Agenda Item: A3 THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Minutes of the Board of Directors Meeting held on 26 th January 2017 Part A: Public Session Present: Mr K W Smith (Chair) Chairman Mrs A Dragone Finance Director Mrs H Lamont Nursing and Patient Services Director Mrs L Robson Business and Development Director Mr A Welch Medical Director Mr D Stout (Vice-Chair) Non-Executive Director Mrs H A Parker Non-Executive Director Mr J Jowett Non-Executive Director Professor K McCourt Non-Executive Director Mr E Weir Non-Executive Director In Attendance: Ms K Douglas, Trust Secretary Mrs J Moon, Head of Patient Safety and Risk 17/01 Apologies for Absence Apologies were received from Dr Patrick Kesteven, Non-Executive Director and Professor C Day, Non-Executive Director. 17/02 Declarations of Interest Mr Weir declared an interest in any matters pertaining to Newcastle City Council. 17/03 Minutes of the Meeting held on 20 th December 2016 These were agreed to be a correct record subject to the inclusion of Mr Welch being recorded as being present at the meeting. 17/04 Strategic Issues i) Report of the Chief Executive Mr Welch and Mrs Robson spoke of a number of topics of current interest. Mr Welch explained that during Sir Leonard s period of extended leave that Mrs Robson and he had taken on the Chief Executive responsibilities for the duration of the period, however acknowledged that it was a team effort and all of the Executive Team members were working together. Mr Welch explained that there had been some alterations to line manager reporting which included Mr King and Mrs Lisle reporting to Mrs Dragone, Estates reporting in to him, Mrs Fawcett reporting in to Mrs Lamont and Ms Douglas 1
reporting in to Mr Welch and Mrs Robson with Mrs Robson overviewing all activities. Mr Welch highlighted that the leadership arrangements for the Sustainability and Transformation Plan (STP) work streams had now been agreed and several of the clinical work stream areas would be led by consultants from this Trust. The Trust recognised the importance of engaging and working collaboratively as part of the STP process. Winter pressures continued and Mr Welch highlighted that this had led to the cancellation of a small number of elective procedures to alleviate emergency demands. Mr Smith commended the staff working within the Trust Accident and Emergency Department during the Christmas and New Year period and throughout the winter. Mr Jowett queried the impact of the milder weather on demand to which Mr Welch explained that warmer winters resulted in a greater number of flu cases and infections, albeit there were fewer fractures and falls resulting in injury. Mrs Lamont advised that the Trust had seen an increase in flu cases earlier in the season than expected which had resulted in some bed closures and infection management. Banner stands had been placed in prominent areas at building entrances advising people with vomiting/diarrhoea symptoms not to visit patients. Mrs Robson commented that the Trust was still receiving a higher than expected number of diverts from other Trusts and advised that under the leadership of the Urgent and Emergency Care Vanguard, work had commenced to review the emergency models in the region which were leading to diversions. An Emergency Care Improvement Programme (ECIP) report published on the Northumbria Specialist Emergency Care Hospital (NSECH) model identified that some changes could improve patient flows and reduce diversions and recommendations for improvement. Mr Welch referred to the Trust commitment to quality and safety crucial and the desire to maintain the Trusts outstanding rating. A number of quality processes were in place which included quality and patient safety meetings, quality review meetings and mortality investigations. Mr Welch added that the mortality investigations had not identified any avoidable deaths; however care could have been improved in a very small number of cases. Mr Welch advised that the installation of white boards across Wards throughout Trust was nearing completion. The white boards were an innovative visual display for Ward staff to highlight key patient information including blood pressure scores and if patients were diabetic or had any allergies. Mr Stout queried the process in place prior to installation of the white boards to which Mrs Lamont confirmed that the process was entirely manual. Ms Douglas agreed to arrange with Mr G King for a demonstration to be given to Board members at a future meeting (ACTION01). Mrs Robson reminded members that the Trust Operational Plan had been submitted on 23 rd December and the plan was being considered alongside 2
commissioner plans by NHS Improvement, NHS England, Health Education England and Local Authority Associations etc. Feedback was awaited. Mrs Robson explained that the Trust would be required to work with other health bodies in the region to develop a joint North East region plan quarter by quarter. Contract discussions with Clinical Commissioning Groups (CCGs) in the region were ongoing and Mrs Robson confirmed that the Trust had agreed the NHS England contract before the 23 rd December deadline. Mr Welch referred to item 2(i) in the report detailing NHS New Models of Care (NMCs) and explained that the Trust was considering the appropriateness of future models including the relevance of the PACS model in continuing integrated services. Mrs Robson added that the models would be geographically based and advised that in relation to MSCPs there were 14 governance documents launched between Christmas and New Year for consideration. Mrs Robson explained that such new models of care would require strategic consideration as involved drawing together resources and a broadened remit to include social care. Reference was made to the NHS Identity briefing pack and the resource implications of the new NHS Identity policy. Mr Welch referred to the recent guidance and communications regarding recovery of the cost of NHS treatment for overseas patients. The Trust had systems and processes in place to recover such costs however acknowledged that it was difficult to guarantee. Mrs Lamont advised that she had raised this matter with commissioners to ascertain how GPs check eligibility as the Trust receives referrals directly from GPs. A meeting was scheduled for 2 nd February 2017 and Mrs Lamont agreed to provide an update at the next Board of Directors meeting. Mrs Robson explained that the Department of Health were considering introducing a new requirement for patients to bring in two forms of ID when attending hospital appointments to test eligibility. Mrs Robson added that the Trust recovers circa 1.5-1.8m per year from overseas patients and a pilot was proposed in the Infectious Diseases Unit regarding testing the operational deliverability of the new requirement. Mr Welch highlighted that CQC and NHS Improvement had issued a consultation on a proposed combined well led and use of resources framework. Mr Welch referred to Jim Mackey s letter of 19 th December regarding Broadening our oversight of A&E and a workshop having been held on 12 th January he added that Mr B Sen, Consultant in Accident and Emergency, was leading on this area for the Trust. Mrs Robson advised that the Trust had submitted bids, some jointly, to the NHS England Transformation Fund. Feedback was expected in March 2017. to receive the briefing and note the current position. 3
ii) The Newcastle Compact Mrs Robson explained that the Newcastle Compact was an agreement between a range of Public, Voluntary and Community Sector (VCS) organisations working within Newcastle. The Compact described the relationship between the sectors and set out the shared principles and commitments they made to working together more effectively in order to meet the needs of the communities and individuals they serve. Mrs Robson advised that by signing up to the Compact the Trust would signal demonstration of its commitment to volunteers. She added that the Trust had previously been asked to sign up to the Compact during 2014 however concern was expressed at that time about distracting the work of Trust volunteers. The current position had been considered and it had been determined that signing up to the broad principles laid out in the Compact would reflect the Trust s ongoing commitment to our own volunteers as well as to strengthen relationships and partnership working with the voluntary and community sector. Mrs Lamont requested that Mr A Pike be made aware of the Compact. Mr Weir explained that he was actively involved in the Compact from his role at the Local Authority and it was deemed national best practice. Professor McCourt queried whether the Universities were involved to which Mr Weir agreed to discuss with Professor Day (ACTION02). 17/05 Safety, Quality and Performance to i) receive the report, ii) note the positive work undertaken, and iii) sign up to the Newcastle Compact. i) Integrated Quality Report The report was presented by Mrs Lamont and Mrs Moon. Mrs Lamont presented the December HCAI 2016 position. No further MRSA cases had been attributed to the Trust in December, meaning that the year-to-date total had remained at five cases. There were seven C. difficile cases, giving a total of 64 cases. Of these, thirteen were successfully appealed reducing the total to 51 cases against a target of 58 or fewer for the year to date. Mrs Lamont commended staff for their work in this area. In December there were six MSSA bacteraemia attributed to the Trust bringing the year-to-date total to 72. As reported previously, reducing MSSA bacteraemia incidence in the Trust was a top priority for the Infection Prevention and Control (IPC) Team as the Trust was currently an outlier in terms of performance. Significant effort had been focussed on the Root Cause Analysis process In December there were 19 E.coli bacteraemia attributed to the Trust, bringing the year-to-date total to 155. 4
There were 6 outbreaks of diarrhoea and vomiting (2 of which were norovirus) and one outbreak of Group A Streptococcus on wards in December. Mrs Lamont advised that December was the first month of 2016/17 where the Trust had reported above the internally set target of 6.2 falls/1000 bed days with a rate of 6.4 falls/1000 occupied bed days. She added that whilst this was disappointing, it was not unexpected as historically December was consistently a challenging month and in recent years had seen an increase in falls due to winter pressures. The Trust continued to report lower than the national acute Trust average of 6.8 falls/1000 bed days and for 2016/17 was still reporting a lower average falls/1000 bed days rate compared to the same period last year. Work was continuing to aim to reduce the incidence of pressure damage occurring in the Trust including implementation of ward specific action plans. Further promotion of the key clinical message of React to Red via ward safety huddles had been undertaken. The Band 5 vacancy factor was at its lowest level since June 2014, sitting at 10.71%. The use of social media for advertising open days and specific vacancies had proved beneficial in maximising recruitment potential. Work continued to support Directorates where there was a higher vacancy factor, including Peri- Operative Care where a dedicated recruitment day had been scheduled. Mrs Lamont advised that overall CAT scores have decreased slightly but continued to be above 95% in December, with staff knowledge scores at 91.47%. She added that two Acknowledging Continuous Excellence (ACE) Awards had been granted for staff knowledge. In relation to Harm Free Care, the Trust continued to meet the national target and was slightly over the Trust target. The Safety Thermometer exceeded 95% which reflected good performance. Mrs Lamont referred to the improved level of engagement in regard to Harm Free Care. In terms of performance regarding Care Hours per Patient Day (CHPPD), despite the vacancy rate reducing the fill rate increased and therefore CHPPD did not change. Mrs Moon reported that there were nine Serious Incidents which included one Never Events. The Never Event related to the removal of a wrong tooth and Mr Welch highlighted that the patient was having a number of teeth removed in order to be fitted with dentures. The remaining Serious Incidents related to two falls causing fractured femurs, one death due to C difficile, two complications of surgery (neither patient was harmed - one related to a retained swab and the other was being investigated and related to robotic equipment usage), one delay to treatment, one obstetric complication and one complication of catheterisation. 5
The delay to treatment was an ophthalmology follow up appointment whereby the letter went to the wrong address. The obstetric complication related to a baby born in a distressed state and it was identified that some improvements could have been made. The catheterisation incident involved a patient with major trauma to the pelvic area and urethra which needed surgical repair. Mr Welch explained that it appeared that national protocol had not been followed and changes had been implemented to prevent this from happening again. Mr Welch explained that for all serious incidents a review panel of 7 to 8 staff was convened and allocated 4 weeks to investigate and report the incident fully. He acknowledged that there was a tendency to over report however this aided transparency. Mrs Moon explained that incident reporting rates had increased, despite increased demand for services which reflected a positive patient safety culture. Mrs Moon commented that the graph showing the December data for total patient incidents reported had been omitted and would be included in the February report. The number of incidents reported per 1000 bed days in December continued to exceed the Trust target although it was slightly below the number of incidents reported in the same month during 2015/16. Mrs Moon reported that the percentage of incidents that resulted in severe harm or death in December was higher than the previous month and higher than that reported in the same month during 2015/16. However none of the incidents had yet been fully investigated so the percentage may reduce once severity was confirmed. The most recent SHMI results showed that the Trust had scored 98 which were slightly lower than the previous quarters. This remained lower that the national average but within the as expected category. The slight decrease seen in the data related to the removal of the January to March 2015 deaths (this quarter showed a higher rate of deaths nationally compared to previous years and impacted on SHMI rates across the UK). The most recent HSMR results showed there had been a slight increase in HSMR for the month of August 16. HSMR rates would continue to be closely monitored. Mr Welch explained that HSMR data was produced 6 months behind and was based on clinical coding data and therefore the HSMR score for each month would change slightly as more patients were discharged or die and the coding is completed. Mrs Lamont explained that Safeguarding was still high however December had seen a reduction in Cause For Concerns (CFC s) across all of the Safeguarding teams which were likely to be reflective of the holiday period. The exception to this was FGM notifications which have risen. Cause For Concerns in relation to selfneglect continued to rise and notably, the Safeguarding teams had been involved in a case of modern day slavery which was notified to the Trust by adult social care and was the first reported case known to the Trust safeguarding teams. 6
Mr Weir commented that there was an expectation that more Modern Day Slavery cases would be reported in the future. Mrs Parker referred to the good recommendation rates which reflected positive patient experience and the reduction in the numbers of complaints. Mr Jowett expressed caution that whilst some of the Never Events could be assumed to be medically insignificant however for the patient itself it may be a significant concern and could have reputational impact. Mr Welch agreed and stated that for every 16,500 patients who go to surgery, on the basis of statistics one would be a Never Event. Mrs Moon explained that medication data was a good indicator of reporting and radiation incidents were relatively stable over the course of the year however there had been a drop in near miss incidents. to receive the briefing and note the current position. ii) Business Delivery and Performance Report Mrs Robson presented the report and explained that overall strong performance was evident. Referral to Treatment targets had been consistently achieved. Mrs Robson explained that the Cardiothoracic Directorate was showing a sustained growth in patients waiting for a first outpatient appointment and December alone showed a growth of 20% when compare to July 2016. Work had commenced to ascertain the reasons for such growth Mrs Robson agreed to provide an update at the next Trust Board meeting (ACTION03). The Trust met all of the Cancer standards in November 2016. Mrs Robson advised that the Corporate Cancer Team continued to work with all tumour groups to establish robust processes to support the new breach re-allocation guidance. A breach re-allocation policy had been drafted by the Cancer Alliance and analysis of the November 62 day standard data showed that applying the breach reallocation guidance resulted in a slight improvement in Trust performance. Further refinements in the process were being made. Mr Welch commended the work of the Trust Cancer Team and all Board members acknowledged the consistently strong performance of the team in meeting the Cancer standards. Whilst the Trust continued to report low numbers of ambulance handover delays, the 21 reported in December 2016 was the highest number reported since April 2014. The breaches have been undergoing validation but initial feedback suggested that these were not genuine delays but were related to the administrative process of handing over the patient on the IT system. Mrs Robson explained that the Trust failed to meet the A&E 4 hour waiting time target in December 2016 and Quarter 3 at 91.4% and 93.3% respectively. She added that there had been no significant increase in the volume of main Emergency Department attendances however there was a higher level of acuity in 7
patients attending the Department; medical staffing shortages were a challenge and bed pressures had compounded the matter further. Mrs Robson highlighted that from April 2017, NHS Trusts would have to report how quickly they were treating patients experiencing mental health crisis in A&E or hospital wards as part of new NHS England standards. Whist the Psychiatric Liaison Service for Newcastle currently operates 8am to 9pm 7 days a week (with Older Peoples service Monday-Friday 9am-5pm), Northumberland Tyne & Wear NHS Trust has requested funding to recruit additional staff into the team to meet core 24 standards and to ensure the service is provided on a 24/7 basis accordingly. Mrs Lamont expressed her support for the work of the Crisis Team. Mr Weir commented that the level of A&E attendances were a real reflection of the pressures faced by staff in the Department. Mrs Lamont explained that patient feedback in the Emergency Department was very positive and demonstrated excellent care provision. Mr Welch added that the Trust was committed to treating patients inside hospital premises rather than in ambulances. to note the content of the report. iii) Clinical Assurance Toolkit (CAT) Update Report Mrs Lamont presented the report and explained that overall CAT scores were between 95% and 96% between July and December. Peer reviews had taken place in August, October and December which provided additional assurance regarding the process. Mrs Lamont outlined that the focus of this report was on Infection Prevention and Control (IPC) Practice. The results demonstrated some areas of good compliance with IPC policies across the Trust. In addition some areas for improvement were identified relating to medical reviews of patients with non-infective diarrhoea in particular. Mrs Lamont explained that in some cases capacity restraints prevented patients with diarrhoea from being isolated appropriately and there was a need to further improve documentation. An overview of the areas with red scores for two months that had been escalated to Matrons was reported. There were 7 areas in October, 7 in November and 6 in December. Cleanliness checks were red in 5 areas for each of the two months ending October, November and December. Mrs Lamont highlighted that Governors were actively engaged in the Acknowledging Continuous Excellence (ACE) awards process. Work had been undertaken to raise the profile of the ACE Awards and to simplify the application process which had led to a surge in applications. One Ward received an award for patients on the Ward not having had a pressure ulcer in the last 2 years. to note the content of the report. 8
iv) Learning Disability Update Report Mrs Lamont presented the report and confirmed that the Trust was demonstrating achievement against all six Care Quality Commission (CQC) requirements and was now able to flag the patient record to alert professionals that patients had a learning disability. Protocols and pathways were present to ensure needs were being met and were being integrated into Trust Policy and Practice. The Trust continued to undertake formal Learning Disability Mortality Reviews and was keen to participate in work to identify a Multi-Agency process and panel to review local cases. Mr Welch highlighted that the Mortality Review Group was working effectively and any lessons learned were shared appropriately. Mrs Lamont advised that the CQC had recently published a report of its review of how NHS Trusts review and investigate the deaths of patients in England. The report was published one year after a NHS England review uncovered failings at Southern Health Foundation Trust. The CQC looked at how acute, community and mental health Trusts across the country investigate and learn from deaths of people who have been in their care. The CQC stated in their report; that they were not able to identify any Trust that demonstrated good practice across all aspects of, identifying, reviewing and investigating deaths, and ensuring that learning is implemented although some Trusts demonstrated promising practice at individual steps. Mrs Lamont explained that NuTH had previously been identified as demonstrating good practice across all areas in the Trust CQC inspection report therefore disagreed with the statement made. Mrs Lamont advised that there was a high level of patient satisfaction and feedback from the high number of appointments was very positive. 17/06 Finance to i) receive the report, ii) note the progress made and iii) endorse the ongoing work. i) 2016/17 Month 9 Finance Report Mrs Dragone presented the position as at 31 st December 2016. At Month 9 the Trust was tracking the planned position with an actual surplus of 10.8m (before impairment). Mrs Dragone explained that the Trust had received a revised Control Total offer for 2016/17 and following formal agreement of the offer the Trust would be forecast to deliver of a 7.5 million surplus at the year end, subject to the removal of fines and penalties for Q3 and Q4. Mrs Dragone confirmed that agreement of the Control Total may provide access to Sustainability and Transformation Funding and other capital funding. 9
Cash holdings stood at a healthy 108.7 million, some 12.6 million higher than plan, mainly due to an increased level of accruals in respect of laboratory medicine managed equipment service contract, pharmaceuticals, estates and CCG fines. Capital expenditure was 4.6 million higher than plan, at 23.8 million, as a result of the deed of variation to the PFI contract taking effect, resulting in the addition of phase 9 with a value of 11.4 million. This was shown as an over spend against Plan with the planned date of addition being March 2017. Under spends have materialised on Estates planned maintenance and new and replacement equipment budgets. Mrs Dragone explained that the Trusts overall Risk Rating was 1 on a scale from 1 to 4, higher numbers reflecting lower risk. Mrs Dragone highlighted that the Trust was expecting to deliver 30.6 million of savings in 2016/17, 2.7 million less than target with a projected 4.2 million recurrent shortfall. Work continued to close the recurrent shortfall. As at 31 st December 22.5 million of planned savings have been recognised, equating to 9/12ths of 30.6 million. 17/07 Items to Receive to receive the report and acknowledge the overall financial position for the period to 31st December 2016. i) Council of Governors 19 th January 2017 Mr Smith advised that Mr P Ramsden had stood down as Chair of the Nomination Committee and that Dr M Saunders had therefore been appointed as Chair of the Nomination Committee. ii) Annual Report & Accounts 2016/17 - Timetable Mrs Dragone explained that the paper set out the key dates for the Annual Report and Accounts process for the financial year 2016/17. to receive the timetable. The meeting closed at 1.50pm. The next scheduled meeting would be held at 12-45pm on Thursday, 23 rd February 2017. 10