no avoidable stage 4 pressure ulcers acquired on the district nurse caseload throughout the year. b) Ensure that the number of avoidable stage 3 pressure ulcers acquired on the district nurse caseload in 2015/16 does not increase from the number in 2014/15 Rationale for inclusion Pressure ulcers are difficult to treat and slow to heal, and prevention is therefore a priority. Although the Trust has continued to reduce the overall numbers, it realises there is still much to do and moving to a zero tolerance of pressure ulcers in hospital should be the aim. Feedback from our patients, staff, community groups and governors indicates this should remain a target. Developments planned for 2015/16 Actions being undertaken to achieve the new Trust target include: Audits of all pressure relief equipment within residential home care settings to ensure it is maintained and used as per the Trust guidance Amend education programmes to include short one hour sessions with a specific focus each month Continue to provide regular educational sessions for community carers Continue weekly joint (community/hospital) pressure ulcer group meetings to ensure cross Trust learning Update the pressure ulcer prevention document and ensure teams have education and support for their continued use Agree process for lead nurses to support tissue viability nurses in the verification of stage 3 and 4 pressure ulcers Once the verification process has been agreed, the tissue viability team will support specific wards with prevention work through structured ward walks and audit. Develop a refusal of care pathway to ensure patients have a clear understanding of the risks associated with refusing equipment or positioning Investigate the use of a new device that can detect possible pressure damage before any redness occurs on the skin Continue to work with the regional group to assist the national level work such as updating and maintaining the national stop the pressure website Board Sponsor: Denise McMahon, Director of Nursing Operational Lead: Lisa Turley, Tissue Viability Lead Nurse 18

48 Priority 3 for 2014/15: Infection control Infection control Reduce our MRSA and Clostridium difficile (C. diff) rates in line with national and local priorities. MRSA Have 0 post 48 hour cases of MRSA bacteraemia (blood stream infections). Clostridium difficile Have no more than 48 post 48 hour cases of Clostridium difficile. How we measure and record this priority Numbers of selected infections are monitored internally on the Trust Board dashboard. In addition, the numbers of selected infections are monitored by our commissioners at Quality Review Meetings Positive MRSA bacteraemia and Clostridium difficile results are reported onto the national HCAI data capture system Developments that occurred in 2014/15 We worked with the hydrogen peroxide vapour fogging contractor to agree a rolling programme of decontamination across all inpatient areas to assist in the prevention of infection We provided additional training for staff around the correct procedures for collecting specimens We developed education programmes and competencies for Infection Control that can be utilised across the Trust We have worked with our community teams to enhance their knowledge around infection prevention and auditing of practice. We have worked with our commissioners to agree a process for determining avoidability of C diff cases. PICTURE/QUOTE 19

49 Current status: MRSA NHS England has set a zero tolerance approach to MRSA bacteraemias. We have reported zero MRSA bacteraemia for 2014/15. 8 Total MRSA cases per year / / / / / / /15 (Figures for 2014/15 are just up to March 11th 15) Current status: C. difficile We have reported a total of 36 cases (to date) of Clostridium difficile for 2014/15. This rate is well below the threshold set of no more than 48 cases. We have achieved this through a continued focus on the clinical management of patients with identified or suspected infection. Total C.difficile cases per year / / / / / / /15 (Figures for 2014/15 are just up to March 11th 15) 20

50 New priority 3 for 2015/16 Infection control Maintain or reduce our MRSA and Clostridium difficile (C. diff) rates in line with national and local priorities. MRSA Have 0 post 48 hour cases of MRSA bacteraemia (blood stream infections). Clostridium difficile Have no more than 29 post 48 hour cases of Clostridium difficile. Rationale for inclusion The Trust and the Board of Governors have indicated that the prevention and control of infections remains a Trust priority. NHS England has a zero tolerance of MRSA bacteraemia. The Trust has a challenging target of 29 C diff cases for the coming year. Developments planned for 2015/16 Actions planned to achieve the above aims include: Review the current documentation used to monitor intravenous cannualae Develop an information leaflet for patients who are identified as C diff carriers. Develop protocols for the implementation of faecal transplant for patients who have relapses of Clostridium difficile. The purpose of faecal transplant is to provide appropriate bowel flora in the gut after infection with C. difficile. Review and redesign the isolation cards.these cards are displayed on the rooms of patients with an infection to indicate specific precautions are required Plan a focus day (C the Difference) in the Trust to highlight the importance of all aspects of management for Clostridium difficile. Board sponsor: Denise McMahon, Director of Nursing Operational lead: Dr. E Rees, Director of Infection Prevention and Control Following a recent accident, I was admitted to Russell's Hall Hospital. I had to undergo three visits to theatre, in all my surgery lasted some 12 hours. I would like to thank all who attended to me from cleaners to consultant surgeons. The nursing staff on B2 were exceptional and the care I received was second to none 21

51 Priorities 4 and 5 for 2014/15: Nutrition and Hydration Nutrition Increase the number of patients who have a weekly risk re-assessment regarding their nutritional status. Through the year on average at least 90 per cent of patients will have the weekly risk assessment completed and this will rise to at least 93 per cent by the end of the year (March 2015). Hydration Ensure that on average throughout the year 93 per cent of patients fluid balance charts are fully completed and accumulated at lunchtime. How we measure and record these priorities Every month 10 observation charts are checked at random on every ward at the Trust as part of the wider Nursing Care Indicators (NCI) monitoring (see Section 3.3.4). This process includes checking the MUST assessment which is a rapid, simple and general procedure commenced on first contact with the patient and then weekly so that clear guidelines for action can be implemented and appropriate nutritional advice provided. The Malnutrition Universal Screening Tool (MUST) has been designed to help identify adults who are underweight and at risk of malnutrition, as well as those who are obese. The tool has been in use at the Trust for a number of years. The NCI monitoring also includes checking that recorded fluid input and output of patients is added up both at lunchtime and at the end of the day. The completion rates of each ward are fed back to the matrons and ward managers for action where necessary. Each ward and the whole Trust is RAG (Red/Amber/Green) rated. Up to 2013/14 a Green was given for a 90 per cent or greater score, an Amber/Yellow for per cent scores and a Red for scores 69 per cent or less. Due to the overall improvement in scores across the Trust, from 2013/14, a Green is given for a 93 per cent or greater score, an Amber/Yellow for per cent scores and a Red for scores 74 per cent or less. Developments that occurred in 2014/15 An escalation process has been developed for tracking areas of concern from the mealtime audits An electronic based learning package has been identified and we are awaiting verification of compatibility with current Trust IT systems Free standing notices at the entrance of each ward area to denote Protected Mealtime Service is occurring have been introduced New national descriptors for speech language therapy in relation to food consistency grading have been rolled out New menus, which have been chosen by patients and staff, have been trialled on three wards and will be rolled out through the Trust. 22

52 This image cannot currently be displayed. This image cannot currently be displayed. Participated in International Nutrition and Hydration week when the importance of a good diet was publicised in a variety of ways across the Trust Current status: Nutrition Results from the weekly reassessments indicate that in the third quarter there was an improvement after the slight drop in performance during quarter 2. Overall up to the end of February, the nutrition weekly screenings have remained on target maintaining a 93 per cent average. (Figures for 2014/15 are just up to the end of Feb 15) Current status: Hydration Results of patients having their fluid balance charts completed at midday show that up to the end of February 2015 the average 90 per cent target has been exceeded as the average completion is actually 94 per cent. (Figures for 2014/15 are just up to the end of Feb 15) 23

53 New priority 4 for 2015/16 Nutrition and Hydration Ensure that the yearly score for every ward in the hospital on the whole of the monthly Nutrition and Hydration Audit (which consists of 24 items) is 93% or above. Rationale for inclusion To retain the emphasis on nutrition/hydration. The two specific targets for 2014/15 are likely to be met. The new target covers all of the 24 items of the nutrition and hydration audit (not just two specific issues) so is more comprehensive. The new target also covers every ward separately not an overall Trust score as last year. This ensures that every ward will have its results published rather than being subsumed into an aggregate Trust score so that the situation in every ward is clear. Poor nutrition and hydration leads to poor health, increased and prolonged hospital admissions and increased costs to the NHS. The consequences of poor nutrition and hydration are well documented and include increased risk of infection, poor skin integrity and delayed wound healing, decreased muscle strength, depression and, sadly, premature death. Put simply poor nutrition and hydration causes harm. From October 2014, as part of the monitoring of care relating to nutrition and hydration care, a more comprehensive audit tool was introduced. This follows the NCI model looking at what is recorded in the nursing notes but it also includes asking patients their views about being offered drinks and choice of food. It also includes observations of the environment, for instance, whether patients have drinks within reach and whether they are placed in an optimal position for eating. In total there are 24 elements to the audit and it is undertaken on ten patients on every ward every month. The results up to the end of December 2014 can be seen on the next page. It can be seen that there is scope for improvement, particularly in terms of achieving the target we have set ourselves. During late 2014 there have been 13 occasions where wards have scored less than the minimum 93% standard required. I recovered on Ward C6, with very attentive nurses and doctors, well fed and hydrated! A big thanks to all involved in my stay from the consultant to the porters and cleaners, much appreciated care of me all the way from North Wales!! 24

54 Table of overall results of the Nutrition and Hydration Audits for each ward starting October 2014 Ward October 2014 November 2014 December 2014 Average score for the three months A1 * * A A A B B B B B B C C C C C C C Medical High Dependency Unit Coronary Care Unit Critical Care Unit Emergency Assessment Unit Clinical Decision Unit * = Ward A1 was refigured in November and so that and previous months results are not comparable + = The Critical Care unit commenced auditing in November Developments planned for 2015/16 New visual display boards which comply with national descriptors in relation to food consistency grading to ensure patients get the right consistency of food and therefore correct nutritional input. Development of Nutrition/hydration Care Bundle incorporating flow chart for escalation when intake is poor. Monthly multi agency meal time audits to ensure patients and staff views are heard and real time actions taken if required. Development of Trust standards for nutrition and hydration for inpatients. Training for volunteers and non ward based staff to support meal times. Board Sponsor: Denise McMahon, Director of Nursing Operational Leads: Kaye Sheppard, Head of Nursing-Medicine, Jenny Davies, Matron for GI and Renal Services, Rachel Tomkins, Matron for Elderly 25

55 Priority 6 for 2014/15: Mortality Mortality Ensure that 85 per cent of in-hospital deaths undergo specialist multidisciplinary review within 12 weeks by March How we measure and record this priority The Trust s Mortality Tracking System (MTS) was developed by our Information Team and launched in January Every patient death is recorded on the MTS and tracked through the following processes: coding, consultant validation, mortality audit and review. Monthly reports will be provided to the Mortality Review Panel and quarterly to the Clinical Quality Safety and Patient Experience Board Committee. Rationale for inclusion Feedback from the Keogh Review in May 2013 indicated that the Trust should consider including Mortality as a Quality Priority. The Keogh Report highlighted the importance of detailed and systematic case note review as the way forward in learning from hospital deaths and, therefore, the Trust needs to ensure that this is undertaken regularly in all specialties. Developments that occurred in 2014/15 The Trust has remained within the expected range for the most widely used risk adjusted mortality indicators HSMR (Hospital Standardised Mortality Ratio) and SHMI (Summary hospital-level Mortality Indicator). Therefore it is even more important the Trust now develops its use of mortality ratios as an indicator to investigate specific areas and respond appropriately to any specific areas where care has not met with our high standards. This year data from Mortality Tracking System has been used to provide information for external assurance to the Clinical Commissioning Group and to the Care Quality Commission (CQC) Timely review of deaths is particularly important should the trust receive mortality outlier alerts from external bodies. We have been able to demonstrate this year that we have current, peer reviewed quantitative as well as qualitative data on all deaths in hospital. The Mortality Tracking System used to capture and record this data, and on which the target is based placed in the finals of the prestigious E- Health Insider Awards in October

56 Current status At present, the Trust has an average of 86.6 per cent of in-hospital deaths undergoing specialist multi-disciplinary review within 12 weeks for the year 2014/2015, meeting our target as expected. However as we reported from Quarter /2014 we have calculated the year to date below to include that period to date. Details by speciality are below: Meeting 85% target Above 50%- Below 85% Target Below 50% Trust Overall YTD 86.6 Specialty % audited within 12 weeks Specialty % audited within 12 weeks Q1 Q2 YTD Q1 Q2 YTD Cardiology Renal Gastroenterology Haematology General Medicine Oncology Medical Assessment Care of the Elderly Orthogeriatrics 100 N/A 100 ENT 50 N/A 66.7 Rehabilitation General Surgery Respiratory Urology Stroke Medicine/Stroke Rehab Vascular Surgery Diabetes T&O Rehabilitation Endocrinology Trauma and Orthopaedics Neonate Gynaecology N/A 0 0 Plastic Surgery N/A

57 New Priority 5 for 2015/16: Mortality Mortality Ensure that 90 per cent of in-hospital deaths available for review undergo specialist multidisciplinary review within 12 weeks by March Rationale for inclusion We believe that all specialities are able to improve beyond the current target of 85% if those audits delayed as a result of issues beyond our control, such as cases referred to the coroner are taken into account. The Trust maintains that timely case note review of deaths provides us with the best source of information regarding patients who died in hospital and the quality of care they received. The Trust will be able to respond more effectively internally to make appropriate changes where care falls below the standards we expect and externally to give assurance if as many in hospital deaths as possible are reviewed within 12 weeks. Developments planned for 2015/16 Escalated exception reports by speciality to Divisional Management through to Directors Development of the Mortality Tracking System with other Trusts Additional End of Life Care Audit to be completed where appropriate as part of mortality audits. Board sponsor: Paul Harrison, Medical Director Operational lead: Teekai Beach, Directorate Manager to Medical Director After my recent hip replacement operation at Russells Hall Hospital, I would like to thank the surgeon and his team and all the wonderful nurses on ward B1. Also many thanks to the staff for all their helpfulness and cheerfulness each time I have had to contact them. 28

58 2.2 Statements of assurance from the Board of Directors Review of services During 2014/15 The Dudley Group NHS Foundation Trust provided and/or subcontracted 59 relevant health services. The Trust has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2014/15 represents 99.1 per cent of the total income generated from the provision of relevant health services by The Dudley Group NHS Foundation Trust for 2014/15. The above reviews were undertaken in a number of ways. With regards to patient safety, the Trust executive and non-executive directors continue to undertake Patient Safety Leadership Walkrounds (see section 3.3.2). Morbidity and mortality reviews are undertaken by the chairman, chief executive and medical director. External input is provided by Dudley Clinical Commissioning Group (CCG). These occur on an 18- month rolling programme, covering all services. Each service presents information from a variety of sources including: internal audits, national audits, peer review visits, as well as activity and outcome data such as standardised mortality indicator figures. We also monitor safety, clinical effectiveness and patient experience through a variety of other methods: Nursing Care Indicators monthly audits of key nursing interventions and their documentation. The results are published, monitored and reported to the Board of Directors monthly by the director of nursing (see section 3.3.4). Ongoing patient surveys that give a feel for our patients experiences in real time so that we can quickly identify any problems and correct them (see section 3.2.2). Every other month, senior medical staff attend the Board of Directors meeting to provide a report and presentation on performance and quality issues within their speciality areas. Every other month, a matron attends the Board of Directors meeting to provide a report and presentation on nursing and quality issues across the whole Trust. The Trust has an electronic dashboard of indicators for directors, senior managers and clinicians for monitoring performance. The dashboard is essentially an on-line centre of vital information for staff. The Trust works with its local commissioners scrutinising the Trust s quality of care at joint monthly Clinical Quality Review Meetings. External assessments, which included the following key ones this year: o The Care Quality Commission (CQC) declared that the Trust was compliant with the regulated activity of medicines management. As part of its new regime of inspections, the CQC visited the Trust in March 2014 and a formal report is expected in June o In February 2015, Dudley Clinical Commissioning Group undertook an unannounced visit to the Trust s frail elderly services. The Trust is awaiting the report but initial verbal feedback was positive. 29

59 o The Clinical Pathology Accreditation (UK) Ltd, which was the longstanding body which approved laboratories, visited the following departments: Haematology (October 2014) and Biochemistry (November 2014). Both maintained accredited status. The new inspectorate, the United Kingdom Accreditation Service (UKAS), is due to review both Cellular Pathology and the Mortuary in March o The Human Tissue Authority (HTA) inspected the Trust Mortuary Services in June 2014 and there was a successful outcome. o In January 2015 the Trust had a JACIE assessment (The Joint Accreditation Committee-ISCT [Europe] & EBMT) and was re-accredited for haematopoietic stem cell (HSC) transplantation. The re-accreditation panel highlighted a well-established Quality Management System. o The Clinical Pathology Accreditation (UK) Ltd, which is the authority which approves laboratories, visited the following departments: Microbiology (July 2013) and Immunology (July 2013). Both maintained accredited status. o In June 2014 the NHS Quality Control North West visited the Trust Aseptic Pharmacy unit and concluded that the unit continues to operate to a very high standard, with a well maintained and well documented quality system. The overall risk rating for the unit remains Low. o In February 2015, an expert review, led by the ex-vice president of the Royal College of Radiologists, of the radiological services took place. The conclusion of the review was that the Trust has an excellent department. o The West Midlands Quality Review Service (WMQRS) visited the Trust on three occasions. In April 2014 the service reviewed our Frail Elderly Services from which no major issues of note were found and a number of improvements were implemented. In February 2015 a team reviewed Day Case Surgery and in the following month our services relating to Transfer of Care from Acute Hospital and Intermediate Care were reviewed. The reports from both of these latter reviews are still awaited. o With regards to education and training, the West Midlands Deanery undertakes a variety of checks on the education of doctors at the Trust. This year the Emergency Medicine services were visited in both May and September Following some initial concerns in May, the latest visit resulted in a commendation for the improvements made. My husband was admitted as an emergency. On the High Dependency Unit all staff are wonderful. My sincere thanks to the staff who were mainly looking after my husband. 100% care given. Thank you to the doctor who showed me empathy and also the anaesthetist who took time out to discuss everything. Thank you for all information you gave in a professional manner. 30

60 2.2.2 Participation in national clinical audits and confidential enquiries During 2014/15, 32 national clinical audits and four national confidential enquiries covered relevant health services that the Trust provides. During that period the Trust participated in 100 per cent of the national clinical audits and 100 per cent of the national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the Trust was eligible to participate in, actually participated in, and for which data collection was completed during 2014/15, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Table 1 National clinical audits that the Trust was eligible to participate in, actually participated in during 2014/15 and the percentage of the number of registered cases submitted by the terms of the audit Name of Audit Type of Care Participation Submitted % ICNARC Case Mix Programme Database Acute Care Yes 100% Adult Community Acquired Pneumonia Acute Care Yes Still in progress National Emergency Laparotomy Audit Acute Care Yes 100% National Joint Registry Acute Care Yes 97% Pleural Procedures Audit Acute Care Yes 100% TARN Severe Trauma Audit Acute Care Yes 96% National Comparative Audit of Blood Transfusion: 2014 Survey of Red Cell Use Blood & National Comparative Audit of Blood Transfusion: Transplant 2014 Blood Use in Sickle Cell Anaemia Yes 100% Yes Still in progress National Bowel Cancer Audit Project Cancer Yes 100% Data for Head and Neck Oncology Cancer Yes 100% National Lung Cancer Audit Cancer Yes 100% National Oesophago-gastric Cancer Audit Cancer Yes 100% National Prostate Cancer Audit Cancer Yes 100% MINAP Acute Coronary Syndrome/Acute Myocardial Infarction Audit Heart Yes 100% Cardiac Rhythm Management Heart Yes 100% 31

61 Name of Audit Type of Care Participation Submitted % National Cardiac Arrest Audit Heart Yes 100% National Heart Failure Audit Heart Yes 84% to end Jan 2015 National Vascular Registry Heart Yes 97% National Diabetes Foot Care Audit (NDFA) National Pregnancy in Diabetes Audit National Paediatric Diabetes Audit Inflammatory Bowel Disease Audit National Chronic Obstructive Pulmonary Disease Audit programme Renal Replacement Therapy (Renal Registry) Rheumatoid and Early Inflammatory Arthritis Long-term Conditions Long-term Conditions Long-term Conditions Long-term Conditions Long-term Conditions Long-term Conditions Mental Health (care in emergency departments) Mental Health Yes Yes Yes 100% Yes 100% Yes 100% Yes 100% Yes 100% Yes Still in progress Falls and Fragility Fractures Audit Programme Older People Yes 100% Sentinel Stroke National Audit Programme Older People Yes 100% Older people (care in emergency departments) Older People Yes 100% Elective Surgery (National PROMs Programme) Other Yes Epilepsy 12 Audit (Childhood Epilepsy) Maternal, Newborn and Infant Clinical Outcome Review Programme National Neonatal Audit Programme Fitting child (care in emergency departments) Women & Children s Health Women & Children s Health Women & Children s Health Women & Children s Health 94% to end Jan 2015 Yes 100% Yes 100% Yes 100% Yes 32

62 Table 2 National confidential enquiries that the Trust was eligible to participate in, actually participated in during 2014/15 and the percentage of the number of registered cases required by the terms of the enquiry Name of Audit Type of Care Participation Submitted % Tracheostomy Care NCEPOD Yes 100% Lower Limb Amputations NCEPOD Yes 100% Gastrointestinal Haemorrhage NCEPOD Yes 100% Sepsis NCEPOD Yes Still in progress As well as the national clinical audits in Table 1, from the Healthcare Quality Partnership (HQIP) list, the Trust has also taken part in these further national audits: Table 3 Additional National Clinical Audits that the Trust participated in during 2014/15 Name of Audit Type of Care Participation Submitted % National Postpartum Haemorrhage Audit Obstetrics Yes 100% First Sprint National Anaesthesia Project (SNAP- 1) Anaesthesia Yes 100% BAUS National Nephrectomy Audit Database Urology Yes From the outset in the day care unit I was put at ease by the nurses. A further visit from the anaesthetist and the surgeon laid any further worries to rest. Following my surgery the aftercare throughout the rest of the day was excellent and reassuring. 33

63 The reports of the following 14 national clinical audits were reviewed in 2014/15: Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) CEM Asthma in Children Audit CEM Paracetamol Overdose Audit CEM Severe Sepsis Audit National Anaesthesia Sprint Audit Project (ASAP) National Audit of Dementia National Audit of Seizure Management National Bowel Cancer Audit National Care of the Dying Audit for Hospitals (NCDAH) National Chronic Obstructive Pulmonary Disease Audit Programme National Diabetes Inpatient Audit (NaDIA) National Emergency Laparotomy Audit (NELA) National Joint Registry National Lung Cancer Audit National Oesophago-Gastric Cancer Audit NCEPOD Lower Limb Amputation: working together Sentinel Stroke National Audit Programme (SSNAP) Trauma Audit Research Network (TARN) From the above reviews, the Trust has taken or intends to take the following actions to improve the quality of healthcare provided: CEM Severe Sepsis Audit Audit outcome and recommendations identified for improved management of patients discussed and disseminated to all ED staff through the ED Governance Newsletter. National Care of the Dying Audit for Hospitals (NCDAH) Planned introduction of a Trust-wide local audit of care of the dying to be included on the annual mandatory audit programme. VOICES bereavement survey commenced with results reported to the Patient Experience Group. End of Life (EOL) work stream is currently reviewing End of Life Care Guidelines working with community / primary care / hospice teams. The hospital pastoral care team is currently writing a strategy to identify adequate resource for the spiritual needs of the dying patient. National Audit of Seizure Management Subsequent recommendations for a sustained improvement include: the development of local guidelines, education of doctors in the assessment and management of epilepsy and introduction of regular departmental audits against NICE guidelines and NASH2 recommendations. National Anaesthesia Sprint Audit Project (ASAP) Pathway to be developed, in conjunction with the trauma and orthopaedics speciality, for provision of pre-operative femoral nerve blockade to all fracture neck of femur patients 34

64 Local clinical audit The reports of 30 completed local clinical audits were reviewed in 2014/15 and the Trust has taken, or intends to take, the following actions to improve the quality of healthcare provided: Microbiology Review and further elaborate section explaining notification already present in the Meningitis section of the Antimicrobial guidelines. The same included in the Meningitis section of the antimicrobial App. Acute Medicine A senior review of patients in the afternoon with the junior doctor/nurse in charge is now routine practice, with a designated SpR on the rota for the afternoon ward round. Trust is undertaking a series of training sessions to raise awareness of encephalitis and its management and posters displayed in the relevant clinical areas; we will be re-auditing our performance. Re-audit showed improved compliance to achieving the sepsis six within 1 hour compared to the previous 2010 audit. To continue education on the Sepsis six pathway (this would include education at the start of the year for all new junior doctors rotating to the Trust) and encouragement of use of the proforma. Set up a Trustwide co-ordinating group to improve identification and treatment of Sepsis. Gastrointestinal Medicine PEG (Percutaneous endoscopic gastrostomy) request and nutrition nurse documentation to be with placing consultant a minimum of 2 days prior to minimise rejection of patient in the endoscopy room. Following discussion with Consultant Microbiologist, nasal swabs for S.aureus to be performed and to treat, if present. A flow chart introduced showing appropriate management and education on sigmoid volvulus to be rolled out to junior doctors within the surgical teaching sessions. Introduction of a simple flowchart to highlight the indication of a PPI (Proton-pump inhibitor) (and the appropriate duration (available on hospital intranet). Department to introduce rectal administration of NSAID for all patients undergoing ERCP Stroke Medicine It was recommended that all patients presenting with atrial fibrillation (AF) should be assessed for stroke risk using CHADS2/CHADVASC score and should be considered for anticoagulation if the bleeding risk is low on using the HASBLED score, taking into account patients preference. There is now a pathway to identify patients with acute ischaemic stroke undergoing intra-venous thrombolysis at Russells Hall Hospital that may potentially benefit from thrombectomy which is performed at the Queen Elizabeth Hospital. 35

65 Rheumatology Database created of patients receiving Denosumab in secondary care on which a serum calcium is recorded both before and after the injection. A patient information leaflet is now given at the time of injection on which it is highlighted the importance of monitoring serum calcium. New Trust guidelines for Acute Hot Joint currently awaiting ratification. Anaesthetics The Trust is now using the West Midlands palliative care document as our guidance on opioid conversion. Introduction of a Standard Operating Procedure for anaesthetic pre-op clinic/cpet clinic. All letters now going to GP's when anaemia identified. Dietetics A new dysphagia menu has now been devised and introduced to the Trust, giving patients more variety of meals and texture to suit their needs. District Nursing 8cm midlines to be used for patients in the community setting requiring IV therapy for IV antibiotics for more than 5 days. Intensive Care Medicine A maximum dose has been added to the electronic prescription for Propofol. This ensures that doses greater than 4mg/kg/h cannot be prescribed and, therefore, given. An advisory has also been developed to prompt clinicians to look for features of PrIS & to consider alternative strategies for sedation. Obstetrics & Gynaecology Abdominal Sacrocolpopexy patients are now pre-assessed to review appropriateness for laparoscopic surgery Programme for updated training sessions on infant feeding is now in place. Specialist Midwife to be contacted via bleep when required to attend Children s Ward and process also now in place for staff on Children s Ward to contact a Maternity Infant Feeding Assistant (MIFA) to provide support when required. Midwifery staffing figures are submitted monthly and shortfalls are now monitored at the monthly manager s meetings. A monthly report to be presented at the managers meeting to outline the number of incidents in relation to staffing shortfalls and escalation within the maternity unit. Lead Midwife to complete a DATIX incident report if community midwife unable to support home birth. To further recruit and establish competence for 4 WTE HPSS workers. Ophthalmology All new prescribers to the department now have a training meeting with non medical prescriber regarding prescription form completion and an annual presentation of findings at doctors audit meeting will take place. 36

66 Paediatrics/Neonates Audit A simpler flow chart for therapeutic hypothermia has been introduced on the neonatal unit. Ensure strict adherence to the new therapeutic cooling and referral pathway to help in identifying suitable patients for therapeutic hypothermia. A new paediatric assessment unit proforma with sections to record the date and time is now within the medical notes. Staff also reminded of the importance of documenting the time when the patient is seen. A Re-audit over longer period of time will also take place in the next audit year; to include a wider range of staff. Pharmacy Improved access to all antimicrobial guidelines with the introduction of the new mobile phone app, both are now constantly being updated with memos sent out for any significant changes. Handy hints card have now been made for health care professionals, these include the sepsis criteria, signs of organ dysfunction, the sepsis 6 and the antibiotic guidelines for treating sepsis. Podiatric Surgery Bleeding risk and contraindications to compression stockings and Dalteparin have all been incorporated into one DVT (Deep Vein Thrombosis) assessment tool. This includes the blood test requirements as a newly added tick list and the discussion of stopping HRT and OCP as part of DVT assessment process. Trauma & Orthopaedics New pro-forma to be used by the on-call post-take team and put in the notes or inpatient referral. Development of proforma for patients needing MRI for suspected Cauda Equina Syndrome PICTURE 37

67 2.2.3 Research and development The number of patients receiving NHS services provided or sub-contracted by the Trust in 2014/15 that were recruited during that period to participate in research approved by a research ethics committee was 1141portfolio and 17 non portfolio. Of these, 157 were recruited to commercial studies (figures as of 31/12/14, full figures & stats to be completed in April 2015). In last year s Quality Report we predicted that dermatology and endocrinology would grow in importance in terms of research. In autumn 2014 the dermatology research team won a national prize for the success of their commercial work, recruiting to time and target and delivering high quality research data. Dermatology s commercial research income now provides sufficient funding for the Trust to have recruited a senior dermatology research nurse in May During the same period, more diabetes studies have opened, with a commensurate increase in research nurse time. This year s success story is the opening of several academic studies in the stroke, anaesthetics and critical care departments. This has been made possible by successfully bidding for Clinical Research Network: West Midlands funding for additional research nurse time. Dudley is also participating in an important regional vascular surgery trial. Musculoskeletal clinical disciplines and cardiology continue to recruit well to commercial trials. The reorganisation of cancer services and increasing number of very selective, targeted treatment has reduced participation in oncology studies; commercial cancer studies are still undertaken in the Trust. The Trust continues to host several research fellows and PhD students from local universities. Two researchers based in rheumatology are currently writing up their doctoral theses. Trust publications for the calendar year 2014, including conference posters, stand at 164, an increase of approximately 50% on 2013, possible due to improved methods of detection! In the field of haematology, the interim results of a recently closed multicentre Hodgkin s disease study have shown that the introduction of centrally funded PET scans for younger patients is an effective prognostic tool. Scan results indicate to clinicians when to escalate treatment, after which 75% of the patients have improved progression free survival. Dudley dermatology patients participation in clinical trials has helped to secure the UK marketing authorisation and NICE approval for the use of existing drugs to treat psoriasis. 38

68 2.2.4 Commissioning for Quality and Innovation (CQUIN) payment framework A proportion of the Trust s income in 2014/15 was conditional upon achieving quality improvement and innovation goals agreed between the Trust and any person or body it entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2014/15 and for the following 12 month period are available online at: CQUIN is a quality increment that applies over and above the standard contract. The sum is variable based on 2.5 per cent of our activity outturn and conditional on achieving quality improvement and innovation goals. The estimated value of CQUIN in 2014/15 is 6.1m forming part of our contracts with clinical commissioning groups and Specialised Services commissioners. Each CQUIN scheme consists of one or more goals for achievement by agreed milestones. A total of 11 CQUIN schemes were agreed for 2014/15 with a combination of locally agreed goals and 2 schemes, Dementia and Friends and Family Test, which are nationally determined. At the time of reporting, February 2015, Pressure Ulcers and Dementia (part 2a: Find, Assess, Investigate, Refer) CQUIN goals are not expected to be fully achieved at the end of the financial year. Mitigating actions have been put in place to ensure the quality of care is improved in areas where goals are partially achieved at the time of reporting, with a monthly report provided to Executive Directors on the progress. The Letters returned to the referring to GP CQUIN scheme was reviewed in February 2015 as it was identified as unachievable for reasons outside the control of both Dudley Group and Dudley CCG. A decision was reached to allocate the financial value associated with the Letters returned to the referring GP CQUIN proportionally across all remaining schemes. The final settlement figure for 2014/15 has not yet been agreed as some targets are contingent upon outstanding information and actions. However, for the purpose of the year end accounts, we are assuming this will equate to approximately 5.68m based on secure and expected income. In the previous financial year 2013/14, the final settlement figure based on achievement of CQUIN schemes was 5.1m. 2014/15 s CQUINs have been rated on a red/amber/green basis dependent on achievement to date as detailed in the tables below: 39

69 Acute and community 2014/15 Goal No. CQUIN targets and topics Quality domains and RAG rating 1 Friends and Family Test (6 parts) Patient experience 2 Dementia and Delirium (3 parts) Patient experience Safety Effectiveness 3 NHS Safety Thermometer Pressure Ulcers (Acute and Community) 4 Culture of Learning Safety Effectiveness Patient experience Safety 5 Safeguarding Safety Effectiveness Patient experience 6 Patient Experience for Learning Disability Patients Patient experience 7 Letters returning to the referring Clinician* Effectiveness 8 Patient Safety Culture *See explanation in text above Safety Effectiveness Specialised services 2014/15 Goal No. CQUIN targets and topics Quality domains and RAG rating 1 Friends and Family Test (6 parts) Patient Experience 2 Dementia and Delirium (3 parts) 3 Quality Dashboards 4 Renal Dialysis Shared Haemodialysis Care Patient Experience Safety Effectiveness Safety Effectiveness Innovation Patient Experience Effectiveness 5 Neonatal Intensive Care Total Parenteral Nutrition Safety Effectiveness 40

70 CQUIN report 2015/16 In 2015/16 the amount the Trust will be able to earn is xx (2.5 last year) per cent on top of the actual outturn value. The estimated value of this is approximately xx ( 6.4m last year). The nationally mandated CQUIN goals have yet to be decided. The specialist national CQUINS have not been decided. The local CQUINs have not been decided. Acute and community Goal No. CQUIN targets and topics Quality domains Physical Health: Acute Kidney Injury Safety 1 Effectiveness Physical Health: Sepsis Mental Health: Dementia Urgent and Emergency Care (indicator yet to be agreed) Safety Effectiveness Patient Experience Effectiveness Specialised services Goal No. CQUIN targets and topics Quality domains

71 2.2.5 Care Quality Commission (CQC) registration and reviews The Dudley Group NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against the Trust during 2014/15. The Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period. On the 26 th /27 th March 2014 a team from the CQC inspected the Trust who also returned on a number of unannounced visits in the following two weeks. Both a summary and full report ( of that inspection have been published. The Trust was rated Good in 30 out of the 38 core services inspected. The majority of the group categories (five out of eight) received an overall rating of Good. Despite this, the overall rating for the Trust was Requires Improvement (see below). 42

72 Chief Inspector of Hospitals, Professor Sir Mike Richards, believes we are not far off achieving an overall Good rating and he has confidence that we are addressing the issues highlighted by the inspection. He noted the following key findings: The trust s staff are seen as highly caring by many of the patients we spoke to and praised the staff for going the extra mile. The trust s leadership team is seen as highly effective by the staff; and is recognised to be clearly in touch with the experience of patients and the work of the staff. Staff value the Dudley Group as a place to work and a team spirit is clearly evident. The trust has responded well to the Keogh review in There are a number of areas of good practice in the trust, which should be encouraged. Staff feel able to develop their own ideas and have confidence that the trust will support them. The emergency department (A&E) is busy and overstretched. There remain challenges in the flow of patients, but much of this relates to flow across the rest of the hospital. Only a small proportion relates to the emergency department itself. The trust does not always follow its own policy in relation to DNACPR (do not attempt resuscitation) notices. The ophthalmology clinics require review to ensure that all patients are followed up as required and that there is capacity for these clinics. The trust must review its capacity in phlebotomy clinics as this is seen as insufficient. The Trust has already taken action to improve any areas of concern. 43

73 2.2.6 Quality of data The Trust submitted records during 2014/15 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included the patient s valid NHS number The Dudley Group National average Admitted patient care 99.8% 99.1% Outpatient care 99.8% 99.3% Accident and Emergency care 99.0% 95.1% The percentage of records in the published data which included the patient s valid General Practitioner Registration Code The Dudley Group National average Admitted patient care 100% 99.9% Outpatient care 100% 99.9% Accident and Emergency care 100% 99.2% All above Trust figures are for April 2014 to Feb 2015 with national figures to Dec 2014 The Trust s Information Governance Assessment Report overall score for 2014/15 was 78 per cent and was graded Satisfactory (this is a mid-year score final figures available in 20 days time). The Trust was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission. During 2014/15 there were eight data protection incidents logged on the Information Commissioner s incident reporting site. Actions taken from these incidents included: Fax audit being undertaken to reduce the number of faxes being used across the Trust Systems put in place for staff to ensure the Electronic Staff Record has up to date address information Importance of data security and confidentiality reinforced for community staff Mandatory training enforced Managers reminded monthly via mandatory training reports of their staff training compliance 44

74 2.2.7 Core set of mandatory indicators This is the second year that all trusts have been mandated to insert this section which includes a stipulated number of measures. The tables include the two most recent sets of nationally published comparative data as well as, where available, more up-to-date Trust figures. It should be appreciated that some of the Highest and Lowest performing trusts may not be directly comparable to an acute general hospital e.g. specialist eye or orthopaedic hospitals that have very specific patient groups and which generally do not include emergency patients or those with multiple long-term conditions. Topic and detailed indicators Summary Hospital-level Mortality Indictor (SHMI) value and banding Percentage of patient deaths with palliative care coded at either diagnosis or specialty level (Context indicator) Mortality Immediate reporting Previous reporting period: Jul 2013 period: Apr 2013 Statements June 2014 March 2014 Value Value The Trust considers that this data is as Trust 1.04 Trust 1.07 described for the following reasons: National National 1 1 The Trust is pleased to note that average average the Trust s SHMI values are within Highest 1.20 Highest 1.20 the expected range Lowest 0.54 Lowest 0.54 The Trust has taken the following action Banding Banding to improve this value and so the quality Trust 2 Trust 2 of its services by: National National 2 2 Continuing to improve reviews of all average average mortality (see new Quality Priority). Highest 1 Highest 1 There is evidence that the Trust s Lowest 3 Lowest 3 SHMI is reducing Trust 27.1% Trust 26.2% National average 24.95% National Average 23.94% Highest 49% Highest 48.5% Lowest 7.4% Lowest 6.4% The Trust considers that this data is as described for the following reasons: There is a very robust system in place to check accuracy of palliative care coding The Trust has taken the following actions to improve these percentages, and so the quality of its services by: Ensuring this percentage will always be accurate and reflect actual palliative care. 45

75 Topic and detailed indicators Groin Hernia Surgery Varicose Vein Surgery Hip Replacement Surgery Knee Replacement Surgery Patient Reported Outcome Measures (PROMS) Immediate reporting Previous reporting period: 2013/14 period: 2012/13 Statements Provisional Final Trust 0.04 Trust 0.07 The Trust considers that this data is as described for the following reasons: National National average average using feedback data (from Highest Lowest Trust Highest Lowest Trust HSCIC) we are very pleased with the outcomes that patient report. Patients who said that their problems are better now when compared to before their operation: Groin Hernia: 95% (national = National National %), average average Hip replacement: 98% (national Highest 0.15 Highest 0.18 = 95%), Knee replacement: 88% Lowest 0.02 Lowest 0.01 (national = 89%), Varicose veins: 93% (national = Trust 0.41 Trust %) National average 0.44 National average 0.44 Highest 0.55 Highest 0.54 Lowest 0.34 Lowest 0.32 Trust 0.31 Trust 0.32 National average 0.32 National average 0.32 Highest 0.42 Highest 0.42 The Trust has taken the following actions to improve these scores, and so the quality of its services by: ensuring the Trust regularly monitors and audits the pre and postoperative healthcare of all patients. Surgical operative outcomes are consistently of high quality and safety, with excellent patient satisfaction for these procedures. Lowest 0.22 Lowest 0.21 In the above table the higher the score, the higher the average patient health gain 46

76 Topic and detailed indicators % readmitted within 28 days Aged 0-15 % readmitted within 28 days Aged 16 and over Readmissions(updated figures not published figures are from last yr s report) Immediate reporting period: 2011/12 Previous reporting period: 2010/11 Statements Trust 9.09 Trust 9.34 The Trust considers that this data is as described for the following reasons: National average National average Highest NA* Highest NA* Lowest NA* Lowest NA* Trust Trust National average National average Highest NA* Highest NA* Lowest NA* Lowest NA* since the national published figures (see across) are historical, we have looked at our latest locally available (pre-published) data. This indicates recent improvements (Aged 16 and over: 2012/ %, 2013/14 9.9%) (Age 0-15: 2012/ %, 2013/14 9.7%) The Trust intends to take the following actions to reduce this percentage, and so the quality of its services by: consultant review of all medical referrals in Emergency department extended consultant cover in assessment areas of the Trust CCG investment into community nursing teams to avoid admissions and readmissions better information and support around discharge via the discharge facilitator service *comparative figures not available Topic and detailed indicators Average score from a selection of questions from the National Inpatient Survey measuring patient experience (Score out of 100) Responsiveness to inpatients personal needs Immediate reporting period: 2013/14 Previous reporting period: 2012/13 Trust 66.5 Trust 64.9 National average 68.7 National average 68.1 Highest 84.2 Highest 84.2 Lowest 54.4 Lowest 57.4 Statements The Trust considers that this data is as described for the following reasons: the Trust notes that it is only slightly lower than the national average and is making year on year improvements, The Trust intends to take the following actions to improve this score, and so the quality of its services by: ensuring the Trust continues to ask these questions as part of the realtime surveys, and ensure actions are taken through the You said we did plans 47

77 Topic and detailed indicators Percentage of staff who would recommend the Trust to friends or family needing care Immediate reporting period: 2014 Staff views Previous reporting period: 2013 Trust 72% Trust 66% National average 67% National average 64% Highest 89% Highest 89% Lowest 38% Lowest 40% Statements The Trust considers that this data is as described for the following reasons: the Trust is pleased to see an increase in the number of staff who would recommend the Trust as a place to receive treatment The Trust intends to take/has taken the following actions to improve this percentage/ and score, and so the quality of its services by: multi-disciplinary groups focusing on action planning for improvements. communicating with and supporting managers to understand their data broken down by division and area and take actions where necessary. The Trust involves and communicates with staff though adopting the Listening in Action programme. This has covered a wide range of topics and new areas are being agreed for 2015/16.. Topic and detailed indicators Percentage of admitted patients risk-assessed for Venous Thromboembolism Venous Thromboembolism (VTE) Immediate reporting Previous reporting period: period: Statements Q2 Jul - Sep 2014 Q1 Apr - Jun 2014 The Trust considers that this data is as described for the following reasons: Trust 95.2% Trust 95.4% National average 96% National average 96% Highest 100% Highest 100% Lowest 86.4% Lowest 87.2% the Trust is pleased to note that it is similar to the national average in undertaking these risk assessments. The Trust intends to take the following actions to improve this percentage, and so the quality of its services by: continuing the educational sessions with each junior doctor intake continuing with a variety of promotional activities to staff and patients 48

78 Topic and detailed indicators Rate of Clostridium difficile per 100,000 bed days amongst patients aged 2 or over Infection control (updated figures not published figures are from last yr s report) Immediate reporting period: 2013/14 Previous reporting period: 2012/13 Trust 19.3 Trust 23.9 National average 14.7 National average 17.3 Highest 32.5 Highest 30.6 Lowest 0 Lowest 0 Statements The Trust considers that this data is as described for the following reasons: the Trust acknowledges it needs to improve its rate and has done so in 2013/14 having had 43 cases compared to 56 the previous year (see section 2.1.3), making the most recent (pre-published) rate 18.2 The Trust intends to take/has taken the following actions to improve this rate, and so the quality of its services by: having an ongoing process to learn from individual cases to reduce the risk of further incidents releasing a smartphone app so that all medical staff can have the correct antimicrobial guidelines available immediately on their mobile telephones having intensive HPV (hydrogen peroxide vapour) cleaning to supplement traditional cleaning methods revising treatment methods to include new drugs and having an associated video e-learning package for this Topic and detailed indicators Rate of patient safety incidents (incidents reported per 100 admissions) (Comparison is to 46 medium acute Trusts) Percentage of patient safety incidents resulting in severe harm or death Immediate reporting period Oct 2013 Mar 2014 Clinical incidents Previous reporting period: Apr 2013 Sept 2013 Trust Trust 9.02 Average 8.03 Average 7.23 Highest Highest Lowest 5.6 Lowest 3.54 Trust <0.1% Trust 0.3% National average 0.7% National average 0.7% Statements The Trust considers that this data is as described for the following reasons: as organisations that report more incidents usually have a better and more effective safety culture, the Trust is pleased to note both it has higher than average reporting rates and its severe incidents are less than the national average. The Trust has taken the following actions to improve this rate, and so the quality of its services by: continual raising of awareness of what constitutes as an incident and how to report and continual improvement of quality investigations and learning using improved report templates. 49

79 Part 3: Other quality information 3.1 Introduction The Trust has a number of different Key Performance Indicators (KPI) reports which are available and used by a wide variety of staff groups monitoring quality on a dayto-day basis. The main repository for the reporting of the Trust s key performance measures is a web based dashboard, which is available to all senior managers and clinicians and currently contains over 130 measures, grouped under the headings of Quality, Performance, Workforce and Finance. In addition, constant monitoring of a variety of aspects of the quality of care include weekly reports being sent to senior managers and clinicians which include the Emergency Department, Referral to Treatment, stroke and cancer targets. Monthly reports are also sent to all wards, which include a breakdown of performance by ward based on Nursing Care Indicators, ward utilisation, adverse incidents, governance and workforce indicators, and patient experience scores. In becoming more transparent, each ward now displays its quality comparative data on a large information board (Patient Safety huddle Boards) for staff, patients and their visitors. To compare ourselves against other trusts, we use Healthcare Evaluation Data (HED), which is a leading UK provider of comparative healthcare information, as a business intelligence monitoring tool. The following three sections of this report provide an overview, with both statistics and examples, of the quality of care at the Trust, using the three elements of quality as outlined in the initial chief executive s statement: Patient Experience Does the Trust provide a clean, friendly environment in which patients are satisfied with the personal care and treatment they receive? Patient Safety Are patients safe in our hands? Clinical Effectiveness Do patients receive a good standard of clinical care? The fourth section includes general quality measures which have remained the same for 2014/15 as the Board of Directors and our stakeholders believe these take into consideration both national and local targets which will be important to patients and give a further perspective of the Trust s quality of care. A1 ward is exceptional on all levels. I have been admitted to this ward on 4 occasions for a week each time. All of the staff and I mean every single one of them are brilliant!. Caring, kind, considerate I could go on and on. No one wants to be in hospital but this ward and team make it so much better. Thank you so much all of you. 50

80 Patient Experience 3.2 Does the Trust provide a clean, friendly environment in which patients are satisfied with the personal care and treatment they receive? Introduction The Trust values and welcomes all feedback to help us ensure we meet the needs and expectations of our patients, their families and carers, our staff and our stakeholders. As a Foundation Trust we are also legally obliged to take consideration of our Members views as expressed through our Council of Governors Trust-wide initiatives We gather feedback via, for example: The Friends and Family Test Real-time surveys (face-to-face surveys) NHS Choices/Patient Opinion (online) National surveys Comment cards Complaints, concerns and compliments Patient Safety Leadership Walkrounds Targeted surveys e.g. food Below are examples of some of the numbers of feedback we have received this year (2014/15) and more detailed information about some of the methods. These methods alone show more than 21,000 opportunities for us to listen to our patients views. Method Number Method Number Friends and Family Test Inpatient Friends and Family Test Emergency Department Friends and Family Test Maternity Friends and Family Test Community Friends and Family Test Day Case Friends and Family Test Outpatients 4932 Real-time inpatient NHS Choices/Patient Opinion Community Services surveys Surveys of carers of people with dementia Discharge surveys Bereavement Surveys 64 51

81 a) Friends and Family Test (FFT) All inpatient and Emergency Department providers in the UK were required to participate in the Friends and Family Test from 1 st April 2013 (inpatients started in April 2012 in Dudley) with maternity services starting in October 2013 and further roll out into community, day case and outpatient areas during 2014/15. Results are published on NHS Choices as: normal, better or worse than others. Friends and Family Test scores are also updated in our wards/departments each month for patients to see on huddle boards. The Test asks a simple question How likely are you to recommend (ED/Hospital/Maternity service) to friends and family if they needed similar care or treatment? rated from extremely likely to extremely unlikely. This is followed up with a question asking Was there anything that could be improved? The charts below show our scores for 2014/15 which indicate, for the majority of months, the Trust was above the national average and a high scorer in the Black Country region. For inpatients we are proud to be above the national average for the whole year Black Country (inpatients) FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average Black Country (A&E) FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average Maternity Antenatal FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average Maternity Birth FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average Maternity Postnatal Ward FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average Maternity Postnatal Community FFT Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Sandwell & West Birmingham Dudley Group Royal Wolverhampton Walsall National average *The national scoring for FFT changed in September 2014 to be a percentage instead of a net promoter score. ** Any gaps in data are a result of not enough responses - less than 5 and the data is not displayed. 52

82 b) Real-time surveys During 2014/15, 1,391(to ) patients participated in our real-time surveys.. The real-time surveys work well alongside the Friends and Family Test and these are reported in a combined report to wards and specialties allowing them to use important feedback from patients in a timely manner. This allows us to react quickly to any issues and to use patient views in our service improvement planning. c) Patient stories The continued use of patient stories at Trust Board during 2014/15 enables the patient voice to be heard at the highest level. Stories have been heard at Board meetings and used for service development planning and training purposes A huge thank you to the staff of the Endocrinology Department and a special thank you to my Consultant, thank you for caring enough to see my distress, how my symptoms were impacting and ruining my life and my confidence. Thank you for caring enough to think about what I would need after my appointment with you, finding information that I could use to seek further support, to get me through a very difficult time. 53

83 3.2.3 National survey results In 2014/15 the results of three national patient surveys were published: inpatients, cancer and emergency department. Participants for all national surveys are selected against the sampling guidance issued. For the national surveys, 850 patients were selected to receive a survey from the sample months indicated in the table below: Survey name Survey sample Trust response National Average month rate response rate 2014 A&E Jan - Mar % 34% 2014 Cancer Patient Experience Sept Nov % 64% *2014 Adult inpatient June - August % 45.2% *2014 Childrens and Results due March Results due March July august 2014 Young Peoples Inpatient *2014 Neonatal: wave two 01/09/ % 35.4% *National comparators published by the CQC not available at time of publication. What the results of the surveys told us Inpatient Survey Complete when published April Cancer services We were delighted by the news that we were the most improved trust in England for cancer patient experience in the National Cancer Patient Experience Survey out of 153 trusts that took part. We always strive to offer our patients the best possible experience whilst in our care, and this fantastic achievement is testament to the hard work of our specialist cancer teams over the past year. Our teams have been working hard with Macmillan over the past few years to make improvements to patient experience and it is rewarding to see this work recognised. Compared to 2013 results:- 53 questions out of 62 show improved score from previous year 4 questions score same as previous year 5 questions show slightly reduced score Areas where we can still improve:- Provision of information on getting financial help and the impact cancer can have on work and education Patients being given a choice of treatments and being more involved in decision making Patients being advised of the cancer Nurse Specialist (CNS) in charge of their care 54

84 Emergency Department In six out of the 34 sections the Trust was worse than other trusts nationally with all other section being about the same as other emergency departments. Areas where improvements could be made: Waiting times Access to food and drink in the department Being told what warning signals to look out for once returned home Below are some examples of actions taken as a result of patient feedback: You Said Information about ward routines Information about discharge processes Information about waiting for surgery In-Patients We Did / Doing Welcome to the ward booklets given out to all new patients. New system put in place to ensure all transferred patients receive a copy of the ward booklet. All discharge information is being updated and ward clerks have received training on how to access the information. Additional training of ward staff has taken place. New patient information leaflet launched to support the launch of the Home for Lunch Letters to patients reviewed to now include advice that even though they may be called to their appointment early in the day, they may not be seen in order of arrival. The day room on the ward is comfortably furnished. Patients receive a phone call the day before their planned surgery where they are again advised to bring in reading materials or hobby activity in case of any waiting around. Cancer You Said We Did / Doing More information was needed around getting We are working with the Dudley Citizens financial help Advice Bureau who, in partnership with Macmillan Cancer Support, help patients in identifying and assisting them to claim benefits they are entitled to. More information about treatments and We are reviewing and improving our options were needed information. We have also purchased some information stands to improve the availability of cancer information. Do not know who my Cancer Nurse Specialist is. Additional information to be produced and made available for all patients explaining CNS/key worker role,the Trust refer to CNS as key worker 55

85 Emergency Department You Said We Did / Doing Waiting times from ambulance to ED To reduce the length of time taken to hand over patients to ED from ambulances, since June 2014 we have had both a staff nurse and CSW on the Ambulance triage team. Their work is supported by a Hospital Ambulance Liaison Officer from WMAS to ensure timely hand over of care even at times of high demand. Communication between patients, their families and GPs We aim to ensure all staff involved in an individual patient s care communicate to avoid contradictions. We have regular board rounds and have introduced a more robust handover procedure. All staff are aware of safe discharge procedures including assessing the home/family situation. Any patient with issues in these areas are referred to our welfare nurse or the IMPACT team. Advice leaflets contain information of who to contact and discharge letters are provided for patients to give directly to GP. PICTURE I wanted to write and say a huge thank you to all the staff on ward C5 at Russells Hall Hospital, my nan was here for the last three weeks of her life and we wouldn't have gotten better treatment if she had been in a private hospital. 56

86 This image cannot currently be displayed Examples of specific patient experience initiatives a) Meeting the needs of patients with learning disabilities The Trust launched its Learning Disability Strategy in March Its key principles include ensuring that all staff listen to and provide care and treatment both appropriately and effectively to people with a learning disability. One of the practical ways that this is demonstrated is by organising patient summits. People with learning disabilities and their carers are invited to attend these Our Hospital-Our Voice meetings. They are an opportunity for this group of patients and their carers to express their hospital experiences, have an input into our patient experience surveys such as the friends and family test and enables their views to be included in any improvements that need to be made and the future planning of hospital services. The meetings have been well attended, with people talking about what worked and what didn t work when they used the hospital. Also, as part of the strategy, a health toolkit, developed by Keele University, has been launched at the Trust to support communication with and gain feedback from patients experience, when they and their carers use our services. Whilst the toolkit is designed for patients with a learning disability it is also hugely beneficial for patients whose first language may not be English and for patients with dementia. My son is blind and has additional needs including challenging behaviour. All staff were extremely responsive to all of the learning disability nurse s suggestions ensuring our time at Russells Hall was stress free. Please continue this wonderful and very necessary service. 57

87 b) Macmillan Link Nurse In November 2014,the Trust s Macmillan Palliative Care Educator won the prestigious Macmillan Excellence Awards for her inspirational work supporting healthcare professionals to deliver high quality palliative care for people affected by cancer in Dudley. The award was for improving the coordination and integration of services which has improved the experiences and outcomes of people affected by cancer. The Palliative Care Educator has trained and educated more than 70 healthcare professionals across Dudley to become Palliative Care Champions, who then share their new skills and expertise with their colleagues to ensure a high standard of care. The post has made a huge difference for our patients. As an educator, they give staff the confidence to have those difficult but important conversations with patients and carers, and support for their colleagues, both clinical and non-clinical, to understand how to give the best possible care at the end of life. c) Food Improvements As part of our commitment to nutrition and hydration, we are introducing a new Chosen by Patients menu. We asked patients which dishes they enjoyed on our current menu and what they would like to see offered in the future. Using this information our dietitians created a new menu that we are now trialling on four of our wards. Patients on our general surgery, medical high dependency unit, respiratory and children s wards are given a choice of meals from our new menu at lunch and dinner and were asked to give us their feedback. Through all the feedback from our patients, staff and Governors we have developed a new menu which we hope will improve patients experience of food. Since trialling the new menus we have received overwhelmingly positive feedback from patients. Just a few of the comments we have received so far include: I was absolutely grateful for the amount and how fabulous the meals have been. Perfect five star! Quite a varied menu a definite improvement on my last visit to hospital Excellent to have a menu choice, especially same day prior to serving. We also recruited 73 Nutrition Support Volunteers in September 2014 to help patients with their nutrition and hydration needs. The volunteers provide mealtime assistance by making drinks, helping with feeding, assisting with menu selection, encouraging eating and drinking and changing drinking water for patients. To make sure our patients receive the very best care and support during their stay, Nutrition Support Volunteers receive in-depth training provided by our nursing staff, dietitians and speech and language therapists. 58

88 3.2.5 Complaints, concerns and compliments This summary contains three sets of tables showing a) the total number of complaints, concerns raised with the Patient Advice and Liaison Service (PALS) and compliments received during the year, compared to both previous years and where possible compared with local trusts b) the types of complaints and concerns this year c) the percentage of complaints compared to the total number of patients visiting the Trust and a further section d) some examples of changes in practice made from complaints and concerns. a) Total numbers of complaints (with local trust benchmarks), PALS concerns and compliments Complaints PALS concerns 2009/ / / / / /15 Walsall complaints New Cross complaints UHB complaints Compliments / / / / /15 (Figures for 2014/15 for both graphs are just up to the end of Feb 15) 59

89 It can be seen that the number of complaints has been reducing for the past four years whilst the number of PALs concerns have risen from last year but still below previous years. The Trust has introduced an improved system of recording the compliments received and so this will account for some of the large increase this year. It is very pleasing to see how many patients take the time to tell us of their good experiences with over 5,000 compliments in 2014/15. b) Types of complaints and concerns throughout the year Although there has been a fall in the number of complaints, the types of complaints (see below) remain similar from year to year, reflecting the importance that patients place on effective and timely treatment from caring staff with good communication skills. Some examples of actions taken and changes in practice following complaints are listed in section d) below. Complaints by type 1st April th March Clinical Care (Assessment/Monitoring) Diagnosis & Tests Appointments, Discharge & Transfers Staff Attitude Records, Communication & Information Medication Obstetrics 19 Patient Falls, Injuries or Accidents Other (Workforce, Facilities, H & S etc) Theatres Equipment 33 District Nursing Care Privacy and Dignity Pressure Sores 56 Violence and Aggression Safeguarding 60

90 Concerns by type 1st April - 31st December Records, Communication & Information Appointments, Discharge & Transfers Clinical Care (Assessment/Monitoring) Diagnosis & Tests Facilities (Security, Estates, Transport etc) Workforce Medication Equipment 178 Infection Control Patient Falls, Injuries or Accidents Obstetrics Health and Safety Theatres 218 Violence/Aggression Other (Security) During 2014/15 the PALS team was re established as a distinct team to the complaints department, although retaining strong links to ensure patients receive a seamless service. This explains the difference in PALS figures over time. With 2013/14 seeing a decrease this was due to a different method of recording concerns during that period. When reviewing PALS concerns over a longer period the numbers remain reasonably static. Like complaints categories the types of concerns raised remain similar year on year reflecting the importance patients place on records, communication and information as the main concern, closely followed by appointments, discharge and transfers. These top concerns are consistent with the types of comments made through other patient feedback. 61

91 c) Percentage of complaints against activity Activity Total patient activity Total for 2013/14 Total Q1 ending 30/6/14 Total Q2 ending 30/9/14 Total Q3 ending 31/12/14 734, , , ,084 Total Q4 ending 31/3/15 Total for 2014/15 Complaints against activity 0.04% 0.03% 0.05% 0.04% d) Examples of actions taken and changes in practice made after complaints and concerns by type from across the Trust Type of complaint Example of actions taken Examples of changes in practice Clinical Care/Diagnosis and Tests Initial X-ray examination performed was reviewed by a senior radiologist and even with the benefit of hindsight a stress fracture diagnosed some weeks later was not visible on the X- ray. A delay in diagnosing the fracture was acknowledged but explanation provided regarding difficulty diagnosing such fractures on initial X-rays. Consultant met with patient and explained results of tests in some detail, which patient was happy with. Consultants discussed question of use of compression stockings after aortic aneurysm surgery with team to ensure they are aware why compression stockings are not used after this type of surgery. Staff reminded to inform parents when tests are sent to specialist hospitals, which might delay results being received Staff encouraged to use calculators to calculate drug dosages rather than mobile telephones as using these can give a poor impression Deputy matron recruited to older people s mental health team to implement and train new patient support team. A business case to increase urology medical staffing establishment was approved and an additional consultant, registrar grade and SHO grade doctors were appointed. Mattress use paperwork reviewed and updated to include instruction to users to treat the chart as a guide only and use it in conjunction with other decision making processes. All patients with a moisture lesion or red area on their skin are now placed on a two hourly skin assessment. Well being workers introduced Mattresses on trolleys upgraded to provide pressure relief Electronic handovers introduced to ensure all information is available for both day and night staff Senior nurses now available during visiting hours to meet with relatives. Two care workers released from night duties to act as floating staff to ensure buzzers are answered within 30-second target Paediatric leaflets reviewed to highlight clinic structure Experienced care workers allocated to work with qualified staff at front triage and in ambulance triage area Patient flow co-ordinator introduced to aid qualified staff in monitoring patient waiting times. 62

92 Type of complaint Example of actions taken Examples of changes in practice Records/ Communication Advised patient he needed to be seen in clinic before going to theatre for procedure Staff asked to ensure patients understand what they have been told and to use non-clinical terminology Trusts newsletter contains information for GPs, particularly relating to ED attendances A number of senior nursing staff have visited Mary Stevens Hospice to discuss care for the terminal patient. More nursing staff will go in future and this will be rolled out to other wards, including elderly care wards. Huddle boards introduced to improve staff communication Communication folder introduced to enable patients and families to raise questions and request meetings if staff not immediately available. Letter of attendance formulated and available at reception for patients who require proof of attendance Patients with rapid access clinic appointments now receive a telephone call as well as a letter to confirm receipt of appointment Leaflet provided by reception staff when patients present following GP Obstetrics Telephone operators given emergency numbers for all local areas and these are readily available for pregnant women who contact the hospital Matron met with midwife concerned and asked her to reflect on contents of complaint letter, her behaviour towards her patient during her admission and to consider how improvements to her practice and approach can be made to prevent a recurrence Consultant reiterated to junior medical staff during meetings and teaching sessions the importance of good communication and of ensuring all patients are provided with full and easily understood explanations during consultations. Reinforced with staff they should continue to emphasise all risks associated with procedure and continue to give written information referral Reviewed information leaflet and statistics, post advice leaflet, service guideline (which is based on best national recommendations and practice Developed a letter that parents can give to doctors when attending ED departments Implemented access to the appropriate member of staff for advice for a number of hours following the clinic session ending. Parents given information on SANDS (a stillbirth and neonatal death charity) who offer emotional support for parents who have suffered the loss of a baby. Patients now provided with a comfort pack, blankets and pillows following admission from the day assessment unit. 63

93 3.2.6 Patient-Led Assessments of the Care Environment (PLACE) Patient-led Assessments of the Care Environment (PLACE) is the new system for assessing the quality of the hospital inpatient environment which replaced Patient Environment Action Team (PEAT) inspections from April All Trusts are required to undertake these inspections annually to a prescribed timescale. Patient assessors make up at least 50 per cent of the assessment team with the remainder being Trust and Summit Healthcare Staff. The inspection covers ward and non-ward areas to assess: Cleanliness The condition of the buildings and fixtures (inside and out) How well the building meets the needs of those who use it, e.g. signage The quality and availability of food and drinks How well the environment protects people s privacy and dignity We were delighted that we scored higher than the national average in three of the four above topics and all of our scores have improved on our own scores in 2013/14. 64

94 3.2.7 Single-sex accommodation We are compliant with the government s requirement to eliminate mixed-sex accommodation. Sharing with members of the opposite sex only occurs when clinically necessary (for example where patients need specialist equipment such as in the Critical Care Unit), or when patients actively choose to share (for instance in the Renal Dialysis Unit). During the year, the Trust reported six breaches of samesex accommodation due to a small number of recovering patients on the Intensive Care Unit waiting for beds on general wards. As part of our real-time survey programme, patient perception is also measured by asking patients whether they shared a room or bay with members of the opposite sex when they were admitted to hospital. Of the 1211 patients who responded to this question, the number whose perception was that they shared a room/bay with members of the opposite sex was 59 (5 per cent). This excludes emergency areas Patient experience measures Patients who agreed that the hospital room or ward was clean Patients who would rate their overall care highly Rating of overall experience of care (on a scale of 1-10) Patients who felt they were treated with dignity and respect Actual 2008/09 Actual 2009/10 Actual 2010/11 Actual 2011/12 Actual 2012/13 Actual 2013/14 87% 87% 88% % 76% 74% % 86% 86% Actual 2014/15 Not published yet Not published yet Not published yet Comparison with other trusts 2014 The above data is from national inpatient surveys conducted for CQC. Scores were initially expressed as percentages but from 2011 scores are reported out of 10 (Previously this table was compiled from raw data scores). 2014/15 data not available yet. If anyone can get better treatment than I have received with better staff I defy them to show me so big thumbs up to everyone one on ward C8. Thank you so much for your kindness, expertise and for going above and beyond the call of duty 65

95 Patient Safety 3.3 Are patients safe in our hands? Introduction The Trust ensures the safety of its patients is a main priority in a number of ways, from the quality of the training staff receive, to the standard of equipment purchased. This section includes some examples of the preventative action the Trust take to help keep patients safe and what is done on those occasions when things do not go to plan Patient Safety Leadership Walkrounds All wards, therapy and community departments are visited throughout the year by a team consisting of, as a minimum, an executive director, a non-executive director, a governor and a scribe from the governance team. The team observes practice by being shown around the ward/department by one of the staff who also provides a verbal summary of the ward activity, specialty and ways of working. The team then meets informally with staff to discuss any issues of concern related to patient safety while the governors talk to patients about their experiences of the care they are receiving. A report and action plan is produced to address areas of concern identified. Some actions taken from these visits include: New seating has been purchased for GUM outpatient area. New intercom system has been fitted for patients attending Renal Dialysis Unit during out of hours. The reception desk is not manned and ward staff were unaware patients were waiting outside trying to gain access. The system allows ward staff to open doors remotely. The Renal Dialysis Unit has extended its service hours to include late evening sessions. Coaxial TV aerials have been pinned back to the walls to reduce the risk of trips. Following a service review, regular meetings have been scheduled with Ambuline, which provides patient transport services for patients attending clinics, outpatients or those being discharged. Previously reported delays and extended patient waits for transport have improved following the commencement of these meetings. Repairs to seating in the cardiology unit. Dedicated triage area has been developed within ward C4. A rehabilitation chair has been introduced into critical care. This will enable ventilated patients to be sat out. In addition, new dignity screens fitted in surgical high dependency department allowing for greater privacy and dignity. New central console monitoring unit has been purchased for Coronary Care unit which is currently waiting installation to provide the latest high specification monitoring of cardiac patients within the department. 66

96 3.3.3 Incident management The Trust actively encourages its staff to report incidents, believing that to improve safety it first needs to know what problems exist. This reflects the National Patient Safety Organisation which has stated: Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are. The latest national comparative figures available are for the period 1st October 2013 to 31st March Organisations are compared against others of similar size. The Trust is the sixth highest reporter of all incidents in its class of medium size acute trusts. With regards to the impact of the reported incidents, it can be seen from the graph below, for the same period stated above, that the Trust is similar to other medium sized trusts. Nationally across all medium sized acute trusts, 68.8 per cent of incidents are reported as no harm (the Trust 68.8 per cent) and 0.7 per cent as severe harm or death (Trust 0 per cent). Incidents Reported by Degree of Harm for Medium Acute Trusts Organisations in England and Wales (1st Oct 2013 to 31st March 2014) Per cent of incidents occuring None Low Moderate Severe Death Degree of Harm All Medium Acute Organisations The Dudley Group NHS Foundation Trust During the period beginning April 2014 to the end of March 2015, the Trust has had one Never Event (a special class of serious incident that are generally preventable) which resulted in no patient harm. It had 268 serious incidents, all of which underwent an internal investigation and, when relevant, action plans were initiated and changes made to practice (Serious incidents are a nationally agreed set of incidents which may not necessarily have resulted from error but need investigating to check the circumstances of their occurrence). 67

97 Some examples of changes made in practice in response to the above incidents have been: Introduction of the Sign and Stamp initiative when all medication prescribers have now to stamp their name as well as sign so that it is clear who the prescriber is Review and re-launch the Think Glucose training programme so that staff on wards that do not commonly have diabetes patients are all aware of their responsibilities when caring for such patients Identification of an alternative supplier of bariatric equipment Full review of neonatal resuscitation guidelines Development of a pre- and post procedure checklist (adapted WHO process) for all invasive procedures, however minor, to be used across the whole organisation ensuring increased patient safety Implementation of a double checking system for any procedures when a guide wire is used to have assurance of complete removal of the wire Introduction of an additional validation check before releasing pathology results Development and introduction of a clinical skills training and competency assessment for nursing staff for the collection and labelling of blood samples Ensuring all District Nurse referrals for equipment are now followed up with a telephone call to reduce the risk of delayed equipment Nursing Care Indicators Every month ten nursing records and the supportive documentation are checked at random in all general inpatient areas and specialist departments at the hospital, and in every nursing team in the community (approximately 430 records are audited per month). The purpose is to ensure nursing staff are undertaking risk assessments, performing activities that patients require and are accurately documenting what has taken place. Following a review of the audit questions and the results being obtained, the audit template has been changed. From September the audits have been abridged within the hospital with the community process due to be changed from April Within the hospital the themes assessed were patient observations, pain management, manual handling, tissue viability, medications, documentation, nutrition, infection control, Think Glucose, bowels and fluid balance. The Trust has decided to concentrate on six criteria: patient observations, manual handling, falls, tissue viability, nutrition and medications. The other elements are no longer on the nurse care indicator audits however they are now managed by the specialist teams within the hospital e.g. Think Glucose is now managed by the Diabetes Team. As can be seen in the table below, the Trust now assesses 6 criteria in hospital and currently eight in the community. Within community services, there are currently two variations of the audit tool and in hospital there are five in order to capture the practice for specialist areas. 68

98 Community results The table below shows the end-of-year results for each of the criteria assessed by the community teams. During 2014, a review has been undertaken and the questions within each of the individual criteria have been amended slightly. Community results are very stable with little fluctuation month on month. Criterion Patient Observations Pain Manual Handling Tissue Viability Medications Documentation Privacy and Dignity Nutrition % 98% 94% 95% 99% 98% 99% 97% % 98% 97% 97% 99% 98% 99% 97% % 99% 97% 99% 98% 98% 99% 98% % 99% 97% 100% 98% 97% 99% 99% Difference % = = 1% = 1% = 1% Inpatient results During 2014, a slight amendment has been made to the audit questions with a new criterion of Falls added although the questions for this criterion had previously been included within the Manual Handling section. By looking at these separately the Trust will be able to focus on Patient safety initiatives. Results continue to show improvements with the largest in the patient observation theme with an increase of 4% per cent on the previous year results. The largest improvement over the five years reported can be seen in Nutrition with an increase of 24% on previously reported results. Improvements can be seen in 5 out of the 5 criteria that are assessed. Criterion Patient Observations Pain Manual Handling Tissue Viability Medications Documentation Nutrition Infection Control Think Glucose Bowels Fluid Balances Falls % 70% 71% 86% 92% 68% 95% % 80% 79% 93% 94% 88% 77% 97% 53% 78% % 88% 85% 95% 94% 88% 82% 91% 79% 81% 77% % 95% 91% 95% 97% 90% 89% 94% 90% 87% 91% % 93% 97% 99% 92% 94% Difference % 2% 2% 2% 3% 69

99 3.3.5 Harm Free Care and NHS Safety Thermometer The NHS Safety Thermometer has been developed as a temperature check on four key harm events pressure ulcers, falls that cause harm, urinary tract infections in patients with a catheter and new venous thromboemboli. It is a mechanism to aid progress towards harm free care and has been adopted across all of the NHS. Each month, on a set day, an assessment is undertaken which has covered on average 650 adult acutely inpatients (with exceptions being day case patients, those attending for renal dialysis and well babies) and 620 patients being cared for in the community. The assessment consists of interviews with the patients, accessing the patient s bedside nursing documentation and, when required, examining the main health record. There are national trials of a Paediatric and Young person s safety thermometer and a Maternity Safety Thermometer and the Trust is taking part in these trails. The Trust regularly monitors its performance and, although direct comparisons need to be made with caution, it is pleasing to note its harm events fall below the national averages. Some examples of actions being taken as a result of the assessments are shown below: A formal escalation process for less than average results is ongoing. A formal review and upgrade of the intentional rounding throughout the Trust (a process of each patient being seen by a member of staff at set times which is documented) has been undertaken as a patient safety measure to improve patient to nurse contact and reduce the prevalence of falls Catheter care bundles have been introduced and are now embedded within the organisation, monitoring for compliance is undertaken by annual spot check audits. New quote 70

100 3.3.6 Examples of specific patient safety initiatives a) Simulation Centre A new simulation centre at Russells Hall Hospital is now complete, offering staff a realistic training environment, complete with manikins which mimic real patient illnesses and responses to treatment. The Ron Grimley Undergraduate Simulation Centre has been designed to offer a training environment as close to real life as possible. The area is made up of a fully functional two-bedded ward area which can also be adapted to become an operating theatre, complete with a working anaesthetic machine and piped oxygen, medical air and suction gases. The facility also boasts an echocardiogram simulator and a state of the art virtual fibrescope that allows anaesthetists to practice the skill of fibreoptic intubation. Controlling the facility from behind the scenes is a team of simulation trainers who can replicate a variety of scenarios from a control room next to the simulation suite. They can control the manikins behaviours and replicate any number of medical conditions and clinical observations. The facility also has full audio and video recording, enabling staff and students to watch their sessions back afterwards and discuss their experience with training staff. The area is already being used by medical students and foundation year doctors as part of their training programmes, and a training pilot with final year operating department practitioners and anaesthetic trainees took place earlier this year. A programme for final year nursing students and student operating department practitioners has just been developed, and the facility will be extended to multi-disciplinary staff in the near future. PICTURE HERE 71

101 b) Mortality Tracking System One technique of ensuring patient safety is to systematically review the care and treatment of all patients who have died in the hospital to see if any lessons can be learned for the effective care and treatment of future patients. To enable this being undertaken in a timely and efficient manner a web-based application has been developed this year by the Trust. It captures information about deaths as soon as they are recorded and it was shortlisted and placed in the finals of a top national award for the use of IT to improve patient safety. The Mortality Tracking System (MTS) solution allows all information and documentation surrounding each individual death to be readily accessible from one place so that it is ready for review and audit by clinical staff. The system also automatically sends s to senior staff informing them of the number of deaths ready for review, completed, or escalated for further investigation. c) Hip A.I.D (Assess, Investigate and Diagnose) This project was launched in mid-february It aims to enhance our service to all patients with possible hip fractures. Many of these patients are elderly and frail so it is important that the correct specialised treatment and care starts immediately both for the general well-being of the patient and to ensure that they are fit for surgery, which should occur as soon as possible after admission. With regards to the latter point, in the last Falls and Fragility Fracture Audit Programme (FFFAP) National Hip Fracture Database Annual Report 2014, at the Trust 83.2% of patients had surgery on the day of or day after admission (in all of the West Midlands hospitals this ranged from 84.7% down to 40.5% with over half of hospitals less than 70%). The Trust realised however that it could do better to ensure patients are admitted to the orthopaedic ward as quickly as possible. This project comprises of ambulance staff specifically phoning ahead to the Emergency Department advising of a patient with a possible hip frature. The specialist hip fracture practitioner then meets the patient on arrival. The patient is assessed immediately and if the patient does not have any comorbidities (e.g. stroke) the patient is transferred straight way to the radiology department for an x-ray where a hip fracture is diagnosed. The patient is then taken directly to the B2 orthopaedic ward where orthopaedic nurses commence the necessary specialist care and where the specialist medical staff are based to treat the patient. Any delays such as waiting in the Emergency Department are avoided with patient safety being maintained at all times. 72

102 3.3.7 Patient safety measures Patients with MRSA infection per 1000 bed days* Never events events that should not happen whilst in hospital Source: adverse incidents database Number of cases of deep vein thrombosis presenting within three months of hospital admission Actual 2008/09 Actual 2009/10 Actual 2010/11 Actual 2011/12 Actual 2012/13 Actual 2013/14 Actual 2014/ # # ** 117** 116** 97**# (# = up to 04/03/2015) Due to the small rates of MRSA infections, figures are now expressed to three decimal places. *Data source: Numerator data taken from infection control data system and denominator from the occupied bed statistics in patient administration system. NB MRSA figure may differ from data available on HPA website due to different calculation methods and Trust calculations using most current Trust bed data. **Previous data collection of Hospital Acquired Thrombosis (HAT) was identified through clinical codes alone. We found that this information was not always a true reflection for a variety of reasons including the fact that the available clinical codes for thrombosis are confusing and, in practice, misleading. Also a majority of deep vein thrombosis (DVT) do not require readmission to hospital which results in further inaccuracies in data collection. To improve the accuracy of our data collection we now review all diagnostic tests for DVTs and pulmonary embolism (PE), cross referencing positive tests with past admissions. This methodology is only undertaken by relatively few hospitals as it is labour intensive, but is recognised as giving a more accurate figure for HAT. As a further check, we receive notification from the bereavement officer if PE was identified as the primary cause of death. As a result of amending our methods of identifying HAT, 2011/12 saw an increase in figures. As stated, this is down to better identification of cases. 73

103 Clinical effectiveness 3.4 Do patients receive a good standard of clinical care? Introduction This section includes the various initiatives occurring at the Trust to ensure patients receive a good standard of care and examples of where we excel compared to other organisations Examples of awards received related to improving the quality of care a) Frenulotomy service This service scooped a Highly Commended certificate for the team, who care for babies with tongue tie, came runner up in the All Party Parliamentary Group Maternity (APPGM) Services Awards 2014 in the category of Most Effective Multidisciplinary Team. The team was rewarded for its work in developing and offering the frenulotomy service to improve feeding for babies with tongue tie and breastfeeding rates. Head of Midwifery Steph Mansell indicated that The frenulotomy service we offer at Russells Hall Hospital is unique and I am very proud of all the staff who have worked really hard to provide better maternity services for woman and babies in our community. This recognition is well deserved by everyone in the team. Members of the team attended the awards ceremony at the House of Commons. The APPGM, which is serviced by the National Childbirth Trust charity, is a cross-party group that aims to highlight maternity issues within Parliament and bring together health professionals, service users and politicians. b) Improving palliative care Macmillan Palliative Care Educator Karen Lewis was presented an award for Integration Excellence at the prestigious Macmillan Excellence Awards. She was recognised for her inspirational work supporting healthcare professionals to deliver high quality end of life care for people affected by cancer in Dudley and her work in improving the coordination and integration of services. Her award winning work involved training and educating more than 70 healthcare professionals across Dudley to become Palliative Care Champions, who can then share their new skills and expertise with their colleagues to ensure a high standard of care. She has put together a standard framework, training and education courses and resources to meet their needs. Her motivation comes from her own negative experience of end of life care as a carer and so respecting the wishes of patients and supporting them to die in the place of their choosing has been at the heart of her work. Karen said, It is a huge honour to have my work recognised by Macmillan and I am really pleased we are making a difference in Dudley. I work with a fantastic team locally and could not do the things I do without the support I get from all of my colleagues. 74

104 I love my job; it gives me so much satisfaction that by training staff I can really have an impact on many patients lives for the better. c) Queen s Nurse District Nurse Team Leader for OPAT (Outpatient Antimicrobial Therapy) Kate Owen has been given the prestigious title of Queen s Nurse by the community nursing charity The Queen s Nursing Institute (QNI). The title is not an award for past service, but indicates a commitment to high standards of patient care, learning and leadership. Earlier this year, Kate was presented with a badge and certificate by Jane Cummings, Chief Nursing Officer for England, at a ceremony at the Royal Garden Hotel in London. Crystal Oldman, Chief Executive of the QNI said, Congratulations are due to Kate for her success. Community nurses operate in an ever more challenging world and our role is to support them as effectively as we can. The Queen s Nurse title is a key part of this and we would encourage other community nurses to apply. d) National Award for tissue viability Clinical nurse specialist Lisa Turley received a national award for her presentation on the Trust s move to static air mattresses. She was presented with the only award of The Wounds UK Annual Conference the Wounds UK Award of Excellence for her paper on the Trust-wide changeover to the new mattresses. Her paper covered the move to static air mattresses from start to finish, covering the whole process from the initial decision making, training and planning, to the implementation, benefits for patients and cost savings. Lisa said, It s really nice to be recognised and to help you realise you ve actually done a good job it s a real confidence boost. Rob Yates, Publishing Director of the WoundsGroup, said, The judges felt that the quality of the work undertaken and the clear, positive health economic impact it demonstrated, was worthy of special mention and ultimately marked it out as a clear winner Examples of innovation a) New equipment allowing improved assessment of surgical patients A brand new machine that tests how well the body responds to exercise has been installed at Russells Hall Hospital to help consultants predict how well a patient will cope with surgery. This state-of-the art cardiopulmonary exercise testing (CPET) machine evaluates how the heart, lungs and muscle simultaneously respond to exercise, mimicking the physiological stress on the body that surgery causes. The CPET machine tests are performed on a stationary bike and, as the patient rides, consultants measure how much air they breathe, how much oxygen they require and how fast and efficiently their heart beats. Adrian Jennings, Consultant Anaesthetist states We are now able to accurately risk assess patients undergoing surgery. This is useful for clinicians as we can better direct care to the patient s individual needs, for example, the type of anaesthetic and the type of postoperative care. Moreover, it is useful for patients who can better understand their surgical risk and make better 75

105 informed decisions about their treatment opinions. In some cases, we may be able to optimise patients fitness further before they embark on surgery. In addition the Trust has acquired a thrombelastography machine for theatres. This device allows clinicians to assess the clotting of the blood in patients who are bleeding heavily, or have an underlying bleeding propensity. We can detect blood clotting problems quicker and identify the cause. This allows treatment, usually blood transfusion, to be directed in an individualised way, ensuring patients only receive the minimum amount of blood products necessary. This reduces transfusion risk, allows blood clotting to be optimised and is cost effective. b) Ensuring radiological expertise is always available With the national shortage of consultant radiologists, specialist medical staff with expertise interpreting complex radiological investigations and who suggest the appropriate treatment of patients, the Trust has taken the innovative step of obtaining that expertise using recent technological developments. When emergencies occur, say in the middle of the night, the tests are undertaken and the results are then sent electronically to London and onto Australia. The results are interpreted and reported back in a follow the sun manner. This ensures that the results of the tests are being interpreted and reported by Consultants who are awake and alert not by on-call staff being woken up; staff who may have worked throughout the previous day and are due to work on the next day. The expert interpretations and suggested treatments return electronically in a timely way. The benefits also include the ability to have reporting done by dedicated specialists in that type of test. It also means that our own staff work efficiently as they are rested and more productive (less sleep deprived) and the service is provided in a cost effective manner. The effectiveness of the service is constantly monitored with a guaranteed turn around time. b) Outdoor exercise The Trust, Action Heart and Dudley Public Health achieved a UK first when an outdoor gym facility was installed at Russells Hall Hospital in May The grand opening was attended by an international delegation from Portugal and has generated many enquiries within the UK. The outdoor gym is to be used as a demonstration site for patients, stepping down from exercise rehabilitation, to be able to maintain their commitment to physical activity via one of the eight outdoor gyms that are strategically located in parks within Dudley Borough. The Trust also hopes to lead the way in highlighting the importance of physical activity in good health by encouraging staff to use the outdoor gym (and other physical activities on site) and becoming appropriate role models for their patients. I have been in the children's ward twice in the last month, both times for a five night stay with our son. I imagine that when you are only in for a night you don't see the tireless work that the nurses and staff do on this ward. The care for both my son and myself was brilliant 76 - nothing too much trouble for him or a timely hug or cup of tea for me.

106 3.4.4 Examples of specific clinical effectiveness initiatives a) Emergency Laparotomy Pathway (EmLap) Patients, who develop severe intra-abdominal problems, can become very ill quickly; for those where this is due to a problem which can be corrected by surgery, many will need to undergo an Emergency Laparotomy. Emergency laparotomy is a highrisk surgical procedure that involves making an incision to provide access to the abdominal cavity, so the problem can be fully diagnosed and where possible corrected. The longer the time between needing such an operation and it being carried out the worse the outcome for the patient. Research indicates that patients who undergo emergency laparotomy have more than a >10% risk of dying within 30 days of their operation, with patients over 80 years old the risk rises to over 30%. Many other patients will suffer post-operative complications, and have a prolonged hospital stay. However, reports reveal a wide variation in care and outcomes, with mortality rates up to 40%, some of this difference is related to the time between symptoms starting and the operation being performed. To improve patient outcomes after Emergency laparotomy at the Trust an evidence based quality improvement care bundle known as the EmLap pathway has been developed (include picture of part of pathway). The bundle enables prompt identification, assessment, resuscitation and operation. The EmLap pathway also identifies how staff can ensure the most effective escalation of care so these high risk patients are cared for by the right people, in the right place at the right time. Other hospitals recently commencing such a scheme have shown a reduction in 30 day mortality by up to 50% 77

107 b) Cardiology One Stop Clinic The department had a long standing Rapid Access clinic for those patients with chest pain who needed to be seen quickly as well as the usual Out Patient (OPD) clinics. With the rising number of referrals, with increasing waiting times and with some patients being referred inappropriately to one of the two types of clinic, the department has developed a one stop clinic which ensures that all patients receive a streamlined personalised effective service according to their individual needs. In collaboration with primary care services, all patients are now referred into one point. The referral requires certain standard detailed information on their condition and all patients (except those with chest pain, in order to avoid referral delay) to have had a heart trace undertaken (electrocardiogram ECG). The referral information and the ECG trace allows specialist staff at the hospital to assess the best course of action: 1) Giving advice and guidance to the GP who will continue to see the patient 2) Arrange further, open access investigations with specialist advice with the results reported back to the GP 3) Ask the patient to attend the One Stop Clinic where a rapid assessment will be made and all necessary, non invasive investigations made on the same day so that a plan of care is put into place straightaway. On this pathway, priority is given to cardiac sounding chest pain and other urgent referrals to be seen in 2 weeks or sooner if necessary 4) If the patient had had a known previous or existing condition and there is no immediate concern then a usual OPD clinic appointment is made. This new system has resulted in a considerable drop in waiting times, improved access for those patients that need it and a more effective service overall. 78

108 3.4.5 Clinical effectiveness measures Actual Actual 2007/ /09 Actual 2009/10 Actual 2010/11 Actual 2011/12 Actual 2012/13 Actual 2013/14 Actual 2014/15 Trust readmission rate for surgery Vs Peer group West Midlands SHA Source: CHKS Insight Number of cardiac arrests Source: Logged switchboard calls Elective admissions where the planned procedure was not carried out (not patient decision) Vs Peer group West Midlands area Source: CHKS insight 4.6% Vs 4.1% 3.9% Vs 4.3% 4.1% Vs 4.2% 4.4% Vs 4.7% 5.6% Vs 5.0% 6.1% Vs 6.8% 6.4%* Vs 7.1% 6.7%^* Vs 7.2% # N/A 2.0% Vs 1.6% 1.4% Vs 1.6% 1.4% Vs 1.3% 0.67% Vs 1.1% 0.68% Vs 1.2% 0.75% Vs 0.8% 0.86%^* Vs 0.9% ^April 2014 to November NOTE: DGNHSFT no longer contract to CHKS for benchmarking information. The date range used is the latest included by CHKS from HES Data. These measures will not be available in the 2015/16 report. *Specialties included in the surgical directorate changed during 2013/14 which has affected the figures compared to previous years and the peer group. #Up to the end of February

109 3.5 Our performance against key national priorities across the domains of the NHS outcomes framework National targets and regulatory requirements 1. Access Maximum time of 18 weeks from point of referral to treatment (admitted patients) Maximum time of 18 weeks from point of referral to treatment (non-admitted patients) Maximum time of 18 weeks from point of referral to treatment (incomplete pathways) A&E: Percentage of patients admitted, transferred or discharged within 4 hours of arrival A maximum wait of 62 days from urgent referral to treatment of all cancers All cancers: 62 day wait for first treatment from consultant screening service All cancers: 31 day wait for second or subsequent treatment: surgery All cancers: 31 day wait for second or subsequent treatment: anti-cancer drug treatments A maximum wait of 31 days from diagnosis to start of treatment for all cancers Two week maximum wait for urgent suspected cancer referrals from GP to first outpatient appointment Two week maximum wait for symptomatic breast patients 2. Outcomes Certification against compliance with requirements regarding access to healthcare for people with a learning disability Data Completeness for community services: Referral to treatment information Data Completeness for community services: Referral information Data Completeness for community services: Treatment activity information Trust 2009/10 Trust 2010/11 Trust 2011/12 Trust 2012/13 Trust 2013/14 Target 2014/15 National 2014/15 Trust 2014/15 Target Achieved/ Not Achieved 95.8% 97.03% 95.7% 96.1% 93.95% 90% % 99.2% 99.2% 99.5% 99.18% 95% N/A N/A N/A 98.1% 96.74% 92% % 98.8% 97.27% 95.4% 93.74% 95% % 87% 88% 88.7% 89% 85% 88.1 N/A 99.6% 96.6% 99.4% 99.6% 90% 98.5 N/A 99.6% 99.6% 99.2% 100% 94% 99.4 N/A 100% 100% 100% 100% 98% % 99.8% 99.7% 99.5% 99.9% 96% % 96.8% 97.2% 96.2% 97.5% 93% % 98.2% 99% 98.1% 98.2% 93% 96.3 N/A N/A Compliant Compliant Compliant Compliant - Compliant N/A N/A N/A 97.3% 98.4% # 50% + N/A N/A N/A 65.6% 64.6% # 50% + N/A N/A N/A 99.1% 100% # 50% + N/A applies to targets not in place at that time applies to national figures not being appropriate + applies to national figures not available = Achieving target up to Dec/Jan 14/15 = Not achieving target up to Dec 15 # Latest monthly figure for March

110 3.6 Glossary of terms AAA A&E ADC BAD Bed Days BBC CRLN BHF CCG Abdominal Aortic Aneurysm Accident and Emergency (also known as ED) Action for Disabled People and Carers British Association of Dermatologists Unit used to calculate the availability and use of beds over time Birmingham and Black Country Comprehensive Local Research Network British Heart Foundation Clinical Commissioning Group C. difficile Clostridium difficile (C. diff) CNS CQC COPD LES CHKS Ltd CQUIN CEM DVD DVT EAU ENT ED FCE Foundation Trust GP HASC HAT HDU HED HES HQIP HSCIC HSMR HTA IBD ICNARC LINK Clinical Nurse Specialist Care Quality Commission Chronic Obstructive Pulmonary Disease Local Enhance Services A national company that works with Trusts and provides healthcare intelligence and quality improvement services Commissioning for Quality and Innovation payment framework College of Emergency Medicine Optical disc storage format Deep Vein Thrombosis Emergency Assessment Unit Ear, Nose and Throat Emergency Department (also known as A&E) Full Consultant Episode (measure of a stay in hospital) Not-for-profit, public benefit corporations which are part of the NHS and were created to devolve more decision-making from central government to local organisations and communities General Practitioner Health and Adult Social Care Scrutiny Committee Healthcare Acquired Thrombosis High Dependency Unit Healthcare Evaluation Data Hospital Episode Statistics Healthcare Quality Improvement Partnership Health and Social Care Information Centre Hospital Standardised Mortality Ratio Human Tissue Authority Irritable Bowel Disease Intensive Care National Audit & Research Centre Local Involvement Network 81

111 MBC MINAP Monitor MRSA MESS MUST NCEPOD NCI NICE NIHR NHS NNAP NOF NPSA NIV NVQ OSC PALS PEAT PFI PROMs RAG ROSE SHMI SKIN SUS SLT TARN TEAMM VTE Metropolitan Borough Council Myocardial Ischaemia National Audit Project Independent regulator of NHS Foundation Trusts Meticillin-resistant Staphylococcus aureus Mandatory Enhanced Surveillance System Malnutrition Universal Screening Tool National Confidential Enquiry into Patient Outcome and Death Nursing Care Indicator National Institute for Health and Care Excellence NHS National Institute for Health Research National Health Service National Neonatal Audit Programme Neck of Femur National Patient Safety Agency Non Invasive Ventilation National Vocational Qualification Overview and Scrutiny Committee Patient Advice and Liaison Service Patient Environment Action Teams Private Finance Initiative Patient Reported Outcome Measures Red/Amber/Green Rivaroxaban Observational Safety Evaluation Summary Hospital-level Mortality Indicator Surface, Keep Moving, Incontinence and Nutrition Secondary Uses Service Speech and Language Therapy Trauma Audit and Research Network Tackling Early Morbidity and Mortality in Myeloma Venous Thromboembolism 82

112 Annex Comment from Dudley MBC Overview and Scrutiny Committee (received xxx) The committee welcomes the opportunity to respond to this consultation as the responsible body for local authority health scrutiny. Members had occasion to assess delivery against leading priorities identified in the previous Quality Account consultation in February Inconsistent compliance regards fluid balance charting remains a concern for the committee. Members will explore this and other key issues underlined across the improvement priorities through follow-up committee s Dignity in Care Review action plan in 2014/15. The committee acknowledges the view that the existing topics are still key care issues of importance to patients and the public and so should remain priorities going into 2014/15. Consistent baseline reporting will enable local scrutineers to better identify with rates of improvement across themes. In addition, members would support proposals to consider mortality as a future priority particularly in the light of recent Keogh Review experiences. On urgent care, The Dudley Group NHS Foundation Trust has demonstrated strong partnership working with the CCG enabling a comprehensive, robust and inclusive clinical and patient-led approach to the design of the service. Activity assumptions based on the opening of the Urgent Care Centre being built into the CCG s contract with The Dudley Group NHS Foundation Trust for 2014 until 2016 was particularly welcomed. Members look forward to The Dudley Group NHS Foundation Trust input on the service model for the triage/streaming element of the urgent care centre and the proposed premises solution as the service specification and procurement framework takes shape in 2014/15. 83

113 Comment from the Dudley Health and Wellbeing Board (received xxx) Health and Wellbeing Boards came into force in April 2013 as part of the Health and Social Care Act As system leader for the health and care sector, the Board needs to be confident that quality assurance processes are in place and robust across the system. Dudley s Health and Wellbeing Board welcomes the opportunity to comment on The Dudley Group NHS Foundation Trust s annual quality account and is encouraged that Dudley s Clinical Commissioning Group as lead commissioner, the Health Scrutiny Committee and Healthwatch Dudley will also be commenting. Some Board members had the opportunity to comment during a recent CQC Inspection of the Trust and welcomed the opportunity to participate and make known their views through that process. The Board is encouraged by the improvements in patient experience supported by the Friends and Family Test and notes some of the innovative work in this area. However, there is still further work to do to embed. The Health Scrutiny Committee will be focusing on hospital patient experience during 2014 and the Board hopes that the Trust will commit to implement any recommendations. It is heartening to see that levels of infection, specifically for MRSA and Clostridium difficile (C. diff) show a reducing trend; however, the Trust remains above the national average for C. diff and should endeavour to maintain or reduce further on 2013/14 levels, and take a holistic approach to infection control. The Board notes the significant amount of work undergone to improve hospital mortality as a result of the Keogh Review and supports the Trust s decision to continue mortality reduction as a priority for 2014/15. The Board acknowledges the improvements that have been made during 2013/14 and that the report demonstrates that the Trust is committed to continuous improvement of quality across the broad spectrum of patient experience, clinical effectiveness and safety. The Board hopes that the Trust will continue to work with partners to make further quality improvements during 2014/15. 84

114 Comment from the Dudley Clinical Commissioning Group (received xx) The CCG note this report outlines the continued focus on the delivery of high quality care by the Trust. The CCG has previously stated its commitment to reducing avoidable mortality and is pleased to note the Trust s continued focus on this key area. In 2013 the Trust was one of 14 hospitals nationally where concerns were raised regarding the mortality indicators over the preceding two year period and subsequently a review was undertaken, led by the NHS England Medical Director, Sir Bruce Keogh. The CCG participated in this review which resulted in a wide range of recommendations for improvement including improving aspects of the patient experience and increased investment in front-line staff. The Trust actively participated in the review, was very receptive to the need for improvement, and has subsequently made significant progress during the year in implementing the recommendations made. The Trust is to be commended for having consistently received positive feedback from patients through the national Friends and Family Test however, there are other areas the CCG would like to see more rapid improvement such reducing the number of patients with hospital acquired pressure ulcers and continued improvements in reducing C difficile and MRSA infections. The Trust did not meet the national A&E waiting time target to admit or discharge 95 per cent of attenders within four hours. Historically, the Trust has been very successful in meeting this target so it is regrettable that this was not achieved in 2013/14. However, Dudley CCG has recently carried out a major public consultation on the redesign of urgent care across the borough with the support of both the Trust and Dudley Health and Wellbeing Board. This will result in the establishment of a new Urgent Care Centre at Russells Hall Hospital by the end of this financial year, which will enable the Trust to provide significant advancements in service and better co-ordinated care with the rest of the local health and social care system in Dudley. In the meantime, we are reinvesting resources non-recurrently into the hospital to assist in resolving their performance. Finally, the CCG will work with the Trust in ensuring that evidence of on-going progress is made throughout the year. This is vital for the interests of the patient population of Dudley and will also continue to hold the Trust to account constructively and assertedly for its future performance. Paul Maubach Chief Accountable Officer 85

115 Comment from the Trust s Council of Governors (received xx) The Trust s Quality Account is presented against a background of continuing change and financial pressures in the NHS. The 2012 Health and Social Care Act came into force on 1 st April 2013 heralding a major re-organisation of the NHS in England, and strict 4 per cent annual efficiency gains continue to be required of all trusts. At the same time, the age profile of the population, and hence the healthcare needs, increase proportionately. Both factors are having, and will continue to have, a significant effect on services and how they are delivered. It is also against this background that actions to satisfy the findings of the Francis Reports which required a rigorous focus on patient care and safety have been implemented. Governors fully support the Chief Executive s Statement in Section 1 of this report and note, in particular, comments on the Keogh Review rationale and outcomes in which the Trust mortality rates were found to be within the expected range. Governors have been kept fully up to date with actions following that review. We are pleased to note the increased focus on patient experience and safety which has had many strands including, for example, a revised complaints process, and reorganisation of the complaints and PALS provision in consultation with stakeholders. Governors now take part in Patient Safety Leadership Walkrounds with directors and will be members of a new Patient Experience Group which reports to the Board. Governors note the successful involvement of the Trust in many clinical audits and research trials. Governors meet many patients, members of the public and community groups each year and gain feedback about the quality of services and patient experience. Governors find that users views of clinical treatment and the care provided by our nurses, doctors and other staff is very positive, reflecting the improved Friends and Family Test scores achieved by the Trust. On occasion, there are less positive views about communication, food and parking. Pressure on services has increased further in 2013/14 particularly in the Emergency Department. In common with many trusts, failure to consistently meet the four hour target has been of concern for some time. Measures are in place to improve this situation and governors have strongly supported the proposed relocation of the walkin centre and primary care out-of-hours service at the Dudley Borough Walk-in Centre to form an Urgent Care Centre at Russells Hall Hospital during 2014/15. This should result in a more appropriate service for all patients and a reduction in waiting and treatment times. The process used to ratify the Trust s choice of Quality Priorities gives a wide range of patients, members, governors, staff and other interest groups the opportunity to be involved and influence choices. While detail is given in section 2 of this report, of the 2013/14 priorities governors are pleased to note the success in reducing the number to zero of avoidable stage 4 pressure ulcers developed in the hospital. The failure to achieve the avoidable stage 3 pressure ulcer target in the hospital is disappointing. In addition, governors are pleased to see that the community target for the reduction in avoidable pressure ulcers has been met. Governors also note that one of the two hospital patient experience targets was achieved and neither of the two community 86

116 patient experience targets were met. Further focus will be required to achieve the new patient experience targets in 2014/15. Governors note the further work undertaken on the new Health and Social Care Passport and look forward to implementation during 2014/15. With regard to infection control, governors recognise that the C. diff target set by the Department of Health was extremely challenging. It was not achieved, though some assurance can be taken that there were fewer cases than in 2012/13. The Council of Governors has agreed the continuation of all 2013/14 Quality Priorities into 2014/15 together with mortality as a new priority as recommended by the Keogh Review. Governors recognise their increased responsibilities following the introduction of the 2012 Health and Social Care Act, the outcomes of the Francis enquiries and the Trust s Keogh Review. The Council of Governors has carried out its own development review and in consultation with the Board of Directors has put in place a future role for governors in which their increased needs for information and assurance can be met in order to hold the Board of Directors to account through its non-executive directors. In common with other acute trusts, the Trust operates under increasing pressure. The increasingly complex demands of an ageing population and efficiency gains have to be met while protecting the quality of services and care and safety of patients. That staff, especially in stressful and pressured situations on the front line, demonstrate such high levels of care and commitment is to be commended. On behalf of patients, carers and the public, governors wish to place on record their recognition and appreciation of the commitment and excellent work done by staff at all levels in the organisation. 87

117 Comment from Healthwatch Dudley (received xx) Healthwatch Dudley recognises the good work undertaken within the Dudley Group, which is highlighted in the performance measures and patient views in the annual Quality Report and Account for 2013/14. In the relatively short time it has been in existence, Healthwatch Dudley has been able to capture many views from local people about their experience of Dudley Group NHS Foundation Trust services. Healthwatch Dudley representatives are pleased to have been invited to meetings and events following the Keogh Review and Care Quality Commission inspection. The team has been reassured by actions already taken to improve patient outcomes and experiences and an invitation has been accepted to become a member of the newly-established Patient Experience Group. The team also welcomes opportunities to undertake Enter and View visits to service areas as a critical friend and staff and valuable volunteers will continue to be involved in all patient and wider public engagement events, to ensure the voices of local people are heard and responded to. In a number of instances marked progress was made against the Quality Priority targets set for 2013/14. Nevertheless, some targets were partially rather than fully achieved by the end of the year. Healthwatch Dudley welcomes the opportunity to work with The Dudley Group to ensure that the views of local people are taken into account, to improve patient experience across all areas of the Trust. NB: Healthwatch Dudley is unable to comment on number of patients using their Single Assessment Process Folder/Health and Social Care Passport or the number of patients that know how to raise concerns about their care and treatment. We look forward to seeing this data in the final report. 88

118 Statement of directors responsibilities in respect of the quality report 2014/15 The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2014/15 and supporting guidance; the content of the Quality Report is not inconsistent with internal and external sources of information including: board minutes and papers for the period April 2014 to [the date of this statement] papers relating to Quality reported to the board over the period April 2014 to [the date of this statement] feedback from commissioners dated XX/XX/20XX feedback from governors dated XX/XX/20XX feedback from the local Healthwatch organisation dated XX/XX/20XX feedback from Overview and Scrutiny Committee dated XX/XX/20XX the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated XX/XX/20XX; the [latest] national patient survey XX/XX/20XX the [latest] national staff survey XX/XX/20XX the Head of Internal Audit s annual opinion over the trust s control environment dated XX/XX/20XX CQC Intelligent Monitoring Report dated XX/XX/20XX the Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered; the performance information reported in the Quality Report is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been prepared in accordance with Monitor s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at as well as the standards to support 89

119 data quality for the preparation of the Quality Report (available at The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board NB: sign and date in any colour ink except black...date...chairman...date...chief Executive Signed Date: xxth of xx 2015 David Badger Chairman Signed Date: xxth of xx 2015 Paula Clark Chief Executive Independent Assurance Report to the Council of Governors of The Dudley Group NHS Foundation Trust on the Annual Quality Report 90

120 91

121 Appendix 1 Dudley Group NHS FT: Quality Reports Review Timeline 2014/15 Element Activity Indicative Dates Set up meeting Initial meeting between Deloitte and designated Trust Lead to January 2015 agree scope and approach. Confirmation of Trust to confirm which mandated and (governor approved) local Late Feb / Indicator Selection indicators are to be reviewed. early March 2015 Interviews Deloitte to undertake interviews with relevant leads for Quality Report. By early March Deloitte to undertake interviews with Information Officers (relevant to indicators) to: Understand the systems used to produce specified indicators, the production of specified indicators, and perform a walkthrough of the systems to gain understanding of the data collection and validation process. Agree data extracts to be provided by the Trust. March Interviews with the operational leads for 3 KPIs to understand the organisational protocols and processes for data recording. Jointly agree the approach to the substantive testing (e.g. criteria, rationale, systems and evidence sources to be used in testing and data fields to be included). Data gathering Deloitte to provide formal request for data extract for initial 11 month sample. w/c 23 rd March Provision of data extracts from the Trust to Deloitte. Trust to provided data extracts provided to Deloitte in preparation for testing phase. Operational/Informatics staff time may be required for any clarification queries at this time. By w/c 31 st March we would require data extract covering first 11 months of qualifying year (1st April th February 2015). Due to the 6 week time lag in the availability of cancer data we would require 10 months of data. Data covering the 12th month (1 st March st March 2015) to follow at the earliest point available and no later than 14th April Due to the 6 week time lag in the availability of cancer data we would require data for the 11 th month. w/c 30 th March Data created sample Deloitte to derive random sample from data extract provided and submit request to Trust in order to arrange pulling of patient casenotes (if applicable). w/c 30 th March Trust preparation for testing Trust to pull patient casenotes (where required). w/c 6 th April

122 Appendix 1 Testing Provision of information from the Trust to Deloitte Feedback on testing/indicators Desktop based review of Quality Report Feedback on Quality Report Draft deliverable Trust review and approval of draft report Final deliverable Presentation to Audit Committee Trust to submit private report to Monitor Deloitte to undertake substantive data testing against mandatory and local indicators. Trust to provide access to staff during the testing period to enable cross referencing of patient case notes and Trust systems. Reconciliation of full year performance data. Trust to provided relevant documentation (including Board minutes, staff survey and patient survey). Full information request attached below. Deloitte to discuss emerging findings with the Trust, clarify and queries and provide opportunity to investigate any outstanding points. Trust to provide copy of (draft) Quality Report; stakeholder feedback and Statements of Directors Responsibilities for Deloitte review against Monitor criteria. Deloitte to provide informal feedback on content of Quality Report and consistency with specified information. Deloitte to issue draft report containing summary of findings and supporting recommendations. Deloitte to meet with key sponsors to discuss draft report. Trust Management to review report and provide management response and completed action plan to Deloitte. Deloitte to issue final report to the Trust (subject to reconciliation of full year cancer performance to reported performance in the Quality Report). Deloitte to present final report to Trust Audit Committee. Trust to submit report to Monitor. The Trust should also make arrangements for sharing the report with Trust Board and the Board of Governors. w/c 6 th April NB. Mop up testing and reconciliation of full year data to be undertaken in late April. (in the case of Cancer this will be mid May). End of March 2015 / Early April Within 1 week of completion of testing. First draft by 6 th April and final draft no later than 16 th April Informal feedback on first draft in mid April and on final draft by 20 th April w/c 20 th April 2015 w/c 20 th April th April th May th May th May

123 Appendix 1 Information request Please the following information/documents to gkhaira@deloitte.co.uk and jbingham@deloitte.co.uk heading DG QA [Document Name] as the subject Please note that further information may be requested following interviews and review of information. Document Name - Copy of project plan/ outline of approach to Quality Report production - CQC Quality & Risk Profile - Board Minutes for period April 2014 to May Papers relating to 2014/15 Quality Report (QR) reported to Board over the period - Feedback from Commissioners on QR - Feedback from Governors on QR - Feedback from LINks - Feedback from any other named stakeholders involved in the sign off of the QR (including local Healthwatch organisations) - The Trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations Latest National Patient Survey results. - Latest National Staff Survey results. - The Head of Internal Audit s annual opinion over the Trust s control environment. - Papers relating to progress against 2013/14 QR External Assurance Recommendations. - Evidence of the process that the Trust has undertaken to secure stakeholder engagement in development of Quality priorities and the production of the QR. - Draft Quality Report. - Statement of Directors Responsibilities in respect of the content of the Quality Report - Statement of Directors Responsibilities in respect of the mandated performance indicators - Statement of Directors Responsibilities in respect of all other indicators included within the Quality Report. - Data extracts for each of the indicators under review (to be agreed directly with information/operational staff). - Any data quality audits/reports available for the 3 indicators under review. 94

124 DUDLEY CLINICAL COMMISSIONING GROUP BOARD Date of Board: 30 March 2015 Report: Primary Care Co Commissioning Approval for Delegated Arrangements Agenda item No: 5 TITLE OF REPORT: PURPOSE OF REPORT: AUTHOR OF REPORT: MANAGEMENT LEAD: CLINICAL LEAD: KEY POINTS: RECOMMENDATION: FINANCIAL IMPLICATIONS: WHAT ENGAGEMENT HAS TAKEN PLACE: ACTION REQUIRED: Primary Care Co Commissioning Approval for Delegated Arrangements To consider the NHS England Delegation Agreement Mr D King Head of Membership Development Mr D King Head of Membership Development Dr T Horsburgh Clinical Lead Primary Care Co Commissioning 1) On 17 March NHS England published a delegation agreement that sets out the statutory delegation of primary care commissioning functions to the CCG 2) NHS England had initially requested that the agreement was signed and returned by 24 th March and then extended the deadline to 26 th March 3) The Chief Executive Officer has replied to NHS England that we are not willing to sign and return the agreement until: The delegation agreement has been considered by the Board and The CCG has taken legal advice on: i. how the agreement compared to the changes to the Constitution previously submitted to NHSE for approval ii. the policies/processes that the delegation agreement requires us to have in place before 1st April e.g. Revised Managing Conflicts of Interest Policy 4) The delegation agreement is appended for information 5) The CCG has taken legal advice from Mills and Reeve and participating in legal webinars organised by NHS England which at the time of the report are not available this advice will be made available to the Board at the meeting 6) The CCG position remains that until we have concluded our handover negotiations with NHS England and resolved any legal issues we are not in a position to sign the delegation agreement The Board is asked to: 1) Note the contents of this report 2) That the decision to sign the delegation agreement is delegated to the Chief Executive Officer 3) The delegation agreement is not signed until all legal issues are resolved and we have an agreed memorandum of understanding with NHS England setting out the agreed functions and tasks transferring to the CCG as a schedule to the delegation agreement 4) The responsibility remains with NHS England for the commissioning of General Medical Services until the CCG has signed the delegation agreement 38m proposed budget Due diligence ongoing on proposed budget Unquantifiable risk based on current agreement Via LMC, Member Practices Communicated to public Decision Approval Assurance 1 P age

125 DUDLEY CLINICAL COMMISSIONING GROUP BOARD 30 MARCH 2015 PRIMARY CARE CO COMMISSIONING APPROVAL FOR DELEGATED ARRANGEMENTS 1.0 PURPOSE OF REPORT 1.1 To update the Board following the release of a National delegation agreement that sets out the statutory delegation of primary care commissioning functions to the CCG from NHS England. 2.0 BACKGROUND 2.1 On the 18 February 2015 NHS England announced that Dudley CCG was one of 64 CCGs Nationally that had been approved to take on responsibility for commissioning the majority of GP services from April Prior to the announcement on 18 February 2015 the CCG had been participating handover meetings and task and finish groups with the Area Team of NHS England. The last handover meeting took place on 4 March attended by Chief Executive Officer, Chief Financial Officer, Interim Chief Nurse and the Head of Membership Development. 2.3 At the meeting on 4 th March the CCG confirmed its position that there would be a managed and phased transition of functions from NHS England to the CCG over a period of 3 months from 1 April 2015 to 30 June At the meeting on 4 March the CCG confirmed its position that we would not assume responsibility for the delegated commissioning of General Medical Services until we had agreed a memorandum of understanding setting out all the tasks and functions that would either be transferred to CCG, or retained by the Area Team of NHS England. It was agreed that NHS England would organise a further handover meeting would be organised prior to 1 April 2015: this has not happened. 2.5 On 17 March, two weeks later than expected, the National delegation agreement was published by NHS England. This required the CCG to sign and return the agreement on 24 March This deadline was extended to the 26 March 2015 the following day. 2.6 The Chief Executive Officer has replied formally to NHS England to confirm that the CCG would not be signing the delegation agreement given the outstanding issues locally and nationally. 3.0 ISSUES TO CONSIDER 3.1 Initial legal advice indicates a number of issues relating to the agreement in terms of finance, governance, responsibility and accountability, and legal obligations are invalid, incorrect or too risky for the CCG to accept. 3.2 Correspondence with NHS England at a local and national level has occurred and further advice from Mills and Reeve, along with national statements on the contract, are expected prior to Board on 30 March. This will be presented to Board for discussion. 4.0 RECOMMENDATION 4.1 Noting the further information that is expected to be available and presented to Board on 30 March, the Board is asked to: Note the contents of this report Delegate the responsibility for signing the delegation agreement to the Chief Executive Officer Agree that the delegation agreement is not signed until all legal issues are resolved and we have an agreed memorandum of understanding with NHS England setting out the agreed functions and tasks transferring to the CCG as a schedule to the delegation agreement Agree that the responsibility remains with NHS England for the commissioning of General Medical Services until the CCG has signed the delegation agreement. Mr D King Head of Membership Development March P age

126 DUDLEY CLINICAL COMMISSIONING GROUP BOARD Date of Board: 30 March 2015 Report: Revised Conflicts of Interest Policy Agenda item No: 6 TITLE OF REPORT: PURPOSE OF REPORT: AUTHOR OF REPORT: MANAGEMENT LEAD: CLINICAL LEAD: KEY POINTS: Revised Conflicts of Interest Policy To present a revised Conflicts of Interest Policy for approval Mr M Hartland, Chief Operating & Finance Officer Mr M Hartland, Chief Operating & Finance Officer Dr J Rathore, Clinical Lead for Finance and Performance Revised policy presented incorporating specific provisions in relation to co-commissioning primary care services Audit Committee to consider policy 27 March and advise the Board Constitution will need to be amended at next opportunity to reflect the revised policy RECOMMENDATION: The Board is asked to approve the revised Conflicts of Interest Policy FINANCIAL IMPLICATIONS: WHAT ENGAGEMENT HAS TAKEN PLACE: ACTION REQUIRED: None None Decision Approval Assurance 1 P age

127 DUDLEY CLINICAL COMMISSIONING GROUP BOARD 30 th MARCH 2015 REVISED CONFLICTS OF INTEREST POLICY 1. INTRODUCTION The NHS England publication Managing Conflicts of Interest: Statutory Guidance for CCGs issued in December 2014 set out how CCGs should manage conflicts of interest. It contained specific provisions in relation to co-commissioning primary care services but the guidance is relevant to CCG responsibilities generally. The CCG s policy on Managing Conflicts of Interest has been revised to reflect this guidance and now needs to be approved by the Board and be in place for 1 st April 2015 when the CCG takes over delegated responsibility for primary care commissioning. 2. CONTENTS OF THE REVISED POLICY The policy incorporates the safeguards for the management of conflicts of interest set out in the previously issued guidance, including: the nature of conflicts of interest; arrangements for declaring interests; maintaining a register of interests; keeping a record of the steps taken to manage a conflict; excluding individuals from decision-making where a conflict arises; and engagement with a range of potential providers on service design In addition, it sets out: the additional factors that the CCG must address when commissioning primary medical care services under delegated commissioning arrangements; the steps that CCG will take to assure the Audit Committee, Health and Wellbeing Board, NHS England and, where necessary, their auditors, that these services are appropriately commissioned from GP practices; procedures for decision-making in cases where all the GPs (or other practice representatives) sitting on a decision-making group have a potential financial interest in the decision; arrangements for publishing details of payments to GP practices; the potential role of commissioning support services; and the supporting role of NHS England. 3. ADDITIONAL INFORMATION The Audit Committee will be considering this policy for the first time at its meeting on Friday 27 th March so it may recommend late changes to the policy for approval by the Board. The current Managing Conflicts of Interest Policy is included within the CCG s Constitution under section 8 and more fully at Appendix F. This policy is enhancing and adding to the existing one at an operational level with effect from 1 st April Amendments to the Constitution will be put forward at the next opportunity i.e. for the June 2015 update, submission to be made in May. Actions will be taken to implement this policy from the beginning of April RECOMMENDATION The Board is asked to approve the revised Conflicts of Interest Policy. 5. APPENDIX Conflicts of Interest Policy M Hartland Chief Operating & Finance Officer March P age

128 Draft Document CONFLICT OF INTEREST POLICY This policy can only be considered valid when viewed via the Dudley CCG website. If this document is printed into hard copy or saved to another location, you must check that the version number on your copy matches that of the one online Page 1 of 23

129 CONTENTS 1.0 Introduction What are Conflicts of Interest? Legislative Framework Principles and General Safeguards Register of Interests Register of Procurement Decisions Procurement Issues General considerations and use of the Template Designing Service Requirements Governance and Decision-making Processes Appointing Governing Body or Committee Members Decision-making when a Conflict of Interest arises: General Approaches Decision-making when a Conflict of Interest arises: Primary Medical Care Record Keeping Role of Commissioning Support Annexes Annex 1: Annex 2: Annex 3: Annex 4: Declaration of Conflict of Interests for Bidders /Contractors Template Declaration of Interests for Members /Employees Template Procurement Template Relevant Legislation and Guidance 14 Page 2 of 23

130 1.0 INTRODUCTION 1.1 All Clinical Commissioning Groups (CCGs) manage conflicts of interest as part of their day to day activities. Effective handling of such conflicts is crucial for the maintenance of public trust in the commissioning system. Importantly, it also serves to give confidence to patients, providers, Parliament and tax-payers that CCG commissioning decisions are robust, fair, transparent and offer value for money. 1.2 This policy reflects the seven principles of public life promulgated by the Nolan Committee: Selflessness Integrity Objectivity Accountability Openness Honesty Leadership. 1.3 The aims of this policy are to: enable the CCG and clinicians in commissioning roles to demonstrate that they are acting fairly and transparently and in the best interest of their patients and local populations; ensure that the CCG operates within the legal framework, but without being bound by over-prescriptive rules that risk stifling innovation; safeguard clinically led commissioning, whilst ensuring objective investment decisions; provide the public, providers, Parliament and regulators with confidence in the probity, integrity and fairness of commissioners decisions; and uphold the confidence and trust between patients and GP, in the recognition that individual commissioners want to behave ethically but may need support and training to understand when conflicts (whether actual or potential) may arise and how to manage them if they do. 1.4 The policy incorporates the safeguards for the management of conflicts of interest set out in the previously issued guidance, including: the nature of conflicts of interest; arrangements for declaring interests; maintaining a register of interests; keeping a record of the steps taken to manage a conflict; excluding individuals from decision-making where a conflict arises; and engagement with a range of potential providers on service design. 1.5 In addition, it sets out: the additional factors that the CCG must address when commissioning primary medical care services under delegated commissioning arrangements. the steps that CCG will take to assure the Audit Committee, Health and Wellbeing Board, NHS England and, where necessary, their auditors, that these services are appropriately commissioned from GP practices; procedures for decision-making in cases where all the GPs (or other practice representatives) sitting on a decision-making group have a potential financial interest in the decision; arrangements for publishing details of payments to GP practices; the potential role of commissioning support services; and the supporting role of NHS England. Page 3 of 23

131 2.0 WHAT ARE CONFLICTS OF INTEREST? 2.1 A conflict of interest occurs where an individual s ability to exercise judgement, or act in a role, is or could be impaired or otherwise influenced by his or her involvement in another role or relationship. The individual does not need to exploit his or her position or obtain an actual benefit, financial or otherwise, for a conflict of interest to occur. For the purposes of Regulation 6 [National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations ], a conflict will arise where an individual s ability to exercise judgement or act in their role in the commissioning of services is impaired or influenced by their interests in the provision of those services. Monitor - Substantive guidance on the Procurement, Patient Choice and Competition Regulations (December 2013) 2.2 As well as direct financial interests, conflicts can arise from an indirect financial interest (e.g. payment to a spouse) or a non-financial interest (e.g. reputation). Conflicts of loyalty may arise (e.g. in respect of an organisation of which the individual is a member or with which they have an affiliation). Conflicts can arise from personal or professional relationships with others, e.g. where the role or interest of a family member, friend or acquaintance may influence an individual s judgement or actions, or could be perceived to do so. Depending upon the individual circumstances, these factors can all give rise to potential or actual conflicts of interest. 2.3 For a commissioner, a conflict of interest may therefore arise when their judgment as a commissioner could be, or be perceived to be, influenced and impaired by their own concerns and obligations as a provider. In the case of a GP involved in commissioning, an obvious example is the award of a new contract to a provider in which the individual GP has a financial stake. However, the same considerations, and the approaches set out in this policy, apply when deciding whether to extend a contract. 3.0 LEGISLATIVE FRAMEWORK 3.1 The starting point is section 14O of the Act. This sets out the minimum requirements in terms of what both NHS England and CCGs must do in terms of managing conflicts of interest. For all CCGs, this means that they must: Maintain appropriate registers of interests; Publish or make arrangements for the public to access those registers; Make arrangements requiring the prompt declaration of interests by the persons specified (members and employees) and ensure that these interests are entered into the relevant register; Make arrangements for managing conflicts and potential conflicts of interest (e.g. developing appropriate policies and procedures); and Have regard to guidance published by NHS England and Monitor in relation to conflicts of interest. 3.2 Section 14O is supplemented by the procurement specific requirements set out in the National Health Service (Procurement, Patient Choice and Competition) (No.2) Regulations In particular, regulation 6 requires the following: The CCG must not award a contract for the provision of NHS health care services where conflicts, or potential conflicts, between the interests involved in commissioning such Page 4 of 23

132 services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract; and The CCG must keep a record of how it managed any such conflict in relation to NHS commissioning contracts it enters into. (As set out below, details of this should also be published by the CCG.) 3.3 An interest is defined for the purposes of regulation 6 as including an interest of the following: a member of the CCG; a member of the CCG s Board; a member of its committees or sub-committees; an employee or a contractor of services (sub-contractor) 3.4 As with section 14O, regulation 6 sets out the basic framework within which the CCG must operate. The detailed requirements are set out in the guidance issued by Monitor (Substantive guidance on the Procurement, Patient Choice and Competition Regulations) and, in particular, section 7 of that statutory guidance. 3.5 Monitor s view is that care must be taken to ensure that conflicts do not affect, or appear to affect, the integrity of the award of commissioning contracts. It is important to ensure that the management of conflicts of interest includes the management of perceived conflicts and that there is an appropriate record of how such issues are managed, particularly in the context of specific procurement decisions. Please see below for further guidance on how such information should be recorded and published. Clear and robust decision making processes must be put in place to deliver co-commissioning and give the public and providers confidence in the integrity of the decisions made. 4.0 PRINCIPLES AND GENERAL SAFEGUARDS 4.1 The general safeguards that will be needed to manage conflicts of interest will vary to some extent, depending on at what stage in the commissioning cycle decisions are being made. The following principles will need to be integral to the commissioning of all services, including decisions on whether to continue to commission a service, such as by contact extension. 4.2 Conflicts of interest can be managed by: Doing business appropriately. If commissioners get their needs assessments, consultation mechanisms, commissioning strategies and procurement procedures right from the outset, then conflicts of interest become much easier to identify, avoid and/or manage, because the rationale for all decision-making will be clear and transparent and should withstand scrutiny; Being proactive, not reactive. Commissioners should seek to identify and minimise the risk of conflicts of interest at the earliest possible opportunity, for instance by: considering potential conflicts of interest when electing or selecting individuals to join the governing body or other decision-making bodies; ensuring individuals receive proper induction and training so that they understand their obligations to declare conflicts of interest. Page 5 of 23

133 They should establish and maintain registers of interests, and agree in advance how a range of possible situations and scenarios will be handled, rather than waiting until they arise. Assuming that individuals will seek to act ethically and professionally, but may not always be sensitive to all conflicts of interest. Rules should assume people will volunteer information about conflicts and, where necessary, exclude themselves from decision- making, but there should also be prompts and checks to reinforce this; Being balanced and proportionate. Rules should be clear and robust but not overly prescriptive or restrictive. They should ensure that decision- making is transparent and fair, but not constrain people by making it overly complex or cumbersome; Openness. Ensuring early engagement with patients, the public, clinicians and other stakeholders, including local Healthwatch and Health and Wellbeing Board, in relation to proposed commissioning plans; Responsiveness and best practice. Ensuring that commissioning intentions are based on local health needs and reflect evidence of best practice securing buy in from local stakeholders to the clinical case for change; Transparency. Documenting clearly the approach taken at every stage in the commissioning cycle so that a clear audit trail is evident; Securing expert advice. Ensuring that plans take into account advice from appropriate health and social care professionals, e.g. through clinical senates and networks, and draw on commissioning support, for instance around formal consultations and for procurement processes; Engaging with providers. Early engagement with both incumbent and potential new providers over potential changes to the services commissioned for a local population; Creating clear and transparent commissioning specifications that reflect the depth of engagement and set out the basis on which any contract will be awarded; Following proper procurement processes and legal arrangements, including evenhanded approaches to providers; Ensuring sound record-keeping, including up to date registers of interests and procurement decisions; and A clear, recognised and easily enacted system for dispute resolution. 4.3 These general processes and safeguards should apply at all stages of the commissioning process, but will be particularly important at key decision points, e.g., whether and how to go out to procurement of new or additional services. Page 6 of 23

134 5.0 REGISTER OF INTERESTS Statutory requirements The CCG must maintain one or more registers of interest of: the members of the group, members of its governing body, members of its committees or subcommittees of its governing body, and its employees. The CCG must publish, and make arrangements to ensure that members of the public have access to these registers on request. The CCG must make arrangements to ensure individuals declare any conflict or potential conflict in relation to a decision to be made by the group as soon as they become aware of it, and in any event within 28 days. CCGs must record the interest in the registers as soon as they become aware of it. 5.1 When members declare interests, this must include the interests of all relevant individuals within their own organisations (e.g. partners in a GP practice), who have a relationship with the CCG and who would potentially be in a position to benefit from the CCG s decisions. 5.2 When entering an interest on its register of interests, the CCG will ensure that it includes sufficient information about the nature of the interest and the details of those holding the interest. 5.3 The CCG will ensure that, as a matter of course, declarations of interest are made and regularly confirmed or updated. This includes the following circumstances: On appointment: Applicants for any appointment to the CCG or its governing body will be asked to declare any relevant interests. When an appointment is made, a formal declaration of interests will again be made and recorded. At meetings: All attendees will be asked to declare any interest they have in any agenda item before it is discussed or as soon as it becomes apparent. Even if an interest is declared in the register of interests, it should be declared in meetings where matters relating to that interest are discussed. Declarations of interest will be recorded in minutes of meetings. Quarterly: The CCG has a system in place to satisfy themselves on a quarterly basis that their register of interests is accurate and up to date. On changing role or responsibility: Where an individual changes role or responsibility within a CCG or its governing body, any change to the individual s interests should be declared. On any other change of circumstances: Wherever an individual s circumstances change in a way that affects the individual s interests (e.g. where an individual takes on a new role outside the CCG or sets up a new business or relationship), a further declaration should be made to reflect the change in circumstances. This could involve a conflict of interest ceasing to exist or a new one materialising. 5.4 In keeping with the regulations, individuals who have a conflict should declare this as soon as they become aware of it, and in any event not later than 28 days after becoming aware. 5.5 Whenever interests are declared, they should be reported to the Governance Support Manager, who will then update the register accordingly. Page 7 of 23

135 Note: Monitoring compliance with this policy will be considered as part of any legal or professional body investigation. Failure to declare an interest where this policy deems it to be appropriate may result in the board member being removed from office in line with the CCG s Constitution. Failure to comply with this policy will be addressed under the disciplinary processes of the CCG, or otherwise as set out in the CCG s Standing Orders for Members of the Governing Body. See Annex 2 for Declaration of Interest Template. 6.0 REGISTER OF PROCUREMENT DECISIONS 6.1 The CCG will also maintain a register of procurement decisions taken, including: the details of the decision; who was involved in making the decision (i.e. governing body or committee members and others with decision-making responsibility); and a summary of any conflicts of interest in relation to the decision and how this was managed by the CCG. 6.2 The register will be updated whenever a procurement decision is taken. 6.3 In the interests of transparency, the register of interests and the register of decisions will be publicly available and easily accessible to patients and the public including by: ensuring that both registers are available in a prominent place on the CCG s website; and making both registers available upon request for inspection at the CCG headquarters. 6.4 Individuals without internet access will be invited to view the register(s) at the CCG s headquarters. 6.5 The registers will form part of the CCG s annual accounts and will thus be signed off by external auditors. See Annex 1 for Declaration of Interest Template. 7.0 PROCUREMENT ISSUES 7.1 The NHS Act, the Health and Social Care Act ( the HSCA ) and associated regulations set out the statutory rules with which commissioners are required to comply when procuring and contracting for the provision of clinical services. They need to be considered alongside the Public Contract Regulations 2 and, where appropriate, EU procurement rules. Monitor's Substantive guidance on the Procurement, Patient Choice and Competition Regulations advises that the requirements within these create a framework for decision making that will assist commissioners to comply with a range of other relevant legislative requirements. 7.2 The Procurement, Patient Choice and Competition Regulations place requirements on commissioners to ensure that they adhere to good practice in relation to procurement, do not engage in anti-competitive behaviour that is against the interest of patients, and protect the right of patients to make choices about their healthcare. Page 8 of 23

136 7.3 The regulations set out that commissioners must: manage conflicts and potential conflicts of interests when awarding a contract by prohibiting the award of a contract where the integrity of the award has been, or appears to have been, affected by a conflict; and keep appropriate records of how they have managed any conflicts in individual cases. 8.0 GENERAL CONSIDERATIONS AND USE OF THE TEMPLATE 8.1 The most obvious area in which conflicts could arise is where a CCG commissions (or continues to commission by contract extension) healthcare services, including GP services, in which a member of the CCG has a financial or other interest. This may most often arise in the context of co- commissioning of primary care, particularly with regard to delegated or joint arrangements, but may also arise in respect of any commissioning issue where GPs are current or possible providers. The CCG will use the procurement template at annex 3 when drawing up commissioning plans for services where this potentially is the case. 8.2 The CCG will make evidence of its deliberations on conflicts publicly available. The template evidences this and supports CCGs in fulfilling their duty in relation to public involvement. It provides appropriate assurance: that the CCG is seeking and encouraging scrutiny of its decision-making process; to Health and Wellbeing Board, local Healthwatch and to local communities that the proposed service meets local needs and priorities; it will enable them to raise questions if they have concerns about the approach being taken; to the Audit Committee and, where necessary, external auditors, that a robust process has been followed in deciding to commission the service, in selecting the appropriate procurement route, and in addressing potential conflicts; and to NHS England in their role as assurers of the co-commissioning arrangements. 9.0 DESIGNING SERVICE REQUIREMENTS 9.1 It is good practice to engage relevant providers, especially clinicians, in confirming that the design of service specifications will meet patient need. Such engagement, done transparently and fairly, is entirely legal. However, conflicts of interest can occur if a commissioner engages selectively with only certain providers (be they incumbent or potential new providers) in developing a service specification for a contract for which they may later bid. 9.2 The CCG will seek, as far as possible, to specify the outcomes that it wishes to see delivered through a new service, rather than the process by which these outcomes are to be achieved. As well as supporting innovation, this helps prevent bias towards particular providers in the specification of services. 9.3 Such engagement should follow the three main principles of procurement law, namely equal treatment, non-discrimination and transparency. This includes ensuring that the same information is given to all. 9.4 Other steps include: advertise the fact that a service design/re-design exercise is taking place widely and invite comments from any potential providers and other interested parties (ensuring a record is kept of all interactions); as the service design develops, engage with a wide range of providers on an ongoing basis to seek comments on the proposed design, e.g. via the commissioner s website or via workshops with interested parties; Page 9 of 23

137 use engagement to help shape the requirement to meet patient need but take care not to gear the requirement in favour of any particular provider(s); if appropriate, engage the advice of an independent clinical adviser on the design of the service; be transparent about procedures; ensure at all stages that potential providers are aware of how the service will be commissioned; and maintain commercial confidentiality of information received from providers. 9.5 When engaging providers on service design, the CCG has ultimate responsibility for service design and for selecting the provider of services. Monitor has issued guidance on the use of provider boards in service design. 9.6 The CCG will also ensure that it has systems in place for managing conflicts of interest on an ongoing basis, by monitoring a contract that has been awarded to a provider in which an individual commissioner has a vested interest GOVERNANCE AND DECISION-MAKING PROCESSES 10.1 Statutory requirement The CCG has arrangements for managing conflicts of interest, and potential conflicts of interest, in such a way as to ensure that they do not, and do not appear to, affect the integrity of its decision-making The CCG has reviewed its governance structures for managing conflicts of interest to ensure that they reflect current guidance and are appropriate, particularly in relation to co-commissioning. This has entailed consideration of the following: the make-up of its governing body and committee structures (including, where relevant, the approach set out below for decision-making in delegated commissioning of primary care); whether there are sufficient management and internal controls to detect breaches of the CCG s conflicts of interest policy, including appropriate external oversight and adequate provision for whistleblowing; how non-compliance with policies and procedures relating to conflicts of interest will be managed (including how this will be addressed when it relates to contracts already entered into). As well as actions to address non-compliance, the CCG has procedures in place to review any lessons to be learned from such cases, by the CCG s Audit Committee conducting an incident review; reviewing and revising approaches to the CCG s registers of interest, together with the introduction of a record of decisions, as set out above; Whether any training or other programmes are required to assist with compliance, including participation in training offered by NHS England APPOINTING GOVERNING BODY OR COMMITTEE MEMBERS 11.1 The CCG considers on a case by case basis whether conflicts of interest should exclude individuals from being appointed to the governing body or to a committee or sub-committee of the CCG or governing body, as set out in the CCG s Constitution. Page 10 of 23

138 11.2 This includes an assessment of the materiality of the interest, in particular whether the individual (or a family member or business partner) could benefit from any decision the governing body might make. This will be particularly relevant for any profit sharing member of any organisation but will also be considered for all employees and especially those operating at senior or governing body level The extent of the interest also forms part of this consideration process. If it is related to an area of business significant enough that the individual would be unable to make a full and proper contribution to the governing body, that individual cannot become a member of the governing body Any individual who has a material interest in an organisation which provides, or is likely to provide, substantial services to the CCG (either as a provider of healthcare or commissioning support services) cannot be a member of the governing body if the nature of their interest is such that they are likely to need to exclude themselves from decision-making on so regular a basis that it significantly limits their ability to effectively operate as a governing body member. Specific considerations in relation to delegated commissioning of primary care are set out below DECISION-MAKING WHEN A CONFLICT OF INTEREST RISES: GENERAL APPROACHES 12.1 Where certain members of a decision-making body (be it the governing body, its committees or sub-committees, or a committee or sub-committee of the CCG) have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision making itself (i.e., not have a vote) The chair of the meeting has responsibility for deciding whether there is a conflict of interest and the appropriate course of corresponding action. In making such decisions, the chair will consult the member of the governing body who has responsibility for issues relating to conflicts of interest. All decisions, and details of how any conflict of interest issue has been managed, should be recorded in the minutes of the meeting and published in the registers The CCG will to decide in advance who will take the chair s role for discussions and decisionmaking in the event that the chair of a meeting is conflicted, or how that will be decided at a meeting where that situation arises Depending on the nature of the conflict, GPs or other practice representatives could be permitted to join in discussions by the governing body, or such other decision-making body as the CCG has created, about the proposed decision, but should not take part in any vote on the decision In many cases, e.g., where a limited number of GPs have an interest, it is straightforward for relevant individuals to be excluded from decision making. In the context of delegated commissioning, the committee structure set out below in relation to decision making for primary medical care has been designed to ensure that lay member and executive involvement ensures that robust decisions can be taken even where there are actual or potential conflicts of interest identified In some cases, all of the GPs or other practice representatives on a decision making body could have a material interest in a decision, e.g., where the CCG is proposing to commission services on a direct award basis from all GP practices in the area, or where it is likely that all or most practices would wish to be qualified providers for a service under AQP. Where such a situation relates to primary medical services, the arrangements set out below provide a Page 11 of 23

139 mechanism for decision-making For decision making where such a conflict arises and which are not covered by the primary medical care arrangements, the CCG adopts the following approach: where the initial responsibility for the decision does not rest with the governing body, refer the decision to the governing body and exclude all GPs or other practice representatives with an interest from the decision making process, i.e., so that the decision is made only by the non-gp members of the governing body including the lay and executive members and the registered nurse and secondary care doctor; where the decision rests with the governing body, consider a) requiring another of the Group s committees or sub-committees, which can be quorate to progress the item of business, or if this is not possible, b) Inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the Governing Body or committee/subcommittee in question) so that the Group can progress the item of business: i) A member of the Group who is an individual ii) An individual appointed by a member to act on its behalf in the dealings between it and the Group: iii) A member of a relevant Health and Wellbeing Board iv) A member of a Governing Body of another clinical commissioning group. ensure that rules on quoracy enable decisions to be made. These arrangements must be recorded in the minutes Specific issues and potential approaches in relation to delegated or joint commissioning of primary care are set out below DECISION-MAKING WHEN A CONFLICT OF INTEREST ARISES: PRIMARY MEDICAL CARE 13.1 Procurement decisions relating to the commissioning of primary medical services will be made by a committee of the CCG s governing body The membership of the committee has been constituted so as to ensure that the majority is held by lay and executive members, including non-gp clinical representatives (ie the CCG s secondary care specialist and Governing Body Nurse Lead) Any conflicts of interest issues will be considered on an individual basis. The specific composition is included in the terms of reference, and these ensure that the chair and vicechair must always be lay members of the committee A standing invitation will be made to the CCG s local Healthwatch and Health and Wellbeing Board to appoint representatives to attend commissioning committee meetings, including, where appropriate, for items where the public is excluded from a particular item or meeting for reasons of confidentiality. These representatives do not form part of the membership of the committee As a general rule, meetings of these committees, including the decision making and the deliberations leading up to the decision, will be held in public (unless the CCG has concluded it is appropriate to exclude the public). Page 12 of 23

140 13.6 The arrangements for primary medical care decision making do not preclude GP participation in strategic discussions on primary care issues, subject to appropriate management of conflicts of interest. They apply to decision making on procurement issues and the deliberations leading up to the decision RECORD KEEPING 14.1 As set out above a clear record of any conflicts of interest is kept by the CCG in its register of interests. It also records procurement decisions made, and details of how any conflicts that arose in the context of the decision have been managed. These registers are available for public inspection as detailed above The CCG ensures that details of all contracts, including the contract value, are published on its website as soon as contracts are agreed. Where the CCG decides to commission services through Any Qualified Provider (AQP), the information published on its website includes the type of services being commissioned and the agreed price for each service. Further, the CCG incorporates all such details in its annual report. Where services are commissioned through an AQP approach information is publicly available about those providers who qualify to provide the service ROLE OF COMMISSIONING SUPPORT 15.1 Commissioning support services (CSSs) can play an important role in helping the CCG to decide the most appropriate procurement route, undertake procurements and manage contracts in ways that manage conflicts of interest and preserve integrity of decision-making. The CCG receives appropriate assurance that a CSS business processes are robust and enable the CCG to meet its duties in relation to procurement (including those relating to the management of conflicts of interest) Where a CCG is undertaking procurement, one way to demonstrate that the CCG is acting fairly and transparently is for the CSSs to prepare and present information on bids, including an assessment of whether providers meet prequalifying criteria and an assessment of which provider provides best value for money A CCG cannot, however, lawfully delegate commissioning decisions to an external provider of commissioning support. Although CSSs are likely to play a key role in helping to develop specifications, preparing tender documentation, inviting expressions of interest and inviting tenders, the CCG itself: determines and signs off the specification and evaluation criteria; decides and signs off decisions on which providers to invite to tender; and makes final decisions on the selection of the provider. Page 13 of 23

141 ANNEXES Annex 1: Annex 2: Annex 3: Annex 4: Declaration of Conflict of Interests for Bidders /Contractors Template Declaration of Interests for Members /Employees Template Procurement Template Relevant Legislation and Guidance Page 14 of 23

142 Annex 1: Declaration of conflict of interests for bidders/contractors template NHS Dudley Clinical Commissioning Group Bidders/potential contractors/service providers declaration form: financial and other interests This form is required to be completed in accordance with the CCG s Constitution, and s140 of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and the NHS (Procurement, Patient Choice and Competition) (No2) Regulations 2013 and related guidance Notes: All potential bidders/contractors/service providers, including sub-contractors, members of a consortium, advisers or other associated parties (Relevant Organisation) are required to identify any potential conflicts of interest that could arise if the Relevant Organisation were to take part in any procurement process and/or provide services under, or otherwise enter into any contract with, the CCG, or with NHS England in circumstances where the CCG is jointly commissioning the service with, or acting under a delegation from, NHS England. If any assistance is required in order to complete this form, then the Relevant Organisation should contact the Governance Support Manager. The completed form should be sent to the Governance Support Manager. Any changes to interests declared either during the procurement process or during the term of any contract subsequently entered into by the Relevant Organisation and the CCG must notified to the CCG by completing a new declaration form and submitting it to the Governance Support Manager. Relevant Organisations completing this declaration form must provide sufficient detail of each interest so that the CCG, NHS England and also a member of the public would be able to understand clearly the sort of financial or other interest the person concerned has and the circumstances in which a conflict of interest with the business or running of the CCG or NHS England (including the award of a contract) might arise. If in doubt as to whether a conflict of interests could arise, a declaration of the interest should be made. Interests that must be declared (whether such interests are those of the Relevant Person themselves or of a family member, close friend or other acquaintance of the Relevant Person), include the following: the Relevant Organisation or any person employed or engaged by or otherwise connected with a Relevant Organisation (Relevant Person) has provided or is providing services or other work for the CCG or NHS England; a Relevant Organisation or Relevant Person is providing services or other work for any other potential bidder in respect of this project or procurement process; the Relevant Organisation or any Relevant Person has any other connection with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG s or any of its members or employees judgements, decisions or actions. Page 15 of 23

143 Declarations: Name of Relevant Organisation Interests Type of Interest Details Provision of services or other work for the CCG or NHS England Provision of services or other work for any other potential bidder in respect of this project or procurement process Any other with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or otherwise influence the CCG s or any of its members or employees judgements, decisions or actions Name of Relevant Person Complete for all relevant persons Interests Type of Interest Details Personal interest or that of a family member, close friend or other acquaintance? Provision of services or other work for the CCG or NHS England Provision of services or other work for any other potential bidder in respect of this project or procurement process. Any other with the CCG or NHS England, whether personal or professional, which the public could perceive may impair or Page 16 of 23

144 otherwise influence the CCG s or any of its members or employees judgements, decisions or actions To the best of my knowledge and belief the, the above information is complete and correct. I undertake to update as necessary the information. Signed On behalf of Date.. Page 17 of 23

145 Annex 2: Declaration of interests for members/employees template Declaration of Interest for Members/Employees This form is required to be completed in accordance with the CCG s Constitution and section 14O of The National Health Service Act 2006, the NHS (Procurement, Patient Choice and Competition) regulations 2013 and the Substantive guidance on the Procurement, Patient Choice and Competition Regulations Notes: The CCG must make arrangements to ensure that the persons mentioned above declare any interest which may lead to a conflict with the interests of the CCG and /or NHS England and the public for whom they commission services in relation to a decision to be made by the CCG and/or NHS England or which may affect or appear to affect the integrity of the award of any contract by the CCG and/or NHS England. A declaration must be made of any interest likely to lead to a conflict or potential conflict as soon as the individual becomes aware of it, and within 28 days. If any assistance is required in order to complete this form, then the individual should contact the Governance Support Manager. The completed form should be sent by both and signed hard copy to the Governance Support Manager. Any changes to interests declared must also be registered within 28 days by completing and submitting a new declaration form. The register will be published on the CCG s public website at Any individual and in particular members and employees of the CCG and/or NHS England- must provide sufficient detail of the interest, and the potential for conflict with the interests of the CCG and/or NHS England and the public for whom they commission services, to enable a lay person to understand the implications and why the interest needs to be registered. If there is any doubt as to whether or not a conflict of interest could arise, a declaration of interest must be made. As part of the CCGs Standards of Business Conduct, members are requires to declare their interest in accordance with the guidelines overleaf. Please detail a personal interest OR that of a family member, close friend of other acquaintance. Page 18 of 23