Council of Governors Meeting DRAFT. Thursday, 2 February Eaglescliffe Golf Club

Transcription

1 Council of Governors Meeting Thursday, 2 February 2017 Eaglescliffe Golf Club

2 PG/BB January 2017 Dear Colleague A meeting of the Council of Governors will be held on Thursday, 2 February 2017 at 10.00am at Eaglescliffe Golf Club, Yarm Road, Eaglescliffe, Stockton on Tees, TS16 0DQ. Refreshments will be served from 9.30am. Free car parking is available. Yours sincerely Paul Garvin Chairman (1) 9.30am Refreshments Agenda (2) 10.00am Welcome Chairman (3) 10.00am Apologies for Absence Chairman (4) 10.00am Declaration of Interests (5) 10.05am Minutes of the last meeting held on 24 November 2016 (enclosed) Chairman (6) 10.10am Matters Arising Chairman (7) 10.15am Chairman s Report and Board Business (BoD agenda enclosed) Chairman (8) 10.30am Chief Executive s Report (enclosed) Alan Foster (9) 10:50am Outcome of Governor Elections 2016 (enclosed) Barbara Bright (10) 11.00am Register of Interests (enclosed) Barbara Bright 11.05am Comfort Break (11) 11.15am Integrated Performance Report (enclosed) Julie Gillon (12) 11.45am Council of Governors Sub-committee Membership Review Barbara Bright (enclosed)

3 (13) 11.50am Sub-Committee Minutes (enclosed) (13.1) Membership Strategy Committee Minutes Wendy Gill 21 November 2016 (13.2) Strategy and Service Development Committee Minutes Steven Yull 19 December 2016 (14) 12.00noon Any Other Notified Business Chairman Date and Time of Next Meeting The next meeting is scheduled to take place on Thursday, 11 May 2017 at The Centre for Excellence in Teaching and Learning, Brierton Lane, Hartlepool, TS25 4BY

4 Governors Roles and Responsibilities Holding the Board of Directors to Account 1. Key Principles 1.1 The overall responsibility for running an NHS Foundation Trust lies with the Board of Directors. 1.2 The Council of Governors is the collective body through which the directors explain and justify their actions. 1.3 Governors must act in the interests of the NHS Foundation Trust and should adhere to its values and Code of Conduct. 2. Standard Methods for Governors to Provide Scrutiny and Assistance 2.1 Receiving the Annual Report and Accounts. 2.2 Receiving the Quality Report and Account. 2.3 Receiving in-year information updates from the Board of Directors. 2.4 Receiving performance appraisal information for the Chair and other Nonexecutive Directors. 2.5 Inviting the Chief Executive or other Executive and Non-executive Directors to attend the Council of Governors meetings as appropriate. 3. Further Methods Available for Governors 3.1 Engagement with the Board of Directors to share concerns. 3.2 Employment of statutory duties. 3.3 Dialogue with Monitor via the lead Governor (if necessary and only in extreme circumstances)

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

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

7 Present: Paul Garvin, Chairman North Tees and Hartlepool NHS Foundation Trust Minutes of the Council of Governors Meeting held on Thursday, 24 November 2016 at Eaglescliffe Golf Club Hartlepool Elected Governors: Pauline Robson Alan Smith Maureen Rogers Stockton Elected Governors: James Newton Mary Morgan Kate Wilson Janet Atkins Tony Horrocks Val Scollen Ann Cains Margaret Docherty Non-Core Elected Governor: Alison McDonough In attendance: Julie Gillon, Chief Operating Officer/Deputy Chief Executive Caroline Trevena, Director of Finance Deepak Dwarakanath, Medical Director Ann Burrell, Director of Human Resources and Education Julie Lane, Director of Nursing, Patient Safety and Quality Graham Evans, Chief Information and Technology Officer Peter Mitchell, Director of Estates and Facilities Rita Taylor, Non-Executive Director/Senior Independent Director Steve Hall, Non-Executive Director Kevin Robinson, Non-Executive Director Barbara Bright, Company Secretary Raechel George, Freedom of Information Lead Easington Elected Governors: Mary King Sedgefield Elected Governor: Wendy Gill Staff Elected Governors: Carol Alexander Manuf Kassem Matt Wynne Steven Yull Partnership Governors: Angela Warnes, Teesside University Jim Beall, Stockton-on-Tees Borough Council CoG/687 Welcome The Chairman welcomed members to the meeting. CoG/688 Apologies for Absence Apologies for Absence were reported from: Alan Foster, Chief Executive, Brian Dinsdale, Non- Executive Director, Jonathan Erskine, Non-Executive Director, John Edwards, Elected Governor for Stockton, Pat Upton, Elected Governor for Stockton, Mark White, Elected Governor for Stockton, Tom Sant, Elected Governor for Hartlepool, Roger Campbell, Elected Governor for Hartlepool, George Lee, Elected Governor for Hartlepool, Deborah Gardener, Elected Staff Governor, Gary Wright, Elected Staff Governor, Simon Forrest, Appointed Governor for Durham University, Morris Nicholls, Appointed Governor for Durham County Council and Dave Hunter, Appointed Governor for Hartlepool Borough Council. 1

8 CoG/689 Declaration of Interest There were no declarations of interest received on open agenda items. CoG/690 Minutes of the last meeting held on 29 September 2016 The minutes of the last meeting were signed by the Chairman as a true record. CoG/691 Matters arising There were no matters arising. CoG/692 Chairman s Report and Board Business a. Consultants Appointments The Chairman reported that an offer of employment had been made to appoint a Consultant Neonatologist and that the Trust were awaiting confirmation of him accepting the post. b. Annual General Meeting 2016 The Chairman placed on record his thanks to Governors and members of the Board of Directors who attended the Trust s Annual General Meeting on Wednesday, 5 October The meeting and presentations provided a comprehensive overview of the work the Trust had done over the past year and its plans for the current year. c. Meetings The Chairman reported that he had met with Foundation Trust Chairs on 13 October 2016 where most of the discussion was around Sustainability and Transformation Plans (STP). Some of the Chairs felt excluded or unaware of progress but he highlighted that the Trust were fortunate in that Chief Executive and STP Lead for the footprint, Alan Foster kept the Board of Directors and Council of Governors up-to-date. d. Collaborative Working The Chairman reported that he and the Chief Executive had met with the Chairs and Chief Executives of South Tees Hospitals and County Durham and Darlington NHS Foundation Trusts on 17 October 2016 with a view to establishing a Committee in Common which would fully engage in the STP process and allow the Trusts to make some decisions together. The Committee in Common had no legal basis but would provide a forum for discussion and agreement on key areas which needed to be achieved. The Chairman reported that any decisions taken in respect to the STP would need to be based on robust evidence and be clinically focussed and led. He confirmed that the work that the Chief Executive was leading on was ahead in its thinking and planning, however, delivery would be challenging and difficult. A number of questions were posed by members and discussion ensued in respect to future configuration of hospitals and services; decision making criteria; and public information, engagement and consultation. Jim Beall, Appointed Governor for Stockton-on-Tees Borough Council reported that a network had been established of the five Tees Valley Health and Wellbeing Boards in order to ensure a joined up approach to STP, with an invite to join the group going to North Yorkshire and Durham and also the Chief Executive as the STP lead. 2

9 The Chairman confirmed that a Governor development session would be held on 5 December 2016 where the Chief Executive would present and provide further detail around the STP. e. PricewaterhouseCoopers event The Chairman reported that he had attended an event hosted by PricewaterhouseCoopers (PwC) on 17 November 2016, which included a number of keynote speakers. A presentation was given by Alan Milburn, former Secretary of State who was undertaking work with PwC on behalf of the Department of Health, on proposals for the development of health and social care. f. National Institute for Health Research The Chairman reported that the Trust had achieved the criteria for continuous improvement in relation to the return rate on research improving from 39% to 79% in 6 months and as a result, had been recognised for an award by the National Institute for Health Research, g. Visit of Mayor of Stockton The Chairman reported that he, the Medical Director and Professor Matt Rutter, Consultant Gastroenterologist had accompanied the Mayor of Stockton on a visit to the Bowel Screening department on 23 November As part of the charitable work of his year in office, the Mayor was supporting this important area of screening by raising funds and public awareness. Jim Beall, Appointed Governor for Stockton-on-Tees Borough Council confirmed that joined up working and public awareness was required in this area of screening and advised that support could be provided through public health and partnership meetings. h. Board of Directors Meeting A copy of the agenda for the Board of Directors Meeting on Thursday, 1 December 2016 had been circulated and Governors were welcome to attend. CoG/693 Resolved: that, the information be noted. Deputy Chief Executive s Report a. Sustainability and Transformation Plan (STP) The DCE/COO referred to the information in the report and previous discussions in respect of the development of the STP for the Durham, Darlington, Tees, Hambleton, Richmondshire and Whitby (DDTHRW) footprint. b. NHS Operational Planning and Contracting Guidance 2017/2019 The Chief Operating Officer/Deputy Chief Executive reported that NHS England and NHS Improvement had jointly published Operational Planning and Contracting Guidance three months earlier than anticipated to assist local organisations to plan more strategically. For the first time, the Planning Guidance covered two financial years, to provide greater stability and to support transformation. This was underpinned by a two-year tariff and two-year NHS Standard Contract with the objective to provide local NHS organisations with an update on the national priorities for 2017/18 and 2018/19, as well as updating on longer term financial challenges for local systems. The nine must-do priorities published in 2016/17 remained the priorities for the next two years and the planning process had been built around STPs. The Chief Operating Officer/Deputy Chief Executive reported that an initial draft of the plan required submission on 24 November 2016, with the final submission by 23 December

10 c. NHS Improvement Event 4 November 2016 Relentless Delivery and Making Change Happen The Chief Operating Officer/Deputy Chief Executive reported that she, the Chairman and the Chief Executive had attended an event led by NHS Improvement on 4 November This reflected on quarters 1 and 2 and looked at key deliverables in the forthcoming months. The Chief Operating Officer/Deputy Chief Executive highlighted the challenges around delivery, which centred the discussion at the event. d. Hartlepool and Stockton Health (HaSH) GP Federation Business Plan Launch The Chief Operating Officer/Deputy Chief Executive reported that Hartlepool and Stockton Health (HaSH) (GP federation) had launched its business plan, in addition to providing an opportunity to discuss a response to the Hartlepool Matters! Shaping the Future of Health and Social Care in Hartlepool report produced by Professor David Colin-Thomé, Independent Chair. The Hartlepool Matters! report was opened up for public review on the evening of 26 September 2016 and was considered by the Health and Wellbeing Board, the Clinical Commissioning Group (CCG) and the full Hartlepool Borough Council during October It was agreed that the Council would formulate an action plan in partnership with the CCG and an implementation group would be created to oversee delivery of the plan. The discussion and debate, with regard to the Hartlepool Matters! report, although extensive, would require further consideration as to a response and as to the collective responsibility of the approach in the wider Federation. The Trust continued to work in close collaboration with the Directors of HaSH with positive outcomes around planning for the needs and challenges of the population it served and in keeping with the strategic approach of the Board of Directors, in the wider context of the STP. CoG/694 Resolved: that, the information be noted. Integrated Performance Report The Chief Operating Officer/Deputy Chief Executive presented the Integrated Performance Report incorporating key compliance, sustainability and transformation planning, quality, workforce and financial information for September 2016 and quarter 2. The A&E 4 hour standard saw an improved position in September and quarter 2, achieving 95.06% and 95.64% respectively, which had continued in October reporting at 96.36%. In respect of the incomplete referral to treatment pathway standard, the Trust remained above the national position at 92.39% for September and 92.59% for quarter 2. The October position showed further improvement reporting at above 93%, which was testament to the progress and improvements with information flows and Trakcare. All of the cancer standards had been achieved with the exception of the cancer 62 day referral to treatment standard for September and quarter 2, achieving 83.19% and 83.14% respectively. The position for October was greatly improved with the Trust reporting at over 90% and the Chief Operating Officer/Deputy Chief Executive noted that there had been a rise in numbers converting to cancer with 58 in comparison to 48 for the same period last year. The Trust had achieved the 6 week diagnostic standard at 99.57% for quarter 2 and had been successful in a bid for funding that would support improvements in activities such as preassessment and endoscopy, waiting times, with additional work on-going to improve access to patient information and GP liaison. 4

11 The latest position indicated that the Trust was performing well within benchmarks against a number of operational efficiency standards, including outpatient new and review ratios, length of stay and pre-op stays. Outpatient did not attend (DNA) were still a challenge to the Trust and were reporting above the internal standard for both new and review appointments, though a downward trend was noted. Bed occupancy rates continued to report above the national recommendation of 82%, indicative of continued pressures within the organisation and across the system. The Safety and Quality Dashboard, was presented as part of the integrated report which is aligned to the Care Quality Commission s (CQC) five domains: Safe, Caring, Effective, Responsive and Well-Led and brings together all of the key indicators and trend analysis. The Trust had exceeded its annual trajectory of 13 cases for Clostridium Difficile with 19 cases between April and September One case of MRSA had also been reported. The overall would recommend the Trust friends and family responses had increased to 95.47% in September from 94.88% in August. The latest HSMR value was (August 2015 to July 2016), which had shown a slight increase from (July 2015 to June 2016), though remained within the as expected range. The SHMI position had continued to reduce from to (April 2015 to March 2016). The Registered Nursing/Midwife fill rates had decreased to 79.11% from 79.50%, however, it was noted that this remained above the 75% expected fill rate to maintain safe staffing. The highlights from the HR, Workforce and Organisational Development dashboard were presented, including the Trust headcount which reported 81 more staff in September 2016 than in September 2015, however was 27 less when compared to the baseline of 31 March Sickness absence reported in September was 4.63%, which showed an increase of 0.04% when compared to August; however it was 0.33% higher when compared to the same period the previous year. The long term sickness absence rate in September saw an increase of 0.45% compared to the previous year. The cost of sickness absence had increased again during the months of June and July but then decreased for the following two months of August and September. A high level overview of the financial position across directorate performance, transformation and continuity of services risk rating was provided. Following a member s query over DNAs, the Chief Operating Officer/Deputy Chief Executive outlined the process in place and work underway to address and improve the position and the need to closely work with the referring GP. It was reported that cancellations were not included as DNAs, however, this position was also under review to ensure that patients were seen in a safe and timely manner. A member raised the issue of DNAs for children and the steps being taken to address this issue. The Chief Operating Officer/Deputy Chief Executive reported that this is an area of concern as the highest number of DNAs could be attributed to children and that the Trust ensured everything was done so that the child was seen appropriately. The process involved staff and key stakeholders across multi-disciplinary teams to ensure a joined up approach. The Director of Nursing, Patient Safety and Quality advised that where the DNAs related to children the casenotes were reviewed by a clinician in order to identify any potential safeguarding issues which would then be addressed through the safeguarding team. In relation to a query on the flu vaccination, the Director of Estates and Facilities reported on the current campaign that the Trust was running to maximise uptake of the vaccine amongst staff, 5

12 which included senior management encouragement, ward vaccinators, daily clinics and a flu video/song. To date, 50% of front line staff had received the vaccination, an increase of 8% on last year and to meet the national target threshold of 60%, a further 500 staff needed to be vaccinated. Following a members query on temporary staffing costs, the Director of Finance reported that yearon-year the agency spend was running at a similar level, however, a number of initiatives had been introduced which would have a positive impact on expenditure. A Temporary Staffing Manager and Senior Rota Maker had recently been appointed, which would have a significant impact on the management of temporary and locum staffing, with a proactive approach being adopted. A specific query was raised in respect to Pathology and the Director of Finance reported that due to vacant posts and some business issues, there had been a reliance on agency and locums to cover gaps and ensure continuity of service. Work was underway to address these concerns with a reduction in spend expected over the coming months. A member raised recent press coverage in relation to staff shortages in Pathology and the Medical Director confirmed that this was a national issue with a shortage of skilled staff especially at Consultant level. The Trust had been actively recruiting and had reviewed staffing establishments and skill mix in order to address shortfalls by developing non-medical staff resources. A member raised the recent press coverage in relation to the Trust position nationally, for the time it takes for stroke patients to get vital brain scans. The Medical Director confirmed the Trust provides a 24/7 CT service for stroke patients and that the Stroke Unit was highly regarded for the services on offer. He expressed concern over the validity and accuracy of the data that had been released and had instigated an investigation and audit to review this. It was confirmed that the Trust complied with NICE guidance criteria and had made changes to referral forms to ensure critical scans were undertaken within timescales. Steve Hall, Non-Executive Director, provided assurance that issues identified were taken seriously and monitored through the Patient Safety and Quality Standards Committee. Kevin Robinson, Non-Executive Director raised a point of clarity with regards to the position on the 62 day cancer standard and the challenges in achieving the target. The Chief Operating Officer/Deputy Chief Executive confirmed that work was undertaken to ensure breaches were the exception, which included involvement with the national Improvement Team, proactively following up DNA s and achieving the initial 2 week standard. The Trust managed this standard well however, due to the need to refer to Tertiary centres and work closely with GP s, there were system wide issues in achieving the standard, which required system wide approaches and leadership to address. A service level agreement had been developed to ensure appropriate management of patients through the patient pathway where more than one organisation was involved, and commissioner support had been requested to successfully implement. A query was raised regarding the recent press coverage on the production of passports to ensure eligibility to receive treatment. The Chairman confirmed that the Trust had robust systems in place to manage overseas visitors, which had been communicated to Governors previously via a development session. A key issue was passports and proof of nationally did not necessarily provide the detail required to prove eligibility for healthcare, as residency was also a factor in the decision making process. Resolved: (i) that, the report be noted; (ii) that, the current position and performance against key standards be noted; and (iii) that, an update on the Trust position for stroke patients be provided at the next meeting. CoG/695 Single Oversight Framework The Chief Operating Officer/Deputy Chief reported on the new Single Oversight Framework, which came into effect on 1 October and replaced Monitor s Risk Assessment Framework and the Trust 6

13 Development Authority s Accountability Framework. The Framework required monthly reporting instead of quarterly and sets out the levels of support that provider organisations would receive based upon their level of performance in 5 areas, which were referred to as themes. The Trust had been assessed as segment 2 emerging concerns/minor issues. It was noted that 45% of Trusts were in segment 2, and 43% in segment 3. The Chief Operating Officer/Deputy Chief reported that as part of the new process the Trust would be happy to accept and engage with support that is offered by NHS Improvement in order to bring about improvements in any of the standards. The new framework suggested an improved relationship between the Care Quality Commission (CQC) and NHS Improvement regulation with more defined areas of monitoring and responsibilities, and aimed to help providers achieve or maintain a CQC rating of good or outstanding. Resolved: that, the report be noted. CoG/696 Update on Governor Elections 2016 The Company Secretary provided a verbal report on the outcome of the 2016 Governor Elections that had concluded on 18 November There were nine public and two staff vacancies; following the nomination stage, with Sedgefield being the only Constituency which went out to public ballot. Electoral Reform Services (ERS) had conducted the elections as the Returning Officer, and it was noted that a problem had been encountered with the dispatch of ballot papers to some Stockton members following an incorrect mapping exercise. This was rectified and to ensure a valid process, no ballots from ineligible members were counted in the final return. The vacancies were filled as follows: Stockton Hartlepool Margaret Docherty (re-elected) Tom Sant (re-elected) Val Scollen (re-elected) Pauline Robson (re-elected) Raymond Stephenson Staff Easington 2 vacancies Mary King (re-elected) John Doyle (2 years) Sedgefield 1 vacancy Wendy Gill (re-elected) Resolved: that, the information be noted CoG/697 Sub-Committee Minutes a. Draft Nominations Committee Minutes The Company Secretary presented the minutes of the Nominations Committee which was held on 15 September 2016 and highlighted the key points. b. Draft Membership Strategy Committee Minutes Wendy Gill, Elected Governor for Sedgefield presented the minutes of the Membership Strategy Committee which was held on19 September 2016 and highlighted the key points. c. Draft Strategy and Service Development Committee Minutes Steven Yull, Elected Staff Governor presented the minutes of the Strategy and Service Development Committee which was held on 19 September 2016 and highlighted the key points. 7

14 Resolved: that, the information be noted. CoG/ Council of Governors Schedule of Meetings, including Sub-Committees and Development Sessions The Company Secretary provided the 2017 Council of Governors Schedule of Meetings for information. Resolved: that, the information be noted. CoG/699 Any Other Business The Chairman reported that Mary Morgan s term of office would come to an end on 30 November 2016 and that this was her last Council of Governors meeting. He thanked Mary, who had joined the Trust as a Governor in 2007, for her commitment and contribution to the Trust over the years and wished her well for the future. The Chairman reported that the terms of office for Debbie Gardner and Matt Wynne, Staff Governors, would also end on 30 November 2016, thanking them for their support and contribution and expressing his hope that they may stand again in the future. The Chairman reported that Angela Warnes, Appointed Governor for the University of Teesside, would be retiring in December Although only a member of the Council of Governors for the last year, he thanked her for her involvement and support during this time and hoped that she would maintain an interest with the Trust as a member for the out of area constituency. The Chairman reported that the Governor Christmas lunch had been organised for Wednesday 7 December 2016 in the Tees Meeting Room at North Tees. CoG/700 Date and Time of Next Meeting The next meeting was due to be held on Thursday, 2 February 2017 at Eaglescliffe Golf Club. The meeting closed at 12.00noon Signed: Date: 8

15 North Tees and Hartlepool NHS Foundation Trust Meeting of the Council of Governors 2 February 2017 Chairman s Report Report of the Chairman Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Manage Our Relationships Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Effective Board Governance 1. Introduction 1.1 The Chairman s Report aims to provide information to the Council of Governors on key local, regional and national issues. 2. Key Issues and Planned Actions 2.1 Alan and I met with the Chairs and Chief Executives of South Tees Hospitals NHS Foundation Trust and County Durham and Darlington NHS Foundation Trust. To progress collaborative working, it was agreed that a Committee in Common be established with Terms of Reference to be agreed by all Trusts. This will provide a form of governance around the STP and decision making forum within the Terms of Reference for the Committee in Common. A proposal was made that Paul Keane, Chair of County Durham and Darlington NHS Foundation Trust, Chair the Committee in Common. I wish to notify the Council of Governors that Deborah Jenkins from South Tees Hospitals NHS Foundation Trust has stood down as Chair and that Amanda Hullick will be fulfilling this role as an interim arrangement. 2.2 I attended the HFMA Chairs conference in London where some really interesting presentations were given as follow up to the Carter Report where they are now looking at unwarranted variations against the model hospital and developing a table of weighted activity units which will allow Trusts to benchmark against each other. STPs are clearly at different stages of development around the country and our STP does appear to have made more progress than many but there were still many concerns over place based regulations. 2.3 The Trust has been assessed against the NHS Standard of Procurement Assessment at level 1 which is ten months ahead of the Carter requirement. We are only the second Trust in the country to achieve this standard, the first being Newcastle Hospitals NHS Foundation Trust. I wish to place on record my thanks to Jane Hawkes, Head of Procurement & Supplies & Scan4Safety Program Lead, her team and Brian Dinsdale, Non-Executive Director.

16 2.4 I attended the NHS Providers conference in Birmingham in November. This concentrated on the shortage of money and the degree of financial challenge in the NHS. It was noted that it was impossible to continue the breadth of the current NHS offer within the money available. The Secretary of State spoke to the conference but was unusually subdued and appeared not to like the message of the impossibility of the challenge. 3. Recommendations 3.1 The Council of Governors is asked to note the content of this report. Paul Garvin Chairman

17 PG/BB February 2017 Dear Colleague A meeting of the Board of Directors will be held on Thursday, 30 March 2017 at 1:00 pm in the Boardroom, University Hospital of North Tees. Yours sincerely Paul Garvin Chairman Agenda Led by 1. (1.00pm) Apologies for absence Chairman 2. (1.00pm) Declaration of Interest Chairman 3. (1.00pm) Minutes of the meeting held on, 26 January 2017 (enclosed) Chairman 4. (1.05pm) Matters Arising Chairman Items for Information 5. (1.10pm) Chairman s Report (enclosed) Chairman 6. (1.20pm) Chief Executive s Report (enclosed) A Foster Quality 7. (1.30pm) Safety, Quality and Infection Prevention Report (enclosed) J Lane

18 Performance Management 8. (1.40pm) Compliance and Performance Report (enclosed) J Gillon 9. (1.50pm) Finance and Contract Performance Report, C Trevena as at 28 February 2017 (enclosed) 10. (2.00pm) Human Resources and Education Report Quarter 3: 2016/17 A Burrell (enclosed) Governance 11. (2.10pm) Annual Operational Plan (enclosed) J Gillon/ C Trevena 12. (2.20pm) Any Other Notified Business Chairman 13. Date of Next Meeting (Thursday, 27 April 2017, Boardroom, University Hospital of Hartlepool)

19 North Tees and Hartlepool NHS Foundation Trust Meeting of the Council of Governors 2 February 2017 Chief Executive s Report Report of the Chief Executive Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Manage Our Relationships Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Effective Board Governance 1. Introduction 1.1 The Chief Executive s Report aims to provide information to the Council of Governors on key local, regional and national issues. 2. Key Issues & Planned Actions 2.1 Work continues on the development of the Sustainability and Transformation Plan (STP) which will lead to the development of a business case in order to secure the capital needed to support any proposed service changes. I continue to be invited to various Health and Wellbeing Boards, scrutiny meetings and other stakeholder meetings in order to provide updates and this engagement will continue to gather pace. All STP leaders have been personally invited to a development session led by Simon Stevens, Chief Executive of NHS England and Jim Mackey, Chief Executive of NHS Improvement on 30 and 31 January 2017 in London. This will provide an opportunity to take stock nationally and get additional feedback on the next steps in the process. 2.2 As the Council of Governors are aware, the Trust is leading on the Scan4Safety project along with 6 other Trusts in order to implement this national initiative. I wish to inform the Council of Governors that the Trust has now completed Phase two of the Scan4Safety programme. This has seen the introduction of GS1 identifiers on patient wristbands, within the Trust s purchasing systems to capture product details, and on all room locations. A point of care technical solution prototype has been built and is currently being tested in order to scan, capture and validate this information. Implementation of the Scan4Safety Programme is being undertaken in four phases. As I write this report I have been invited to speak at the national Scan4Safety Leadership Conference to give a Chief Executive perspective. I will report back to the Council of Governors on this at the next meeting. 2.3 The NHS continues to be under severe operational pressure and this has been played out in the national news everyday. We have seen an increase in attendances at Accident and Emergency and an increase in emergency admissions to hospital and as the winter period continues to bite, I anticipate that this pressure will continue to increase during the coming weeks. 1

20 I wish to reassure the Council of Governors that our operational winter plans are working effectively and that we have opened additional beds in cope with demand and that this is under constant review. Patient safety and dignity remains at the forefront of our thinking and this will not be compromised despite having a very challenging financial target to deliver. Although we have had to cancel some elective/planned surgery, I wish to reassure the Council of Governors that we have not cancelled any cancer surgery as a result of this. 2.4 In early January the Trust achieved accreditation with the Nursing and Midwifery Council to establish a North Tees and Hartlepool Nursing Academy in collaboration with Sunderland University. Whilst the programme will be delivered by Sunderland University the clinical placements will be within the organisation. Students are being recruited and we will welcome the first cohort of 20 to the organisation in April 2017 with a second cohort to be recruited ready for September Recommendations The Council of Governors are asked to note the content of this report. Alan Foster Chief Executive 2

21 North Tees and Hartlepool NHS Foundation Trust Meeting of the Council of Governors 2 February 2017 Outcome of Governor Elections 2016 Report of the Company Secretary Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance 1. Introduction This report presents the outcome of the Governor Elections that were carried out to fill the vacant seats from December Background There were nine Public Governor and two Staff Governor vacancies to fill and following the nomination stage, only the vacancy in the Sedgefield constituency went out to public ballot with the other constituencies uncontested. The elections were conducted in accordance with the rules and constitutional arrangements as set out by the Trust s Constitution using the Single Transferable Vote electoral system. Electoral Reform Services (ERS) were employed to assist the Trust for the purposes of this round of elections and conducted the elections as the Returning Officer. It was noted that a problem had been encountered with the dispatch of ballot papers to some Stockton members following an incorrect mapping exercise. This issue was rectified and ERS confirmed that they are satisfied that the resulting process was in accordance with accepted good electoral practice. 3. Election Results The Election round closed on 18 November 2016 at 5.00pm and the Trust were notified of the results on 21 November The following candidates were elected with effect from 1 December 2016:- 3.1 Hartlepool Constituency (2 Governor vacancies) Thomas Sant Pauline Robson (re-elected) (re-elected) 1

22 3.2 Stockton Constituency (3 Governor vacancies) Margaret Docherty Val Scollen Raymond Stephenson (re-elected) (re-elected) (declined the seat, now vacant) 3.3 Easington Constituency (3 Governor vacancies) Mary King John Doyle One seat remains vacant (re-elected) (2 years) 3.4 Sedgefield Constituency (1 Governor vacancy Wendy Gill (re-elected) 3.5 Staff (2 Governor vacancies) No nominations, two seats remain vacant 3.6 Terms of Office All Governors were elected to a term of office of 3 years unless otherwise specified. 4. Recommendation The Council of Governors are asked to: Note the outcome of the 2016 Governor Elections. Barbara Bright Company Secretary 2

23 North Tees and Hartlepool NHS Foundation Trust Meeting of the Council of Governors 2 February 2017 Executive Summary Register of Interests Report of the Company Secretary Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governor Reports) Maintain Compliance and Performance Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governor Reports) Maintain Compliance and Performance 1. Introduction 1.1 In accordance with Annex 6, of the Trust s Constitution the Council of Governors are required to declare interests that may conflict with their position as a Governor of the Trust. Interests are to be recorded in a register which is available for inspection on request. 1.2 The requirement for directors and governors to meet a fit and proper persons test is already included in Monitors provider licence for NHS Foundation Trusts and the Trust s Constitution, section 12, identifies the criteria as to why Governors may not become or continue as a member of the Council of Governors. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) introduced a new fit and proper person test from 27 November 2014 which broadened the requirements in terms of scope and nature of the test. As good practice the Trust ensures that fit and proper person declarations will be completed on an annual basis for both Governors and Directors, and recorded in the register. 1.3 A copy of the register is attached to this report. 2. Recommendations The Council of Governors is requested to: note the contents of the appended updated register; and note that the register will be referred to in the Annual Report and Accounts 2016/17. Barbara Bright Company Secretary 1

24 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Thomas Sant Public Governor (Hartlepool constituency) Maureen Rogers Public Governor (Hartlepool constituency) Pauline Robson (Hartlepool constituency) Alan Smith (Hartlepool constituency) George Edward Lee (Hartlepool constituency) None None None Director / Trustee Hartlepool Voluntary Development Agency None None None None None None None None None None None None None None None None None None None None Member of Executive Committee (Voluntary) Durham Association of Boys and Girls Clubs Chairman of Board (Voluntary) Central Estate Management Organisation, Hartlepool 1

25 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Roger Campbell (Hartlepool constituency) None None None None Member of Tenants Consultative Council Thirteen Group Ltd Non-voting Director of Housing Hartlepool Ltd 2

26 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Janet Atkins Public Governor (Stockton constituency) Kate Wilson Public Governor (Stockton constituency) Patricia Upton Public Governor (Stockton constituency) James Newton Public Governor (Stockton constituency) Ann Cains Public Governor (Stockton constituency) None None None None Volunteer Community Health Ambassador DoH/HaST CCG None None None None None None None None None None None None None None None None None None None Chair of Patients Group, Norton Medical Centre 3

27 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Margaret Docherty Public Governor (Stockton constituency) John Edwards Public Governor (Stockton constituency) Tony Horrocks Public Governor (Stockton constituency) None None None None Member of patient group, Norton Medical Centre P&I Design Ltd Joint Owner and Director (Engineering Consultancy business) P&I Design Ltd Joint Owner and Director (Engineering Consultancy business) Member of NHS Podiatry patient group, One Life Centre Volunteer Community Health Ambassador DoH/HaST CCG None None None None None None Treasurer Teesside Samaritans None 4

28 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Mark White (Stockton constituency) Val Scollen (Stockton constituency) Director Association of Colleges and Education and Training Foundation None None Trustee The Halo Project Member of Labour Party and Unison Chair of Abingdon Primary School, Middlesbrough Chair Stockton Riverside College Visiting Fellow Teesside University None None None None Board Member Billingham Environmental Link Programme Board Chair & Director Billingham Community Newspaper Member of Council Thirteen Housing Group 5

29 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Mrs Mary King Public Governor (Easington constituency) Mr John Doyle Public Governor (Easington constituency) None None None None None None None None None None 6

30 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Dr Wendy Gill Public Governor (Sedgefield constituency) None None None None None 7

31 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Mrs Alison McDonough Public Governor (Non-core constituency) Director of Small Business Matters (Northern) Ltd (Consultancy Business) Chief Executive of Sunderland Live Ltd (Events Company) None None None None 8

32 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Mrs Carol Alexander (Staff Governor) Mr Manuf Kassem (Staff Governor) Steven Yull (Staff Governor) Gary Wright (Staff Governor) None None None None None None None None None None None None None None Union Steward Royal College of Nursing None None None None None 9

33 Declaration of Interest by Council of Governors of North Tees and Hartlepool NHS Foundation Trust Name Directorship including nonexecutive directorships held in private companies or PLCs (with the exception of dormant companies) Ownership, or part ownership, of private companies businesses or consultancies likely or possibly seeking to do business with the NHS Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS A position of authority in a charity or voluntary body in a field of health and social care Any connection with a voluntary or other body contracting for NHS services Signed Fit and Proper Person Dec Cllr Jim Beall (Appointed Governor, Stockton Borough Council) Cllr Dave Hunter (Appointed Governor, Hartlepool Borough Council Cllr Morris Nicholls (Appointed Governor, Durham County Council) None None None None Deputy Leader and Cabinet Member for Adult Services and Health Stockton Borough Council None None None None None Chair Eastern Ravens Trust Chair, Stockton Health and Wellbeing Board None None None None Secretary and Vice Chair Young peoples and Children s Services, Durham County Durham Simon Forrest (Appointed Governor, Durham University None None None None Chair of Board of Trustees AIDS Education and Research Trust Linda Nelson None None None None None (Appointed Governor, Teesside University) 10

34 North Tees and Hartlepool NHS Foundation Trust Meeting of the Council of Governors Integrated Performance Report February 2017 Strategic Aim and Strategic Objective (the full set of Trust Aims and Objectives can be found at the beginning of the Council of Governors Reports) 1. Introduction 1.1 This report highlights performance against standards included in Monitor s Risk Assessment Framework (Single Oversight Framework) Sustainability and Transformation Plan, NHS Outcomes Framework and Core National and Local Standards for the month of November An overview of performance against key standards covering Compliance and Sustainability and Transformation Planning, Lord Carter/Model Hospital Operational Efficiency, Human Resources, Workforce and Organisational Development and Quality and Finance is given within the Appendices. 1.3 The Finance section on Appendix 1 provides an overview of the Trust s position against the key financial metrics across Directorates, Transformation and Continuity of Services. 1.4 Appendix 2 outlines the trend analysis against the key Compliance and STP standards. 1.5 Appendix 3 and 4 provide additional dashboards covering Quality and HR, Workforce and OD metrics, providing the Council of Governors with a combined overview of operational performance across the organisation. 2. Performance Overview 2.1 Compliance and Sustainability and Transformation Planning (STP) Performance against the emergency care standard achieved in the month of November reporting at 95.39% against the national requirement of 95% The Trust achieved all of the cancer standards in November The Trust achieved the Referral to Treatment standard, reporting at 93.27% for November. A zero tolerance approach to any incomplete RTT non-adjusted pathways over 52 weeks remains a national measure. The Trust reported no over 52 week waits. 1

35 2.1.4 The Trust has a strong history of achieving the national standard for the number of patients waiting over 6 weeks for diagnostic procedures however under achieved against this standard for November reporting at 98.33%. Recovery is expected by January Lord Carter/Model Hospital The latest position indicates the Trust is performing relatively well against a number of the operational efficiency standards, including outpatient new to review ratios, lengths of stay, day case rates and pre-op stays though acknowledges there is work to be done in these areas to further improve the position Outpatient DNAs are reporting above the internal standard for both new and review appointments, however indicating a downward trend Bed Occupancy rates continue to report above the national recommendation of 85%, indicative of the continued pressures within the organisation together with delayed transfers of care Readmissions for elective and emergency admission are reporting above target with a variable trend. 3. Nursing, Quality and Patient Safety 3.1 The Trust has established a new Safety and Quality Dashboard (Appendix 3) which utilises the CQC domains of Safe, Caring, Effective, Responsive and Well-Led. The dashboard allows users to see month on month positions and the trend from April 2016, together with the benchmark position against data from the same time period the previous year. 3.2 The Trust reported five Trust attributed cases of Clostridium difficile infection for November Zero cases of Methicilin-Resistant Staphylococcus Aureus (MRSA), two Methicilin- Sensitive Staphylococcus Aureus (MSSA) and six cases of hospital acquired Escherichia Coli (E.coli). 3.3 The Trust has revised the Staff, Patient Experience and Quality Standards (SPEQS) process for In-patients from August. The revised SPEQS forms have been created to align with the CQC domains. The values for the November SPEQS CQC domains are as follows: Safe increased to 93.75% from 85.57%, Caring decreased to 88.10% from 91.77%, Effective increased to 91.89% from 84.87%, Responsive decreased to 62.50% from 70.36% and Well-Led increased to 77.78% from 75.79%. 3.4 The Trusts overall Harm Free care in November 2016 was 99.39% this has increased from 98.46% in October The Trust overall New Harm decreased from 1.54% in October 2016 to 0.61% in November The Trust Would Recommend for Friends and Family returns decreased to 93.87% for November 2016 from 93.88% in October The latest HSMR value is (November 2015 to October 2016), this has increased from the previous value of (revised October 2015 to September 2016). The Trust crude mortality rate for HSMR has increased to 3.59% from 3.53%. 3.7 The latest SHMI data has been released for the time period of July 2015 to June 2016 with the value reducing to from in the previous period. The new value of now places the Trust within the as expected range; this is the first time since the 12 month reporting period of April 2012 to March There has been no Never Events in the reporting period. 2

36 3.9 Registered Nurse/Midwife fill rates across inpatient areas for the month of November has increased to 81.82% from 80.53%, which is above the expected 75% expected fill rate to maintain safe staffing. 4. Human Resources, Workforce and Organisational Development 4.1 The Trust headcount as at 31 December 2016 is 67 more than 31 December 2015, and it is 25 higher when compared to the baseline of 31 March The sickness absence rates for quarter /17 are for the months of October and November only - further analysis will take place once the information for December 2016 is available. 4.3 The sickness absence rate for the month of November 2016 is 5.05%, an increase of 0.47%, when compared to the previous month (October 2016). 4.4 The sickness absence rate for quarter /17 (excluding December 2016) has shown an increase of 0.15%, when compared to quarter / The long term sickness absence rate for quarter /16 (excluding December 2016) has shown a decrease of 0.04%, when compared to quarter / The cost of sickness absence increased during the months of October and November The total cost for quarter /17 (excluding December 2016) is 1,117,934, which is 104,160 higher when compared to quarter / Turnover has decreased by 0.62% for quarter /17 when compared to quarter /16, however it is 0.32% more than the baseline of 31 March The overall compliance for mandatory training is 92%, which is 3% below the target. (Figures are reported up to November 2016 only). 4.9 The Staff Friends and Family Test is carried out as part of the annual NHS Staff Survey and therefore the Trust is not required to carry out this activity for the Q3 period. The Staff Survey Results are expected February Finance 5.1 A high level overview of the financial position across Directorate performance, transformation and continuity of services risk rating is provided in Appendix Recommendations 6.1 The Council of Governors is asked to note the detail in the Integrated Performance Dashboard and performance against the key national indicators for November 2016, in the context of the Sustainability and Transformation Plan, the Trusts Terms of Licence and the Everyone Counts: Planning for Patients 2014/ /19 document. 6.2 In addition the Council of Governors is asked to note the on-going operational performance risks to regulatory key performance indicators and the financial risks together with the work that is being taken forward to mitigate and address going forward to provide a level of assurance and sustainability. 3

37 Julie Gillon, Chief Operating Officer/Deputy Chief Executive Julie Lane, Director of Nursing and Infection Prevention and Control Ann Burrell, Director of Human Resources and Organisational Development Caroline Trevena, Director of Finance 4

38 Appendix 1 Trust Income & Expenditure Position Month 8 Annual Budget YTD Plan YTD Actual YTD Variance '000 '000 '000 '000 Income Accident & Emergency (0) Anaesthetics (6) Audit North Central Expenditure 0 Central 15,421 12,134 9,847 (2,287) Contract Income 263, , ,134 3,655 EAU & Ambulatory (3) Education & Organisation Development 3 2 (2) (4) Endoscopy (4) Estates 4,606 3,309 3,273 (35) Finance 1,648 1,150 1, Human Resources ICT (21) In Hospital care Medical Director Nursing & Patient Safety Obs and Gynae Orthopaedics 1, (955) Out of Hospital Care Paediatrics (0) Pathology Pharmacy 1,656 1,102 1, Radiology (15) Research & Development Strategy, Operations & Performance Surgery and Urology Total Income 291, , , Pay Expenditure Accident & Emergency 6,695 4,587 4,646 (59) Anaesthetics 16,965 11,394 11, Audit North (20) Central Expenditure (3,021) (789) 48 (837) Chief Executive 1, EAU & Ambulatory 9,793 6,537 7,027 (490) Education & Organisation Development 1,708 1,157 1,247 (89) Endoscopy 3,070 2,060 2,106 (46) Estates 13,293 8,939 8, Finance 3,319 2,200 2, Human Resources 1,654 1, ICT 4,141 2,771 2, In Hospital care 24,111 16,260 17,333 (1,073) Medical Director (95) Nursing & Patient Safety 2,891 1,965 1, Obs and Gynae 11,870 8,020 7, Orthopaedics 10,841 7,239 7,413 (174) Out of Hospital Care 31,017 20,800 20, Outpatients 1, (9) Paediatrics 14,696 9,950 9, Pathology 7,084 4,804 5,215 (411) Pharmacy 3,953 2,638 2,651 (13) Radiology 9,150 6,159 6, Research & Development (50) Reserves 1, Strategy, Operations & Performance 2,401 1,616 1, Surgery and Urology 11,574 7,765 8,113 (348) Total Pay Expenditure 192, , ,645 (1,732)

39 Non Pay Expenditure Accident & Emergency Anaesthetics 4,958 3,421 3, Audit North Central Expenditure 8,253 (1,676) (212) (1,464) Central Income Chief Executive EAU & Ambulatory 1,480 1,079 1,080 (1) Education & Organisation Development (72) Endoscopy 1,778 1,229 1, Estates 9,912 6,603 6, Finance 12,196 8,249 8, Human Resources ICT 1,732 1,154 1,149 5 In Hospital care 12,554 11,236 11,319 (83) Medical Director Nursing & Patient Safety Obs and Gynae 1,962 1,496 1, Orthopaedics 6,452 4,465 3,403 1,062 Out of Hospital Care 7,512 5,211 4, Outpatients Paediatrics 1,624 1,241 1,242 (1) Pathology 5,558 3,860 3, Pharmacy Radiology 5,172 3,551 3,577 (27) Research & Development Strategy, Operations & Performance Surgery and Urology 2,275 1,596 1, Total Non Pay Expenditure 86,890 55,165 54, Trust Total 12,122 7,516 7, Optimus Health Limited 16 2 (69) (71) Group Total 12,138 7,519 7,475 (44) CIP Scheme Revenue Generation Employee Expenses Drugs Clinical Supplies Non-Clinical Supplies Other Recurrent/Non Recurrent Recurrent Non-Recurrent Recurrent Non-Recurrent Recurrent Non-Recurrent Recurrent Non-Recurrent Recurrent Non-Recurrent Recurrent Non-Recurrent YTD Plan YTD Actual YTD Variance '000 '000 ' (63) , (1,241) 40 1,647 1, (81) (234) (331) Total Recurrent Non-Recurrent 3,559 1,703 (1,856) 296 2,419 2,123 Grand Total 3,855 4,

40 Appendix 2 - Compliance & STP Monitoring - Responsive ID T00 A&E 4 hr target(excludes walk-in centres) 01 T00 New Cancer 31 days subsequent Treatment (Drug 02 Therapy)* t00 New Cancer 31 days subsequent Treatment (Surgery)* 03 t00 New Cancer 62 days (consultant upgrade)* 04 t00 New Cancer 62 days (screening)* 05 t00 New Cancer GP 62 Day (New Rules)* 06 t00 New Cancer Current 31 Day (New Rules)* 07 t00 New Cancer Two week Rule (New Rules)* 08 T00 Breast Symptomatic Two week Rule (New Rules)* 09 T00 RTT incomplete pathways wait (92%) 12 T01 Number of patients waiting over 6 weeks for diagnostic 16 procedures **** ID T00 Outpatient DNA (new) 55 T00 Outpatient DNA (review) 56 T00 Average depth of coding 57 T00 Length of Stay Elective 58 T00 Length of Stay Emergency 59 T00 Day case Rate 60 T00 Pre - Op Stays 61 T00 Revised Occupancy Hartlepool 62 T00 Revised Occupancy North Tees 63 T02 Delayed bed days 05 T02 Excess bed days 06 T00 Readmission rate 30 days (Emergency admission) 25 T00 Readmission rate 30 days (Elective admission) 26 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 QTR 1 QTR 2 QTR 3 QTR 4 Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% Actual 93.62% 93.40% 92.95% 93.32% 95.30% 96.65% 95.06% 95.64% 96.36% 95.39% Variance -1.38% -1.60% -2.05% -1.68% 0.30% 1.65% 0.06% 0.64% 1.36% 0.39% Target 98.00% 98.00% 98.00% 89.95% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% Actual % % % % % % % % % % Variance 2.00% 2.00% 2.00% 10.05% 2.00% 2.00% 2.00% 2.00% 2.00% 2.00% Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% Actual 95.00% 90.91% % 97.83% % % % % % % Variance 1.00% -3.09% 6.00% 3.83% 6.00% 6.00% 6.00% 6.00% 6.00% 6.00% Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% Actual % % % 75.00% % % % % % % Variance 15.00% 15.00% 15.00% % 15.00% 15.00% 15.00% 15.00% 15.00% 15.00% Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% Actual 95.60% % 97.18% 97.69% 98.30% 93.90% 98.39% 97.04% % 97.10% Variance 5.60% 10.00% 7.18% 7.18% 8.30% 3.90% 8.39% 7.04% 10.00% 7.10% Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% Actual 86.50% 88.06% 75.00% 83.57% 78.22% 86.92% 82.54% 83.06% 90.10% 92.00% Variance 1.50% 3.06% % -1.43% 6.80% -1.70% -2.46% -1.94% 5.10% 7.00% Target 96.00% 23.34% 30.06% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% Actual 98.90% 99.17% 99.16% 99.10% % % % % % % Variance 2.90% 3.17% 3.16% 3.10% 4.00% 4.00% 4.00% 4.00% 4.00% 4.00% Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% Actual 94.00% 97.69% 90.83% 94.13% 92.90% 93.70% 93.04% 93.25% 94.70% 95.40% Variance 1.00% 4.69% -2.17% 1.13% 0.10% 2.10% 0.04% 0.25% 1.70% 2.40% Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% Actual 95.50% 94.40% 96.10% 95.26% 94.80% 98.20% 97.86% 96.84% 99.10% 98.30% Variance 2.50% 1.40% 3.10% 2.26% 1.80% 5.20% 4.86% 3.84% 6.10% 5.30% Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% Actual 92.01% 92.02% 92.13% 92.05% 92.71% 92.65% 92.39% 92.59% 93.03% 93.27% Variance 0.01% 0.02% 0.13% 0.05% 0.71% 0.65% 0.39% 0.59% 0.39% 0.39% Target 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% Actual 99.53% 99.30% 99.41% 99.42% 99.45% 99.82% 99.46% 99.57% 99.96% 98.33% Variance 0.53% 0.30% 0.41% 0.42% 0.45% 0.82% 0.46% 0.57% 0.96% -0.67% Lord Carter Model Hospital - Effective T00 New to Review ratio (cons led) 54 T01 Readmission rate 30 days (Total) 19 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 QTR 1 QTR 2 QTR 3 QTR 4 Target Actual Variance Target 5.40% 5.40% 5.40% 89.95% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% 5.40% Actual 8.31% 9.11% 9.71% 9.09% 8.42% 9.31% 8.62% 8.97% 8.02% 9.02% Variance 2.91% 3.71% 4.31% % 3.02% 3.91% 3.22% 3.57% 2.62% 3.62% Target 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% 9.00% Actual 11.85% 12.60% 11.68% 11.91% 10.61% 10.72% 10.79% 10.75% 11.06% 9.87% Variance 2.85% 3.60% 2.68% 2.91% 1.61% 1.72% 1.79% 1.75% 2.06% 0.87% Target Actual Variance Target Actual Variance Target Actual Variance Target 72.72% 23.34% 30.06% 74.59% 74.82% 74.63% 74.92% 74.92% Actual 72.68% 72.96% 71.55% 71.55% 71.67% 71.26% 70.96% 70.96% Variance -0.04% 0.20% -3.04% -3.04% -3.15% -3.37% -3.96% -3.96% Target 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% 4.50% Actual 0.80% 2.16% 0.93% 1.75% 0.88% 1.35% 1.37% 1.50% 1.12% 1.19% Variance -3.70% -2.34% -3.57% 2.75% -3.62% -3.15% -3.13% -3.00% -3.38% -3.31% Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% Actual 86.48% 92.06% 90.14% 89.54% 92.29% 85.09% 91.83% 89.67% 86.06% 87.31% Variance 1.48% 7.06% 5.14% 7.54% 7.29% 0.09% 6.83% 7.67% 1.06% 2.31% Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% Actual 97.19% 97.12% 96.13% 96.80% 95.46% 93.98% 96.61% 95.33% 93.21% 94.88% Variance 12.19% 12.12% 11.13% 14.80% 10.46% 8.98% 11.61% 13.33% 8.21% 9.88% Target Actual Variance Target Actual Variance Target 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% 9.73% Actual 9.27% 13.11% 12.37% 12.82% 13.02% 11.99% 11.39% 12.02% 12.21% Variance -0.46% 3.38% 2.64% 0.00% 3.29% 2.26% 1.66% 2.29% 2.48% Target 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Actual 4.42% 4.55% 4.00% 4.31% 4.56% 3.76% 3.18% 4.00% 3.80% Variance 4.42% 4.55% 4.00% 0.00% 4.00% 4.00% 4.00% 4.00% 4.00% Target 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% 7.70% Actual 9.27% 9.66% 8.68% 9.22% 9.58% 8.51% 7.86% 8.68% 8.73% Variance 1.57% 1.96% -3.70% 0.00% -3.70% -3.70% -3.70% -3.70% -3.70% Oct 16 Oct 16 Nov 16 Nov 16 Dec 16 Dec 16 Jan 17 Jan 17 Feb 17 Feb 17 Mar 17 Mar 17

41 Appendix 3