Agenda Item: A3 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting held on 22 nd June 2017 Part A: Public Session Present: Mr K W Smith (Chair) Chairman Mrs A Dragone Finance Director Mrs L Robson Business and Development Director Mr A Welch Medical Director Mrs H Lamont Nursing and Patient Services Director Mr D Stout Non-Executive Director Mr J Jowett Non-Executive Director Mrs H A Parker Non-Executive Director Mr E Weir Non-Executive Director Professor K McCourt Non-Executive Director In Attendance: Mrs K Jupp, Trust Secretary Mrs J Moon, Head of Patient Safety and Risk (minute ref. 17/100(i) only) 17/96 Apologies for Absence Apologies were received from Professor C P Day, Non-Executive Director. 17/97 Declarations of Interest Mr Weir declared an interest in any matters pertaining to Newcastle City Council. 17/98 Minutes of the Meeting held on 25 th May 2017 These were agreed to be a correct record. 17/99 Patient Story Mrs Lamont presented the story and explained that the paper detailed the experience of Mr G, a patient who had suffered from a number of long term conditions and had received treatment from a number of providers, including this Trust. This Patient Story was presented at Gateshead & Newcastle Long-term Conditions Board and the patient had consented for the story to be shared within the Trust as it provided an insight into the challenges faced by such individuals. The aim of the inclusion of a patient story was to remind Board members about the impact on patients and how simple things can make a significant difference in improving the patient experience. The story presented highlighted poor communication from different providers, identified a system that was not fully integrated and information was not always accessible. 1
The patient had a visual impairment however information had continued to be sent to the patient in hard copy which required translation. In addition the story referred to the patient trying to eat scrambled eggs and toast with a spoon because the staff had not given him a knife and fork and he wasn t feeling well enough to ask. Professor McCourt commented that there was insufficient continuity in that there was no one person who oversaw the full patient treatment and provided administrative support. Mrs Robson stated that there was a role for GPs in overseeing the patient pathway for those patients with long term conditions. Mr Welch commented that as a consequence of the Trust being unable to undertake direct Consultant to Consultant referrals there was a need to GPs to coordinate such referrals which in some cases resulted in delays and an unsatisfactory patient experience. Mrs Lamont commented that transitions between areas or providers often resulted in a higher number of complaints rather than those patients who receive treatment in one standalone area/location/service. to receive the patient story. 17/100 Safety, Quality and Performance i) Integrated Quality Report Mrs Lamont and Mrs Moon presented the report. Mrs Lamont presented the May HCAI 2017 position and confirmed that there was one case of Trust-acquired MRSA bacteraemia in May. The final year-end figure for 2016/17 was confirmed at 9 cases. One case had been challenged however the Panel had decided that the blood culture was contaminated as a consequence of Trust practice and therefore the case had been allocated to the Trust. In relation to MSSA Mrs Lamont highlighted that the Trust had some of the highest cases in the Country and half of these cases were line-related. She added that there was a high mortality link and therefore significant work had been undertaken regarding training for the aseptic technique. The Trust IPC Team had visited other Trusts to ascertain whether any further changes could be made to improve the position and it was noted that some organisations had a dedicated IV Team. This option is being pursued in the Trust. Alternatives for the types of antiseptic washes in use are being explored to ascertain whether this could result in improvements being made, as a more user friendly product may be available. Mr Stout queried whether IV Teams could assist a reduction in MSSA to which Mrs Lamont confirmed that a Business Case had been completed previously however was unsuccessful. A temporary post had been created but was unsuccessful in its recruitment. 2
Mrs Parker commented that the Charitable Fund may be able to provide support. There were two cases of C. difficile in May, giving a total in year of six to date against a trajectory of thirteen. One of which had been appealed. The Trust s C. difficile objective for 2017/18 remained at 77 cases or fewer. The year-to-date C. difficile rate per 100,000 bed days at the end of May was 6.9 against the target of 16.3 or less. In May there were seven MSSA bacteraemia attributed to the Trust, giving a total of 15 to date which was a slight improvement on the previous year. As reported previously, reducing MSSA bacteraemia incidence in the Trust was a top priority for the Infection Prevention and Control (IPC) Team and every Directorate now presented their action plan at the Serious Infection Review Meetings, and the reduction of line-related MSSA bacteraemia was a key topic of discussion and action. An internal target had been set at delivering a 10% reduction. In April there were 17 E.coli bacteraemia. In addition there were 7 cases of Klebsiella, bringing the total to 8 for the year and also 2 cases of Pseudomonas, bringing the total to 4 for the year. Mrs Lamont highlighted that despite a reduction in falls, May 2017 had been a challenging month in terms of managing falls with serious harm (11 falls with serious harm were reported in May). Mr Stout queried why the number of falls with serious harm had increased to which Mrs Moon advised that it depended upon the fragility of patients. Mrs Lamont added that many of the patients who had fallen, and suffered serious harm, had already fallen before and were often mobilising against advice. She added that every patient was risk assessed, with a very high proportion of patients being noted to be at risk. In some Elderly care areas this can be 100% of patients in the ward. Mrs Lamont reported that there had been an increase in the number of pressure ulcers reported this month when compared to last month however the Trust continued to exceed the 95% harm free care target. Pressure ulcers were still a challenge for the Trust. Mrs Lamont highlighted that a gap analysis had been undertaken between NuTH and other Trusts which had highlighted some areas for improvement. Professor McCourt asked whether Directorate performance could be viewed to which Mrs Lamont advised that Directorate information was available. Mrs Lamont agreed to ask Mr Price and a Trust Microbiologist to attend a future Trust Board meeting to provide a briefing on the practicalities and how improvements could be made (ACTION01). In April, the total nursing vacancy factor was 7.6% which was the lowest recorded figure since data collection commenced. 3
The CAT results demonstrated a stable set of results over the last six months, with total scores between 95% and 96%. Following changes to the application process, Acknowledging Continuous Excellence (ACE) Awards had now been awarded to 66% of the clinical areas who completed CAT across the Trust. The simplified application process and continuing work to raise awareness had contributed to an increased number of applications being made. Mrs Moon reported that there were seven Serious Incidents, none of which were Never Events. The Incidents related to 5 falls causing fractured femurs, one delayed diagnosis of malignancy and one extravasation of intravenous fluid leading to tissue damage. The case of the delayed diagnosis dated back to 2011 and Board members were advised that this delay had had a serious impact on the patient s outcome. The patient was involved in a road traffic accident and has incurred multiple fractures. A number of tests had been run and it was identified that a mass was present in the ovaries. The patient should have been referred on at that time for further investigation however the specific test result which had identified the mass had been missed. The case related to the tissue extravasation was identified following a complaint being raised about a significant injury to a child. Processes had been reviewed and actions identified/improvements made as a consequence. Mrs Moon advised that one Never Event had occurred to date in June relating to a wrong tooth extraction. Medication incident reporting numbers and radiation incident reporting had reduced. Mrs Moon highlighted that work was ongoing in relation to medication incident reporting to ensure consistency of the grading of such incidents. Professor McCourt asked how long it took in terms of hours to investigate a medication incident to which Mrs Moon explained that it varied depending on the complexity of the incident. Professor McCourt commented that there was a significant amount of time and resource involved. Assuming one hour each then this would result in over 2,000 hours. Mrs Moon explained that the Radiology department would be undertaking an audit over a period of time for near misses and the results would be reported back to Board members in due course. Mr Weir queried the actual number of incidents which resulted in the movement of 0.6% to 1.3% from April to May for the percentage of patient safety incidents that resulted in severe harm or death. Mrs Moon confirmed that it represented roughly 20 incidents but advised that the numbers would reduce as a consequence of retrospective reporting. 4
The most recent SHMI results showed that the Trust had scored 96 which was lower than the previous quarter. This remained lower that the national average and within the as expected category. The most recent HSMR results showed there had been an increase for the month of January, however as advised previously this result may change as the percentage of discharges coded increased. Mrs Parker commented on the apparent conflict between the HSMR and SHMI scores to which Mr Welch explained that one of the scores was based on first diagnosis. Mrs Parker commented that the increase in the HSMR score was a concern to which Mrs Robson commented that this may in part be as a consequence of an improvement in coding. Mrs Lamont advised that the Friends and Family Test recommendation rates were slightly down but this level of fluctuation had previously been noted and would be kept under review. Complaints numbers were also lower however it was identified that there was a need to focus on response rates as only 24% had hit the agreed deadline. Mrs Parker referred to the Stroke Audit results and commented that it was difficult to determine whether the reports reflected good or bad performance. Mrs Moon agreed to follow up with Mrs O Brien and report back at the July Board meeting (ACTION02). Mr Jowett added that the narrative was inconsistent with the charts. Mr Jowett asked how regularly the CQUIN Group met to which Mrs Robson confirmed that the Group met monthly and were responsible for overseeing CQUIN schemes of circa 16m in value. to receive the briefing and note the current position. ii) Quarterly Healthcare Associated Infections Report This report was covered in detail earlier under 17/100(i). Mrs Lamont highlighted that this report was the quarterly supplementary report which complemented the Integrated Quality Report. to note the content of the report. iii) Nursing and Midwifery Report This report was covered in part under 17/100(i) above. An initial GAP analysis for safe staffing levels for District Nurses demonstrated compliance in most areas. Investment was likely to be required to improve the IT infrastructure to support mobile working. 5
Mrs Lamont highlighted that the total Nursing vacancy factor and Band 5 vacancy factor had continued to improve significantly with a total vacancy factor of 7.6% and a Band 5 vacancy factor of 9.4%. Turnover had decreased to 8.6% which reflected a good position and was near to the best national score at 7.9%. The Nursing and Midwifery Recruitment and Retention Group (NMRRG) continued to manage and prioritise strategic recruitment and retention activity. Generic monthly recruitment exercises were continuing and it was highlighted that the recruitment timetable had been successfully reduced to 13 weeks. Mrs Lamont explained that new students were invited to come in to the Trust for a visit before they were due to commence and this appeared to be working well. There was a reduction in Registered Nurse (RN) percentage fill rates in March. This was expected due to vacancies being held for newly qualified registrants qualifying in March. 90 new RN started in the Trust in March. It was noted that changes to the Bursary system for Nurses and AHPs had resulted in a significant reduction in applications for Nurse training. Mr Weir queried the impact of Brexit specifically on nursing to which Mrs Lamont explained that the Trust had not specifically recruited in Europe. However others had done and the impact on the recruitment pool available was a risk. The Trusts new degree programme with Sunderland University had received significant interest. The first cohort of 19 commenced in April and a further 41 were expected to start in September. Professor McCourt commented that Health Education England had entered into a significant partnership with Indian organisation to facilitate overseas recruitment. Mrs Lamont noted these staff would only come to the UK for 2-3 years and would then return to India. Mr Weir advised that there was also a large challenge with social care recruitment and noted that Sunderland Council were working closely with Sunderland Foundation Trust to resolve this matter. He added that there was an opportunity for NuTH to work together with Newcastle Council in order to improve recruitment in both areas. Mrs Robson, Mr Weir and Mrs Lamont agreed to meet to explore the options for working together on both social care and nursing recruitment activity (ACTION03). Mrs Lamont stated that much work was ongoing to maintain workforce supply with Teesside University on further developing the Assistant Practitioners role and a pilot was ongoing for ten nursing associates. In addition the Trust was reviewing the role of apprenticeships. to note the content of the report. iv) 2016 Inpatient Survey Publication and Results 6
Mrs Lamont presented the report and explained that the report was provided for information. She highlighted that the report included the latest data from the Care Quality Commission (CQC) National Patient Survey of Inpatients 2016 benchmark results which were published on 31st May 2017 on the CQC website. The Trust s National Patient Survey of Inpatients was undertaken by Picker Institute Europe in Autumn 2016, with the initial results received in January/February 2017. The paper demonstrated that the Trust performed better than other Trust in 22 of the 65 questions and has improved significantly in one area compared to the 2015 survey. The Trust did not score worse than other Trusts in any question although the results had significantly worsened in seven questions which was disappointing. The Trust scored very favourably when compared to the local Trusts and Trusts in the national peer group, being the best performer in the Shelford Group. Mr Stout queried whether it was possible to rationalise why the scores had reduced for the seven questions referred to and why the Trust was not scored at the top locally. It was noted that nationally there had been a reduction in scores and that the Trust had requested further information to see whether this was a trend or a recognised fluctuation. to i) receive the briefing and acknowledge the positive findings of the CQC benchmark data published on the CQC website on 31 May 2017. v) Safeguarding Annual Report Mrs Lamont presented the report and explained that the report was provided for information. She added that the report summarised the activity of the Trust s Safeguarding Teams across 2016/17 and demonstrated the Trust s commitment to protecting the vulnerable and working in line with the relevant legislation and guidance. It was noted that the report demonstrated increased activity across most workstreams, with good levels of participation in training and the variety of work undertaken by teams. The report also highlighted the priorities and challenges for 2017/18 across all teams and defines the Trust s strategic safeguarding priorities for 2017 to 2019, which had been refreshed to account for emerging priorities. Professor McCourt commended the work of the Safeguarding team. to (i) receive the report (ii) recognise ongoing commitment by Safeguarding Professionals and Trust staff to protect the vulnerable (iii) recognise the challenges and priorities ahead and (iv) support 7
the sharing of the report with both Newcastle s Safeguarding Children and Safeguarding Adults Boards. vi) Business Delivery and Performance Report Mrs Robson presented the report and explained that the Trust had achieved the 18 week referral to treatment (RTT) key three targets, the 6 week diagnostic standard (May 2017) and met all but one (2 week Symptomatic Breast) of the Cancer standards in (April 2017). As reported historically, Mrs Robson advised that although the RTT incompletes, admitted and non-admitted targets were achieved overall, there were specialty level breaches in Trauma and Orthopaedics. The Trust could expect to receive the associated 187.8k penalty (for the incompletes target) as a consequence of not yet signing it s 2017/18 Control Total. Mrs Robson explained that the Trust very narrowly missed meeting the A&E 4hr (at 95%) standard in May 2017 at 93.1% due primarily to Delays to Be Seen (DTBS) in the Emergency Department (ED) which was being compounded by significant medical staffing pressures, particularly junior and middle grade gaps in the ED rota. She added that the target had been achieved for the previous few days however such performance was not deemed to be sustainable. The A&E improvement plan was continuing at pace with dedicated clinical and nursing leadership driving the improvements. The Five Year Forward View Next Steps document strongly indicated that success for STPs in the future would be primarily measured on two key metrics emergency inpatient bed days and emergency admissions growth. To this effect, NHS England was planning to publish metrics for each STP, benchmarking their emergency admission rates and bed days from July 2017. The Trust reported 38 ambulance handover delays in May 2017 due to the administrative process of handing over the patient on the IT system. The ED department was currently working with North East Ambulance Service (NEAS) to try and rectify the issues, particularly as the ambulance delays have had significantly increased over the last few months. This would incur a financial penalty of 7.6k for the Trust. 17/101 Strategic Items to note the content of the report. i) Report of the Chief Executive Mr Welch and Mrs Robson presented the report. Mr Welch referred to the continued prioritisation of safety and quality issues through Directorate Quality Reviews, proactive intervention, mortality surveillance 8
and the Sign up to Safety drive in order to maintain and improve upon the CQC inspection status. Mr Welch referred to the recent inquest conclusion which had been reported heavily in the media regarding a patient who had died following cardiac surgery. Statements had been issued to the press. The Trust had admitted that it was at fault and the Coroner had identified that all necessary action had been taken. Mr Welch explained that the reported incident had happened four times in four million procedures, one of such instances being at the reported incident for this Trust. Mr K W Smith queried what lessons had been learned to which Mr Welch explained that the incident had arisen from technical failure however a full investigation had occurred and further changes made to processes and procedures. Mr Jowett asked whether discussions had occurred with the supplier to request that the supplier alters the item in order to make it easier to identify which way around the item should be inserted. Mr Welch confirmed that discussions had taken place however it appeared that the supplier had not intended to make an adjustment to the product. He added that the Coroner had agreed to approach the supplier to discuss the matter further. Mr Jowett commented that there were only four available products which could be used during this type of surgery and of the four, three could be inserted only one way and the fourth (being the product used in this incident) could be inserted either way. Mr Jowett queried whether any further claim against the Trust could arise to which Mrs Dragone advised that any potential claim would be processed via the NHSLA insurance cover. Mr Welch confirmed that the white boards installation process for NEWS assessment of patients was continuing. Mrs Robson added that there was a rapid rollout programme and Mrs Lamont confirmed that the programme was due to be concluded in October. Mr Welch advised that the white board capabilities were being further explored to identify whether they could be linked to the Trust blood pressure technology. Mr Stout queried whether the technology was resilient to which Mr Welch explained that the white boards were purely a recording display aid. Reference was made to the establishment and expansion of the Trust Transformation Team. Collaboration with Ernst and Young on the NHS Improvement Financial Improvement Programme 2 was progressing. Mr Welch commented that the outcomes from the work to date had been as expected, with few new areas being identified. This demonstrated that the Executive Team and Transformation Team members had good awareness of the financial improvements required and the areas of focus. 9
Scoping of strategic estates issues in relation to anticipated future requirements and affordability was ongoing and the maintenance of the Estates infrastructure was being reviewed. Mr Welch advised that proposals relating to re-location of the Cherryburn unit were being developed due to concerns identified over medical cover and security at the site. The development of the Hyper Acute Stroke services for the people of Gateshead provided at the Royal Victoria Infirmary had been successfully evaluated as a positive patient centred move. Mrs Robson advised that the approach to service transfer and the joint working arrangements were being used as a template for consideration for other such service transfers e.g. the potential move of vascular surgery from Gateshead to NuTH. Mr Welch confirmed that there had been a successful completion of the Infinnit/Carestream transfer, the Trusts X-Ray storage system. Some minor hiccups had occurred which had been resolved. It was noted that in relation to the 100,000 genomes project, there had been problems in recruiting the numbers of patients required however such numbers were gradually increasing. The interim appointment of Mrs Caroline Parnell as the Trust Freedom to Speak up Guardian was reported. Current CCG issues relating to QIPP, including Procedures of Limited Clinical Value had been discussed at a very useful Executives to Executives meeting yesterday. Both organisations expressed a desire to collaborate more effectively. Ongoing collaboration with other Trusts in the Sustainability and Transformation Plan (STP) footprint was ongoing in order to facilitate further streamlining of patient pathways without impacting on quality and safety. The Trust was leading and influencing a number of the workstreams and Mrs Robson confirmed that she would be sitting on the oversight group. Engagement and influence with the Shelford Group of the Teaching Hospitals Foundation Trusts was continuing. Mrs Robson commented that the focus of the Shelford was more on key policy areas rather than a detailed operational focus. Group responses had been lobbied both before and after the general election. Mrs Robson confirmed that Mrs Fawcett chaired the national Human Resources Group and was very much engaged. Mrs Lamont added that Mrs Fawcett had very good national links. Mr Welch advised of the changes to the Clinical Directorate structures with the merger of the Laboratory Medicine and Genetics directorates. In addition the ENT directorate was to be merged with the Plastics, Ophthalmology and Dermatology directorate. 10
It was noted that the Trust had received the formal confirmation of the outcome of the QRM which was undertaken on 3 rd April. This was detailed within Agenda item A8(i) and highlighted a very positive review. Mrs Robson highlighted that the letter referred to this Trusts work with Cumbria on Radiology; however this should read Radiotherapy, Oncology and Chemotherapy. An apology had been issued by the NHS Improvement team for this error. Reference was made to the changes in the CQC inspection framework and the well-led review requirements. 17/102 Finance to receive the update. i) 2017/17 Month 2 Finance Report Mrs Dragone presented the position as at 31 st May 2017 and highlighted that at Month 2 the Trust reported a deficit of 0.6 million which did not include any Sustainability Transformation Funding (STF) as the Trust had not yet agreed a Control Total. In terms of the Use of Resources metrics, an overall risk rating of 2 was noted. However because a Control Total has not been signed an override meant a score of 3 was assigned. Operating income for the period ending 31 st May was 164.8 million, 6.7 million behind Plan and operating expenditure for the period to Month 1was 156.7 million, 5.7 million behind Plan. The Trust had an EBITDA surplus of 8 million which was 1 million behind Plan. Mrs Dragone advised that the Trust s Plan required 27 million in cost improvements. The Trust was reviewing plans to deliver the target and had voluntarily engaged with Ernst & Young as part of the NHSI-led Financial Improvement Programme to firm up on existing CIP plans and develop additional CIP opportunities. The Capital Plan was in the region of 32 million and year to date expenditure was running at 4 million, ahead of plan by 0.9 million. This related to a Linear Accelerator that was initially planned for September 2017 but the purchase was brought forward to provide flexibility for drawing down PDC funding in 2016/17. The Cash balance at the end of April 2017 was 121.5 million; 8.9 million higher than Plan. Working capital movements improved cash by 10.3 million, partly offset by a capital programme overspend of 0.9 million. to receive the report and acknowledge the overall financial position for the period to 31 st May 2017. 11
17/103 Items to Receive i) Outcome of the NHS Quarterly Review Meeting held on 3 rd April 2017 ii) Freedom to Speak Up Guardian Update Report i) ii) to receive the items. The meeting closed at 2.15pm. The next scheduled meeting would be held at 12-45pm on Thursday, 27 th July 2017. 12