A P NE UBLIC MEETINGthe introduction of a summative assessment rather than a formative assessment. Once the assessment becomes summative systems and processes have to be very precise

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Agenda - 26 April 2012.doc

Russell Hardy �� 4358 Chairman

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TTHHEE BBOOAARRDD RROOOOMM

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1.0 Apologies:

2.0 Minutes of the previous meeting held on 29th March 2012 Paper 1

3.0 Matters Arising

4.0 Declarations of Interest

SSTTRRAATTEEGGYY 5.0 Launch of Patient Information DVD : Oswestry Pain Management Programme Presentation

6.0 Future Education and Training Arrangements in the NHS Presentation

PPEERRFFOORRMMAANNCCEE 7.0 Month 12 Integrated Performance Report Paper 2

GGOOVVEERRNNAANNCCEE,, QQUUAALLIITTYY AANNDD SSAAFFEETTYY 8.0 Directors Declarations of Interest Paper 3

9.0 Quarter 4 Board Assurance Framework Paper 4

10.0 Quarter 4 Monitor Return Paper 5

11.0 Statement of Going Concern Paper 6

12.0 Equality Delivery System 2012 Paper 7

13.0 Monitor 2012-13 Compliance Framework Paper 8

14.0 2012-13 Trust Balanced Scorecard Paper 9

15.0 Reports from Board Sub Committees

16.0 • Business Risk and Investment Committee – 21st March 2012 Paper 10

• Quality and Safety Committee – 30th March 2012 Paper 11

17.0 Any Other Business: None notified

18.0 Questions from the Public

19.0 Date and time of next meeting: 9.30 a.m. on 29th May 2012, The Board Room, RJAH Orthopaedic Hospital NHS Foundation Trust, Oswestry

Questions from the Public on Agenda items – time limit of 15 minutes There will be an opportunity for the public to ask questions on agenda items. These should be limited to two questions per person and the time in total for each person should be limited to five minutes. If topics are likely to exceed this, they should be the subject of discussions between the hospital management and the individual concerned or there should be a formal request agreed by the Board of Directors or the item to be included on the next agenda. If questions are detailed and require information that is not instantly available, the hospital will respond to the question within ten working days.

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Agenda - 26 April 2012.doc

To resolve, in accordance with Trust Standing Orders, that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

(Section 1(2) Public Bodies (Admission to Meeting) Act 1960)

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20.0 Minutes of the previous meeting held on 29th March 2012 Paper 12

21.0 Matters Arising

• Update on 2012-13 Financial Plan

Verbal

22.0 Chief Executive’s Report Verbal

23.0 18 Week Referral to Treatment : Letter from Monitor Paper 13

24.0 18 Week Referral to Treatment Position Update Presentation/ Paper 14

25.0 Statement on Balance of Board Membership Paper 15

26.0 Minutes from Board Sub Committees

27.0 • Business Risk and Investment Committee – 21st March 2012 Paper 16

• Quality and Safety Committee – 30th March 2012 Paper 17

28.0 Any Other Business: None notified

29.0 Date and Time of Next Meeting: 29th May 2012 following the Public Board of Directors meeting

Paper 1

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 01 Draft Trust Board Minutes 29-

03-12.doc

1



2299TTHH MMAARRCCHH 22001122

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PPRREESSEENNTT:: Russell Hardy, Chairman Wendy Farrington Chadd, Chief Executive

David James, Director of Operations

John Grinnell, Director of Finance Jayne Downey, Director of Nursing

Professor Iain McCall, Medical Director James Turner, Non Executive Director

Glen Lawes, Non Executive Director

Peter Jones, Non Executive Director Mervyn Dean, Non Executive Director

Richard Clarke, Non Executive Director

IINN AATTTTEENNDDAANNCCEE:: Ruth Tyrrell, Associate Director of HR

Margaret Surrage, Head of Board Governance (Trust Secretary)

Janet Cox, Minutes Secretary

MMEEMMBBEERRSS OOFF TTHHEE PPUUBBLLIICC::

Paul Harris, Community Health Council June Jones, Shropshire Patient Group

PPAARRTT OONNEE –– PPUUBBLLIICC MMEEEETTIINNGG

MMIINNUUTTEE NNOO TTIITTLLEE AACCTTIIOONN

29/03/1.0 AAPPOOLLOOGGIIEESS

There were no apologies.

29/03/2.0 MMIINNUUTTEESS OOFF TTHHEE PPRREEVVIIOOUUSS MMEEEETTIINNGG

The minutes of the previous meeting were agreed as an

accurate record.

29/03/3.0 MMAATTTTEERRSS AARRIISSIINNGG

The Chairman went through the actions which had been completed.

The Director of Finance commented that the Business Risk

and Investment Committee had received reports relating to both the Cash position and Capital Programme at its meeting

on 21st March and that the minutes ought to be amended to

reflect this. This was agreed.

29/03/4.0 DDEECCLLAARRAATTIIOONNSS OOFF IINNTTEERREESSTT

There were no new declarations of interest to be recorded.

29/03/5.0 CCHHAAIIRRMMAANN’’SS RREEPPOORRTT The Chairman updated the Board of Directors on the Council

of Governors meeting which had been held on the 23rd

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2

February. He explained that the main focus had been around

the business planning cycle and the Governors had received a presentation from the Chief Executive and Director of Finance

which outlined the key principles for the annual plan which

had been identified in the Integrated Business Plan and presented to Monitor as part of the authorisation process. He

confirmed that the Governors had been happy with the three strategic aims identified and the approach which had been

taken towards producing the annual plan.

The Board of Directors noted the Chairman’s Report.

SSTTRRAATTEEGGIICC DDIIRREECCTTIIOONN AANNDD DDEEVVEELLOOPPMMEENNTT

29/03/6.0 RREEVVAALLIIDDAATTIIOONN

The Medical Director gave a presentation which updated the Board of Directors on progress since the previous update in

2010. He explained that the systems haven’t changed significantly.

Peter Jones, Non Executive Director commented that he was pleased that throughout the presentation reference was made

to the involvement of the Quality and Safety Committee and the Board of Directors in elements of this process and asked

whether it was the intention for the Board of Directors to

receive an annual report to give assurance on the process. The Medical Director replied that the Board of Directors

receive an annual report on Consultant Medical Appraisals but the Board of Directors need to be comfortable with the

processes that the Medical Director undertakes as the responsible officer for Revalidation. The Chairman suggested

that the responsible officer for Revalidation (the Medical

Director) gives an annual update to the Board on appraisal and revalidation.

The Chief Executive then asked the Medical Director to update

the Board of Directors on the timescale for the

implementation of the process. The Medical Director explained that it should have been implemented in October

2012 but he understands that this has now been deferred with no date yet suggested. He said that the important thing

was for the process to be carried out correctly when it is

introduced. He added that secondary and tertiary services have been ‘ready’ for this as the formal appraisal process has

been in place since 2001 but that the main difference now is the introduction of a summative assessment rather than a

formative assessment. Once the assessment becomes summative systems and processes have to be very precise as

they are open to scrutiny. For the primary care system this is

a major change with enormous system changes to be introduced.

The Chairman said that the Board of Directors need

appropriate assurance on Consultant’s fitness to practice and

purpose as they would be concerned if a Consultant was found not to be.

James Turner, Non Executive Director said that he was very

reassured by the information provided by the Medical Director and asked whether there was opportunity for the hospital to

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3

supplement the standards expected by the GMC. The Medical

Director said that the fitness for purpose is the key point and the organisation has to consider whether the standard is

appropriate and may wish to set its own standards. He added

that most individuals will already be performing above the national average.

The Chief Executive added that this was an ideal opportunity

for the hospital to set the highest standards around performance, conduct, behaviour and leadership. This was

supported by the Chairman.

The Board of Directors noted the update on Revalidation.

29/03/7.0 SSTTAAFFFF OOPPIINNIIOONN SSUURRVVEEYY 22001111 The Associate Director of Human Resources presented the

results of the 2011-12 NHS Staff Opinion Survey. She explained that the Trust exceeded the national average in the

majority of the following areas:

• Staff receiving appraisals

• Staff who would recommend the hospital as a place

to work

• Staff feeling satisfied with the quality of care provided

to patients • Staff would recommend the hospital to a friend or

relative if they required treatment (91% against the

national average of 62%) • Staff being able to carry out their job to a standard

they are personally pleased with

The Trust was lower than the national average in the following areas:

• Communication between senior managers and staff

• Staff experiencing physical violence from patients,

their relatives or other members of the public • Staff experiencing bullying or harassment from

patients, their relatives or other members of the

public • Reported incidents of physical violence and abuse.

She added that the Trust responses are benchmarked against

acute specialist Trusts which makes the average higher as generally this group have better scores than the larger acute

Trust group.

Mervyn Dean, Non Executive Director commented that he was

surprised and concerned that only 58% of staff would recommend the Trust as a place to work as this was at odds

with the reflections he has had during recent visits. He added that a lot of effort has been put into improving communication

and again he was surprised at how low the score was for this area. The Associate Director of Human Resources responded

that 4 out of 5 nurses and 4 out of 5 doctors would

recommend the hospital as a place to work. For those that wouldn’t, she said that this reflects the changes which have

been implemented locally for staff. She added that communication across the NHS is a cultural issue and is

generally very low but that the hospital would continue to

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focus on this.

Glen Lawes, Non Executive Director said he was disappointed

in the scores relating to appraisals and asked whether the

training provided in this area was sufficient and appropriate. The Associate Director of Human Resources said that the

appraisals were linked to the Knowledge and Skills Framework (KSF) which is a bureaucratic process but that this had now

been simplified which should help with the process.

The Chief Executive added that it was important to note that

this was a response to a survey and was not necessarily the views of all staff. The Associate Director of Human Resources

added that there had been a 46% response rate to the 350 staff who were randomly selected to complete the survey.

James Turner, Non Executive Director commented that this

was 12% of the workforce and was a big enough sample to use.

The Associate Director of Human Resources commented that

it was important to separate the internal and external influences such as the Health and Social Care Bill. Richard

Clarke, Non Executive Director agreed with this statement but

said that this was at odds in comparison to other specialist trust scores where the hospital had scored lower, for example

31% of staff being satisfied with the extent to which the Trust values their work.

The Chairman questioned whether the results were truly representative and said it was important to balance these

against what Executive and Non Executive Directors ‘hear’ when meeting staff themselves. He said that it was important

the hospital does not become complacent in its aim of being

the best place to work.

The Chief Executive added that the Board currently has little or no influence or control over pay and conditions and

particularly with the national position on pensions the impact of this should not be under-estimated.

James Turner, Non Executive Director said that as over 100 members of staff have completed the survey it is important

that the results are taken as they are. He commented that with regards to the results for communication, for him, this

was one of the most disappointing scores given the overall

size of the organisation and low turnover of staff and this should be an area that the hospital excels in. He added that

he would like a clearer action plan put in place to ensure that next year when the scores are reviewed, this will have

improved. The Associate Director of Human Resources clarified that it was about cultural change and confirmed that

actions are in place to improve this specifically the

introduction of team brief sessions; the appointment of communications champions; staff Governors; the online

participation in the development of the HR strategy as well as presentations to staff groups. She added that there was lots

that would be done to engage and involve staff and embed

the work that has already started and make it work better than it had in the past.

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The Board of Directors noted the contents of the report agreed the support for the implementation of the action plan and agreed that the JCG regularly oversee progress.

PPEERRFFOORRMMAANNCCEE AANNDD GGOOVVEERRNNAANNCCEE

29/03/8.0 MMOONNTTHH 1111 IINNTTEEGGRRAATTEEDD PPEERRFFOORRMMAANNCCEE RREEPPOORRTT

The Chief Executive introduced the Month 11 integrated

performance report and explained that February had been a good month with overall delivery in terms of quality, safety,

activity and financial metrics continuing at very strong levels. She added that all domains remain on track for year end

delivery. The 18 week compliance would be discussed later in

the agenda.

Domain 1 Patient survey The Medical Director reported that overall performance within

the domain remains strong with the majority of targets forecasted to achieve by year end and reported as green on

the scorecard. He highlighted that:

• The Trust is on track to achieve the Clostridium

Difficile ceiling of 2 cases which will change from

amber to green on 31st March 2012 pending no further cases.

• Disappointingly, patient falls increased slightly in

month and were above the target ceiling of 1.6% at

1.73% of inpatient activity. The action taken to reduce these and educate patients will be discussed in

more detail at the Quality and Safety Committee on 30th March 2012.

Peter Jones, Non Executive Director asked for confirmation

around the definition of falls that this includes falls or

stumbles that do not cause patient harm. The Medical Director confirmed that these are included in the data. The

Director of Nursing added that one area that the Trust needs to concentrate on is the visibility of the nursing staff so that

patients know that they are available to assist with trips to the

bathroom where the majority of falls are occurring.

The Chairman commented that there is a difference between

a patient who is determined to be independent and a patient who can’t find a member of staff to help and the potential

outcome to these scenarios. The Medical Director confirmed that work was being done to reinforce to patients during both

sets of circumstances.

Domain 2 Patient experience The Director of Nursing reported that all metrics are reported

to achieve by year end and are rated as green on the scorecard with the exception of the English patient access

target which remains under review. She highlighted that:

• Patient satisfaction remains above target at 98.21%

• There were 10 complaints in month which is one

above the ceiling and is therefore rated amber on the

scorecard. There were no trends identified. • Delayed Discharges increased in month as a result of

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difficulties with Social Services care packages being in

place. Improved performance in this area will be targeted over the next 12 months.

The Director of Operations reported that:

• Access targets for tumour have been maintained.

• The Welsh 26 week referral to treatment target was

achieved although there were 2 none admitted breaches and 3 admitted breaches over the overall 36

week target. • The 18 week referral to treatment target is rated red

on the scorecard owing to the non submission of data

pending the waiting list management review.

Mervyn Dean, Non Executive Director commented that he had

recently visited Sheldon Ward and spoken to some patients who could have been discharged but it had taken time to

organise the finances and paperwork to move them to a local

nursing home. He asked at what point is a discharge recorded as delayed and if these would be considered as

delayed discharges. The Director of Nursing confirmed that once a patient is medically fit, they are then classed as a

delayed discharge if they do not then leave hospital.

Russell Hardy, Chairman commented that as there are going

to be changes to funding routes in the future, it is important

that the links with Social Services previously in place are reinforced to ensure that patients can go back home or into

the community in a timely way.

Richard Clarke, Non Executive Director raised a query

concerning an Orthotic device and the Director of Nursing promised to respond outside of the meeting.

Domain 3 Efficiency The Director of Operations reported that strong performance

across the domain continued in February and focus will remain to ensure that performance to the end of the year is

improved. He highlighted that:

• Surgical inpatient activity was behind plan in month.

However as a result of a richer casemix, inpatient

activity was ahead in terms of financial performance. • Medicine inpatient activity was below plan but the

Outpatients activity was above plan.

• The new to follow up ratio has fallen as a direct result

of the additional Outpatient activity undertaken in

February. • Both the outpatient and inpatient waiting lists

decreased in month. The outpatient waiting list is

rated red on the scorecard as a result of the number of patients waiting for spinal disorders, upper and

lower limb. • Theatre utilisation remains high.

• The cases per session reduced slightly in February as

a result of a more complex casemix.

• The daycase rate also decreased slightly again as a

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7

result of the more complex casemix.

• The average length of stay has reduced to 4.7 days

but remains red on the scorecard as this is still above the target. The number of hips and knees discharged

in 4 days has increased to 64%.

• Bed occupancy remains below target at 81%

Russell Hardy, Chairman commented that it was important

that bed occupancy and day case rate remain under close focus as the Trust moves into the new financial year as these

metrics are key to driving efficiencies.

The Chief Executive commented that the metrics would be

updated for the 2012-13 plan.

Domain 4 Resources The Director of Finance reported that performance within this domain remained strong in February as all metrics continue to

perform ahead of plan. He highlighted that:

• A surplus of £70k had been delivered in February

against a plan of £50k. Cumulatively the surplus

stood at £1.3m at month 11 which is the full year target. The forecast has therefore been revised to

deliver a £1.5m surplus at year end which is supported by the bookings position for March.

• The February income position was strong with the

heaviest casemix financially for a number of years.

This had however impacted on the cost base with the mix of patients treated.

• Expenditure had been high in month which was

driven by the cost of some complex cases. Added focus has therefore been concentrated on the areas

of bank and agency spend and this will be monitored

closely over the coming months. • CIP performance was lower than plan in month at

£26k as a result of cost pressures owing to the

increased activity. It is still forecasted to achieve the £3.07m target at year end.

• Cash balances reduced to £7.3m and is forecast to be

£5m at year end which is £2m more than planned. • Capex is in line with plan at Month 11 with a forecast

delivery of £5m by year end.

• Compliance against the CBI Prompt Payment Code

declined in month as a result of the upgrade to the

financial system so is rated as amber on the scorecard.

• Financial risk rating is at level 4 which confirms the

Trust is performing at a low risk level.

The Associate Director of Human Resources reported that:

• Sickness absence reduced to 3.3% in February and is

predicted to be at this level at year end which his

above the predicted 3% target and is therefore rated as amber on the scorecard. She explained that the

SHA has targeted all Trusts within the region to achieve 3.39% by 2015 and it is likely that the Trust

will reach this ahead of this deadline. She added that

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she had attended the regional HR Directors meeting

on 28th March to update them on the measures which had been implemented to improve sickness absence

at the Trust.

• Performance against the staff appraisal metric

improved in month but is rated red on the scorecard as it remains below target. Managers have been

instructed to put plans in place to improve this by year end.

Glen Lawes, Non Executive Director asked whether a post

project evaluation would be undertaken for the Rheumatology

service in Telford. The Director of Finance said that in the usual course of events this would not be tracked given the

size of the service.

James Turner, Non Executive Director confirmed that cash

management had been reviewed at the Business Risk and Investment Committee and one area that required additional

focus was the cash forecasting.

Russell Hardy, Chairman commented that 4 years ago the Trust’s financial position was extremely delicate and since that

point, very solid financial performance has continued to be

delivered. He said he was pleased that in the Trust’s first year as an NHS Foundation Trust, it had been able to over

deliver on its original budget. He added that the Executive Directors deserved praise for their good leadership and

management that had brought the Trust to this position.

The Board of Directors noted the Month 11 Integrated Performance Report.

29/03/9.0 UUSSEE OOFF TTRRUUSSTT SSEEAALL 22001111//1122

The Head of Board Governance (Trust Secretary) presented information relating to the use of the Trust Seal during

2011/12 in line with the Trust’s Standing Orders.

The Board of Directors noted the use of the Trust Seal during 2011/12.

29/03/10.0 MMOONNIITTOORR QQUUAARRTTEERR 33 FFEEEEDDBBAACCKK

The Chief Executive presented the Quarter 3 Feedback from Monitor following the recent submission. She explained that

the Trust retains its financial risk rating of 4 and governance rating of amber/green. The amber relates to the risk of

infection because of the extremely low ceiling. The 18 week policy had been flagged up as the Trust had highlighted this

as an issue.

The Board of Directors noted the Quarter 3 Monitor Feedback.

29/03/11.0 FFOOUUNNDDAATTIIOONN TTRRUUSSTT BBUULLLLEETTIINNSS The Chief Executive presented the February and March Foundation Trust Bulletins from Monitor which the Head of

Board Governance (Trust Secretary) had reviewed to ensure that required actions were being progressed.

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The Board of Directors noted the Foundation Trust Bulletins for February and March.

29/03/12.0 AANNYY OOTTHHEERR BBUUSSIINNEESSSS

On behalf of patients, their families and staff, the Chairman gave his thanks to Professor Iain McCall, Medical Director and

David James, Director of Operations for their many years of service to the hospital and in the part they had played in

ensuring the future of the hospital and its aim of delivering

outstanding patient care.

Patient Outcomes Paul Harris, CHC Representative asked when data regarding

outcomes would be available to the public. The Medical

Director responded that national data is already available to the public but data relating to individual surgeons was not

currently available.

29/03/13.0 QQUUEESSTTIIOONNSS FFRROOMM TTHHEE PPUUBBLLIICC

There were no questions from the public.

29/03/14.0 DDAATTEE OOFF NNEEXXTT MMEEEETTIINNGG::

Thursday 26th April 2012 at 9.30 a.m. in the Board Room.

CCHHAAIIRRMMAANN’’SS CCLLOOSSIINNGG RREEMMAARRKKSS The Chairman thanked everyone for their contribution and

closed the public session of the meeting.

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BBOOAARRDD OOFF DDIIRREECCTTOORRSS MMEEEETTIINNGG


SSUUMMMMAARRYY OOFF KKEEYY AACCTTIIOONNSS

Action Lead

Responsibility

Progress

2299//0033//22..00 MMIINNUUTTEESS OOFF TTHHEE PPRREEVVIIOOUUSS MMEEEETTIINNGG

• Minutes to be corrected.

Minutes Secretary

Completed.


2266TTHH AAPPRRIILL 22001122

Russell Hardy �� 4358

Chairman

Executive Responsible John Grinnell, Director of Finance

Paper prepared by (if different from above)

Helen Ashcroft, Business Planning Manager Craig Macbeth, Deputy Director of Finance

Category of Item Strategic Direction and Development

Performance and Governance �

Context Previous Board discussion

Link to National Policy �

Link to Trust’s Strategic

Objectives

�

Risk if no action taken

Executive Summary

The Trust’s month 12 Performance Report is detailed in the attached paper.

Received or approved by

Legal Implications None

Recommendation It is recommended that the Board note: • The performance at March 2012 (Month 12).

Subject/Title March (Month 12) Integrated Performance Report

Nature of Report For Information

For Discussion �

For Approval �

Paper 02

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 02 Month 12 Integrated Performance Report 1

Balanced Scorecard Trust Board

2011 / 2012 Month - 12

VISION

To be the leading centre for high quality, sustainable Orthopaedic and related care, achieving excellence in both experience and outcomes for our

patients

Period Key Metric Actual Year to date Change Year End

Position

Mar-12 Infection Control Overall g g better g

Mar-12 Serious Incidents a g worse g

Mar-12 Never Events g g same g

Mar-12 Deaths a a worse a

Mar-12 Medicine Management g g same g

Mar-12 Patient Falls g a better a

Mar-12 Pressure Ulcer Assessments g g same g

Mar-12 CQUIN Overall g g same g

Feb-12 30 day Readmission Rates to RJAH for all specialties g g same g

Patient Safety

Overall Performance


Position

Mar-12 Monitor Risk Rating - Finance g g same g

Mar-12 Monitor Risk Rating - Quality Governance a a worse a

External Perception

Overall Performance


Position

Mar-12 Patient Satisfaction g g same g

Mar-12 Number of Complaints a g same g

Mar-12 Access to Bone Tumour Services g g same g

Mar-12 Access to Services (RTT) - Welsh g g worse g

Mar-12 Access to Services (RTT) - English r r same r

Mar-12 Reportable Cancellations g g same g

Mar-12 Delayed Discharges g g better g

Patient Experience

Overall Performance


Position

Mar-12 Income and Expenditure g g same g

Mar-12 CIP Delivery g g worse g

Mar-12 Capital Expenditure g g better g

Mar-12 PSPP a a same a

Mar-12 Liquidity Ratio g g same g

Mar-12 Sickness Absence a a worse a

Mar-12 Staff Turnover g g same g

Mar-12 Staff Appraisal a a better a

Resources

Overall Performance


Position

Mar-12 Activity - Surgery g g better g

Mar-12 Activity - Medicine r r same r

Mar-12 New to Follow Up Ratio (Consultant Led Activity) g g same g

Mar-12 Demand Against Contract r r same r

Mar-12 Daycase Rates a a same a

Mar-12 Admission on Day of Surgery g g same g

Mar-12 Theatre Efficiency g g same g

Mar-12 Average Length of Stay - Overall g g same g

Mar-12 Average Length of Stay - Hips and Knees r r same r

Mar-12 Bed Occupancy - Adult Orthopaedic Wards r r same r

Efficiency

Overall Performance

Paper 02


BOARD OF DIRECTORS

INTEGRATED PERFORMANCE REPORT

MARCH 2012

1. Introduction

1.1 This paper presents the Trust’s performance at the end of March 2012, the twelfth

and final month of the 2011/12 financial year.

1.2 The 2011/12 performance report details performance against the core standards set

nationally by Monitor, the Department of Health and Care Quality Commission, locally agreed CQUIN quality improvement targets and internally driven improvement

targets.

1.3 The scorecard and performance report format and metrics have been developed

using the Trust’s electronic planning and performance system (interplan) and reflect the format agreed by the Board in the May 2011 Trust Board paper ‘2011/12 Trust

Balanced Scorecard’.

1.4 Domain 5, of this report looks at the external perception of the Trust and includes

further details of performance against Monitor’s compliance framework which supports the Trust’s self declarations to Monitor at the end of the quarter.

2. Chief Executive’s overview

2.1 March has shown continued positive performance overall across all domains, with the

exception of patient access due to the admitted 18 week target. This was highlighted in the last performance report and whilst we have a recovery plan in place, the year

end performance is reflected in the balanced scorecard. Whilst this is disappointing we have responded promptly to the recommendations following the IST review and

have a recovery trajectory agreed for this measure. The revised access policy is in

place effective from April.

2.2 Performance across the other key measures including financial metrics, key quality indicators and efficiency has been positive and for the year overall we have

demonstrated excellent performance across the Trust. Considerable improvements in efficiency have been made and we continue to score highly in terms of patient

satisfaction.

2.3 The graphs in the report show significant improvements in year in daycase rates,

admissions on the day of surgery and in overall length of stay which is now at 2.3 days. This is particularly impressive when we factor the increase in hips and knees

overall. Bed occupancy has throughout the year been 10% below planned levels.

These metrics are important and demonstrate on going improvements in our operational efficiency which are key to the sustainable delivery of high quality care.

3. March performance overview

3.1 Domain 1 – Patient safety

3.1.1 Patient safety: Directors assessment – Overall performance within this domain

has been exceptionally strong throughout the year with a majority of targets having been achieved at the year end.

Paper 02


3.1.2 Infection control & screening - There were no cases of hospital acquired MRSA bacterium or C. Difficile in March and across the year as a whole infection rates have

remained low with the Trust achieving all externally set targets.

Quarter 3 Surgical Site Infection rates for hips and knees have been received by the

Trust. During that quarter hip infection rates were 0.8% (3 infections) against an internally set target of 0.9% whilst knees infection rates were 0.9% (again 3

infections) against a target of 0.7%.

3.1.3 Never events & serious incidents – There were no never events in March, however there were three serious incidents. The three serious incidents all related to

safeguarding issues. All three incidents have been managed in line with Trust policies

and will be reviewed by the Trust’s Quality and Safety Committee.

3.1.4 Deaths – There were two patient deaths in March both of which were patients on end of life care pathways and were expected. The total number of deaths in year is

reported as amber at year end; however this not considered an overall concern as a majority of those which have occurred have been expected following the patient’s

admission to medical wards for deteriorating long term conditions and co-morbidities.

This metric is to be reassessed for 2012/13 to reflect only unexpected deaths.

3.1.5 Medicines management – There were 11 medication incidents in March which resulted in a change to Patient’s planned treatment. Two involved prescribing, six

were administration errors, two dispensing errors, one mislabelling medication brought in with a patient. This represented 0.79% of the total Trust inpatient activity.

Each incident has been investigated by the Medicines Management Co-ordinator and

no patient harm occurred.

3.1.6 Patient falls – The % of patient falls decreased in March to 1.28% of inpatient activity (10 falls) bringing performance within the target ceiling of 1.60%. There were

no clear trends in the falls which occurred.

3.1.7 Pressure ulcer assessment – The Trust continues to maintain its performance with regards to pressure ulcer assessments undertaking 100% of pressure ulcer

assessments against a target of 99%. In month there were no grade 3 or 4 pressure

ulcers which would require external reporting.

3.1.8 CQUINs – The year end position against the key 2011/12 CQUIN metrics demonstrates an overall achievement of 85%. Following positive discussions with

commissioners this metric is reported as green within the Balanced Scorecard.

3.1.9 30-Day readmission rates to RJAH for all specialties – The percentage of readmissions in March for patients who were initially treated in February increased

slightly in month to 1.16%, however remained within the target ceiling of 1.30%.

3.2 Domain 2 - Patient experience

3.2.1 Patient experience: Directors commentary – All metrics within this domain are

reported within the scorecard have achieved their year end targets with the exception of the patient access target.

3.2.2 Patient satisfaction – 95.79% of patients rated the Trust as excellent or good in

March, exceeding the Trust’s 95% satisfaction target.

3.2.3 Complaints - There were 10 complaints in March representing 0.11% of activity

against a target ceiling of 9, as such the in month position is reported as amber. Over the year the overall number of complaints has remained below the target set and so

is reported as green.

Paper 02


Three of the complaints related to operational issues and included delays within outpatients, a transport issue and the timely provision of an orthoses. Seven

complaints related to quality of care and included a communication issue between a patient and the medical team, care within a ward, medical advice and diagnosis

received by two patients and 3 complaints regarding the outcome of treatments

provided.

3.2.4 Access to services (waiting times) – All core National cancer targets were achieved both in month and across the year as a whole.

The Welsh 26 week referral to treatment (RTT) targets for both admitted and non

admitted patients were achieved in month and no patients waited over the maximum

waiting time of 36 weeks.

The Trust has recently reviewed its waiting list management arrangement with regards to the 18 week RTT target and as a result has resubmitted its data from

December 2011 onwards. In March the non admitted RTT was achieved with 98.33%

of patients seen in 18 weeks against a target of 95%. 60.40% of admitted patients were treated in 18 weeks against a target of 90%. Plans have been agreed with

Monitor and our commissioners to turn around this performance in the first half of the new financial year.

3.2.5 Delayed discharges – Delayed discharges decreased in March to 2.00% (3

patients), against a target ceiling of 3.5%.

3.3 Domain 3 - Efficiency

3.3.1 Efficiency: Directors Commentary – The delivery of efficiencies within the Trust

has been challenging during the financial year, however excellent performance has been noted in terms of the overall delivery of surgical activity, new to follow up ratios

and improvements in both the % of patients admitted on the day of surgery and the overall average length of stay over the year.

3.3.2 Activity - Surgery – Overall surgical inpatient activity was behind that planned for the month by 16 cases. However due to the complex case mix undertaken activity

was ahead of the planned financial performance. The total outpatient numbers, including new, follow up and preoperative assessments were above the revised plan

by 338 patients.

3.3.3 Activity Medicine – Medicine inpatient activity continues to be below that planned,

as previously highlighted this is due to the redesign of the Metabolic service model, which will be resolved within the 2012/13 contracts. Outpatient activity exceeded that

planned in month by 216 patients. Due to the inpatient activity profile this metric reported as red within the balanced scorecard.

3.3.4 New to follow up ratio – The new to follow up ratio in month was 1:1.93, achieving the year end target set.

3.3.5 Demand against contract – Additions to the outpatient waiting list increased

sharply in month to 2,420. The outpatient waiting list decreased in month whilst the inpatient waiting list increased slightly, this was due to the number of outpatients

seen in the month.

Both demand and the inpatient waiting list remain within acceptable tolerance

ranges, however the size of the outpatient waiting list mainly within the subspecialties of spinal disorders and upper limb remains a concern and is therefore

this metric is reported as red at the year end. Locum Consultant support is being

utilised to reduce the subspecialty waiting list for lower limb which was previous reported as an area of priority.

Paper 02


3.3.5 Daycase rate – During March the percentage of patients treated as a daycase

decreased slightly to 48.61% against a year end target of 53% and is as such reported as amber in the scorecard. This reduction was due to the complexity of the

case mix which required treatment in month. It should be noted that there has been an overall improving trend in performance with regards to daycase rates though the

year.

3.3.6 Admission on the day of surgery – 81.52% of patients were admitted on the day

of surgery in March against a year end target of 80%. Performance against this target has consistently improved though out the year increasing by 7.95% since April

2011.

3.3.7 Utilisation of available sessions – Theatre session utilisation rates decreased

slightly in March to 95.36%, however remaining above the target of 95%.

3.3.8 Cases per session – During March the Trust achieved an average of 2.24 cases per session against a year end target of 2.4 cases. This represented an increase in the

number of cases undertaken per list from February (2.22), however was lower than projected due to the complexity of the patients treated.

3.3.9 Average length of stay hips and knees – Overall average length of stay (including daycases) was 2.3 days in March against a year end target of 2.3 days.

The average length of stay for both hip and knee patients increased in March to 4.93

against a year end target ceiling of 4.25. This metric is therefore reported as ‘red’

within the scorecard.

It should be noted that 67.01% of hip and 57.54% of knee patients were discharged within 4 days however the overall performance in this area continues to be affected

by a number of patients whose was over 10 days due to medical co-morbidities.

3.3.10 Bed occupancy – The percentage bed occupancy decreased slightly in March to

77.19%. As the overall target occupancy however is 87% this metric is reported as red within the balanced scorecard for the year end.

3.4 Domain 4 – Resources

3.4.1 Resources: Directors Commentary - Performance within this domain remained strong to the year end achieving all financial targets.

3.4.2 Finance overall – We completed the year with the delivery of an additional £0.19m

surplus to take our total for the year to £1.52m (pre impairment). This was in line

with our revised forecast and ahead of original plan by £0.22m.

3.4.3 Income - exceeded plan in month by £1.1m the majority of which was linked to additional activity delivered from our extended capacity working as we successfully

completed additional contracted work for our Welsh Commissioners and recovered the shortfall of our Shropshire contract. In addition to this new RTA claim

notifications were £0.25m higher than expected. We ended the year having earned

an additional £1.9m than originally planned which includes £0.7m from additional RTA and private income. Year end agreements have been reached with all English

Commissioners and the Welsh over performance is within the parameters of additional contracts agreed.

3.4.4 Expenditure - Pay costs increased once more linked to additional surgical capacity.

The pay cost per spell did however reduce in month following review of a number of

surgical areas. We ended the year having overspent against our original pay budget by £0.5m.

Paper 02


Non pay expenditure rose sharply in month driven by a combination of increased surgical volumes and end of year provision re-assessments. We ended the year

having spent an additional £1.3m than originally planned; this was however within the parameters of the additional income earned.

3.4.5 Cost improvements - Further cost efficiencies of £0.34m were recognised in month. This was higher than the monthly plan as adjustments were made to

recognise the cost pressures from additional volumes of work delivered in the final quarter of the year. Cumulatively we have ended the year having identified

efficiencies totalling £3.10m which is £0.03m in excess of the original target.

3.4.6 Cash balances - reduced by £2m to £5.3m as a backlog of creditor payments was

cleared and progress continued with the capital programme. This was slightly higher than the previous months forecast of £5m due to a greater clearance of debtors than

had previously been anticipated.

3.4.7 Capital expenditure - for the month was £1m to take our total spend for the year

to £4.89m which was £0.6m under plan. Most of the shortfall is linked to the remaining spend on the Main Entrance project that will be completed in the new year

and funded by our agreed charitable contributions.

3.4.8 Financial risk rating –The Trust's overall forecast risk rating remains unchanged at level 4 confirming that the Trust is performing at low financial risk.

Sickness rates – Sickness absence rates remained constant in March at 3.49% against a year end target of 3%, as such this target is reported as ‘amber’ at year

end. The average sickness rate across the year was 3.3%.

It should be noted that the sickness absence data and RAG for April to February has

been updated following an internal data audit, this does not materially affect the position reported to the Board.

3.4.9 Staff Appraisal - Performance increased in March to 74.56% of staff having

received an appraisal within a 12 month rolling period from 64.62% in February.

Performance however remains below target and as such is reported as ‘amber’ within the balanced scorecard.

3.5 Domain 5 – External perception

3.5.1 The balanced scorecard reflects the Trust’s Quarter 4 position which will be reported

to Monitor as shown in appendix 1.

3.5.2 The Quality Governance forecast on the Balanced Scorecard front sheet is highlighted as ‘amber’ to reflect the revised referral to treatment figures as detailed in section

3.2.4, which translates using Monitor’s own methodology to a risk rating of 1 ‘amber-

green’.

3.5.3 Following discussions with Monitor they have chosen, due to the primary nature of the RTT target to override the Quarterly return assessment to ‘amber-red’.

3.5.4 The Quarter 4 submission to Monitor will highlight that the Trust was fully compliant

with all other Monitor’s ‘targets and indicators’ including C. Difficile, MRSA, Cancer

waiting times, and Learning Difficulties.

3.5.5 Further details regarding this submission are included within the Trust Board paper “Quarter 4 Monitor Return”.

Paper 02


4. Recommendation

4.1 It is recommended that the Board:

Note the performance for March (Month 12)

John Grinnell Director of Finance, Contracting and Performance

Paper 02


2011/12 Month - 12

Balanced Scorecard - Trust Board

Patient Safety

Infection Control Overall

Hospital Acquired MRSA

0

1

2

3

4

5

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er

Period Target Actual Performance

gApr-11 0.00 0.00

gMay-11 0.00 0.00

gJun-11 0.00 0.00

gJul-11 0.00 0.00

gAug-11 0.00 0.00

gSep-11 0.00 0.00

gOct-11 0.00 0.00

gNov-11 0.00 0.00

gDec-11 0.00 0.00

gJan-12 0.00 0.00

gFeb-12 0.00 0.00

gMar-12 0.00 0.00

Patient Safety

Infection Control Overall

Hospital Acquired C Difficile

0

1

2

3

4

5

6

7

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 0.00

gJun-11 1.00 1.00

gJul-11 2.00 1.00

gAug-11 2.00 1.00

gSep-11 2.00 1.00

gOct-11 2.00 1.00

gNov-11 2.00 2.00

gDec-11 2.00 2.00

gJan-12 2.00 2.00

gFeb-12 2.00 2.00

gMar-12 2.00 2.00

Patient Safety

Serious Incidents

0.0

0.4

0.8

1.2

1.6

2.0

2.4

2.8

3.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 1.00

gJun-11 1.00 0.00

gJul-11 1.00 1.00

gAug-11 1.00 1.00

gSep-11 1.00 1.00

aOct-11 1.00 3.00

gNov-11 1.00 0.00

aDec-11 1.00 2.00

gJan-12 1.00 0.00

gFeb-12 1.00 0.00

aMar-12 1.00 3.00

Paper 02


2011/12 Month - 12


Patient Safety

Never Events

0.0

0.2

0.4

0.6

0.8

1.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 0.00 1.00

gMay-11 0.00 0.00

gJun-11 0.00 0.00

gJul-11 0.00 0.00

gAug-11 0.00 0.00

gSep-11 0.00 0.00

gOct-11 0.00 0.00

gNov-11 0.00 0.00

gDec-11 0.00 0.00

gJan-12 0.00 0.00

gFeb-12 0.00 0.00

gMar-12 0.00 0.00

Patient Safety

Deaths

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 1.00 0.00

gMay-11 1.00 0.00

aJun-11 1.00 4.00

gJul-11 1.00 1.00

gAug-11 1.00 0.00

aSep-11 1.00 4.00

gOct-11 1.00 1.00

gNov-11 1.00 0.00

aDec-11 1.00 2.00

aJan-12 1.00 2.00

gFeb-12 1.00 0.00

aMar-12 1.00 2.00

Patient Safety

Medicine Management

Medication Errors - Total Numbers

4

8

12

16

20

24

28

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 15.00 12.00

gMay-11 15.00 15.00

gJun-11 15.00 12.00

aJul-11 15.00 18.00

gAug-11 15.00 7.00

gSep-11 15.00 8.00

gOct-11 15.00 12.00

gNov-11 15.00 9.00

gDec-11 15.00 8.00

gJan-12 15.00 7.00

gFeb-12 15.00 8.00

gMar-12 15.00 11.00

Paper 02


2011/12 Month - 12


Patient Safety

Medicine Management

Medication Errors as % of activity

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 1.25 1.02

gMay-11 1.25 1.19

gJun-11 1.25 1.02

aJul-11 1.25 1.49

gAug-11 1.25 0.62

gSep-11 1.25 0.61

gOct-11 1.25 0.89

gNov-11 1.25 0.63

gDec-11 1.25 0.63

gJan-12 1.25 0.52

gFeb-12 1.25 0.61

gMar-12 1.25 0.79

Patient Safety

Patient Falls

0.8

1.2

1.6

2.0

2.4

2.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%Period Target Actual Performance

aApr-11 1.60 1.75

rMay-11 1.60 2.07

aJun-11 1.60 1.76

aJul-11 1.60 1.62

gAug-11 1.60 1.40

gSep-11 1.60 1.55

rOct-11 1.60 2.35

aNov-11 1.60 1.86

rDec-11 1.60 2.79

gJan-12 1.60 1.35

aFeb-12 1.60 1.73

gMar-12 1.60 1.28

Patient Safety

Pressure Ulcer Assessments

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 99.00 99.30

gMay-11 99.00 99.52

gJun-11 99.00 99.83

gJul-11 99.00 100.00

gAug-11 99.00 100.00

gSep-11 99.00 99.40

gOct-11 99.00 100.00

gNov-11 99.00 99.86

gDec-11 99.00 99.42

gJan-12 99.00 99.71

gFeb-12 99.00 99.53

gMar-12 99.00 100.00

Paper 02


2011/12 Month - 12


Patient Safety

CQUIN Overall

VTE Risk Assessments

55

60

65

70

75

80

85

90

95

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 90.00 98.56

gMay-11 90.00 98.09

gJun-11 90.00 98.12

gJul-11 90.00 99.77

gAug-11 90.00 99.88

gSep-11 90.00 99.79

gOct-11 90.00 99.69

gNov-11 90.00 99.91

gDec-11 90.00 99.53

gJan-12 90.00 99.80

gFeb-12 90.00 99.78

gMar-12 90.00 99.90

Patient Safety

30 Days Readmission Rates to RJAH for all specialties

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


rApr-11 1.30 1.54

gMay-11 1.30 1.02

gJun-11 1.30 0.96

rJul-11 1.30 1.83

gAug-11 1.30 1.16

gSep-11 1.30 1.17

gOct-11 1.30 1.18

gNov-11 1.30 0.94

gDec-11 1.30 1.13

gJan-12 1.30 0.44

gFeb-12 1.30 1.16

Mar-12 1.30 no data

Paper 02


2011/12 Month - 12


Patient Experience

Patient Satisfaction

95.0

95.5

96.0

96.5

97.0

97.5

98.0

98.5

99.0

99.5

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 95.00 99.48

gMay-11 95.00 98.03

gJun-11 95.00 99.19

gJul-11 95.00 98.01

gAug-11 95.00 99.09

gSep-11 95.00 98.76

gOct-11 95.00 96.12

gNov-11 95.00 97.82

gDec-11 95.00 96.23

gJan-12 95.00 98.01

gFeb-12 95.00 98.21

gMar-12 95.00 95.79

Patient Experience

Number of Complaints

2

4

6

8

10

12

14

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 9.00 3.00

gMay-11 9.00 8.00

gJun-11 9.00 6.00

gJul-11 9.00 7.00

gAug-11 9.00 6.00

aSep-11 9.00 14.00

aOct-11 9.00 10.00

gNov-11 9.00 2.00

gDec-11 9.00 8.00

gJan-12 9.00 5.00

aFeb-12 9.00 10.00

aMar-12 9.00 10.00

Patient Experience

Access to Bone Tumour Services

2 week cancer referral target

82

84

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 93.00 100.00

gMay-11 93.00 100.00

gJun-11 93.00 100.00

gJul-11 93.00 100.00

gAug-11 93.00 100.00

gSep-11 93.00 100.00

gOct-11 93.00 100.00

gNov-11 93.00 100.00

gDec-11 93.00 100.00

gJan-12 93.00 100.00

gFeb-12 93.00 100.00

gMar-12 93.00 100.00

Paper 02


2011/12 Month - 12


Patient Experience


Cancer 1 month wait

65

70

75

80

85

90

95

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 96.00 100.00

gMay-11 96.00 100.00

gJun-11 96.00 100.00

gJul-11 96.00 100.00

gAug-11 96.00 100.00

gSep-11 96.00 100.00

gOct-11 96.00 100.00

gNov-11 96.00 100.00

gDec-11 96.00 100.00

gJan-12 96.00 100.00

gFeb-12 96.00 100.00

gMar-12 96.00 100.00

Patient Experience


Cancer 2 month wait

0

20

40

60

80

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 85.00 100.00

gMay-11 85.00 100.00

gJun-11 85.00 100.00

gJul-11 85.00 100.00

gAug-11 85.00 100.00

gSep-11 85.00 100.00

gOct-11 85.00 100.00

gNov-11 85.00 100.00

gDec-11 85.00 100.00

gJan-12 85.00 100.00

gFeb-12 85.00 100.00

gMar-12 85.00 100.00

Patient Experience

Access to Services (RTT) - Welsh

26 week RTT (Admitted)

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 95.00 94.27

gMay-11 95.00 99.22

gJun-11 95.00 97.17

gJul-11 95.00 97.78

gAug-11 95.00 96.79

gSep-11 95.00 97.98

gOct-11 95.00 96.36

gNov-11 95.00 99.64

gDec-11 95.00 97.99

gJan-12 95.00 98.64

gFeb-12 95.00 97.31

gMar-12 95.00 96.43

Paper 02


2011/12 Month - 12


Patient Experience

Access to Services (RTT) - Welsh

26 week RTT (Non-Admitted)

96.0

96.5

97.0

97.5

98.0

98.5

99.0

99.5

100.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 98.00 96.40

gMay-11 98.00 98.85

gJun-11 98.00 99.76

gJul-11 98.00 99.05

gAug-11 98.00 99.50

gSep-11 98.00 99.33

gOct-11 98.00 99.51

gNov-11 98.00 99.34

gDec-11 98.00 100.00

gJan-12 98.00 98.90

gFeb-12 98.00 98.47

gMar-12 98.00 98.78

Patient Experience

Access to Services (RTT) - English

18 weeks RTT Admitted

55

60

65

70

75

80

85

90

95

100

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 90.00 92.21

gMay-11 90.00 95.64

gJun-11 90.00 93.60

gJul-11 90.00 93.25

gAug-11 90.00 93.03

gSep-11 90.00 93.99

gOct-11 90.00 93.77

gNov-11 90.00 95.51

rDec-11 90.00 58.64

rJan-12 90.00 60.07

rFeb-12 90.00 56.30

rMar-12 90.00 60.40

Patient Experience


18 weeks RTT Admitted 95th percentile

16

20

24

28

32

36

40

44

48

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 23.00 21.30

gMay-11 23.00 17.98

gJun-11 23.00 19.75

gJul-11 23.00 19.81

gAug-11 23.00 21.85

gSep-11 23.00 20.88

gOct-11 23.00 19.85

gNov-11 23.00 17.99

rDec-11 23.00 43.25

rJan-12 23.00 44.06

rFeb-12 23.00 47.69

rMar-12 23.00 41.89

Paper 02


2011/12 Month - 12


Patient Experience


18 weeks RTT Admitted Median

11

12

13

14

15

16

17

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 11.10 16.28

rMay-11 11.10 15.31

rJun-11 11.10 16.14

rJul-11 11.10 15.92

rAug-11 11.10 16.07

rSep-11 11.10 16.50

rOct-11 11.10 16.50

rNov-11 11.10 15.57

rDec-11 11.10 15.13

rJan-12 11.10 16.00

rFeb-12 11.10 16.28

rMar-12 11.10 15.43

Patient Experience


18 weeks RTT Non-Admitted

95.0

95.5

96.0

96.5

97.0

97.5

98.0

98.5

99.0

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 95.00 98.63

gMay-11 95.00 97.22

gJun-11 95.00 98.12

gJul-11 95.00 97.87

gAug-11 95.00 97.56

gSep-11 95.00 96.84

gOct-11 95.00 98.42

gNov-11 95.00 98.02

gDec-11 95.00 98.75

gJan-12 95.00 98.16

gFeb-12 95.00 97.13

gMar-12 95.00 98.33

Patient Experience


18 weeks RTT Non-Admitted 95th percentile

8

10

12

14

16

18

20

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 18.30 17.08

gMay-11 18.30 17.33

gJun-11 18.30 17.46

gJul-11 18.30 17.61

gAug-11 18.30 17.59

gSep-11 18.30 17.74

gOct-11 18.30 17.49

gNov-11 18.30 17.63

gDec-11 18.30 9.33

gJan-12 18.30 12.88

gFeb-12 18.30 15.18

gMar-12 18.30 15.36

Paper 02


2011/12 Month - 12


Patient Experience


18 weeks RTT Non-Admitted Median

6.6

6.7

6.8

6.9

7.0

7.1

7.2

7.3

7.4

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 6.60 7.04

rMay-11 6.60 7.35

rJun-11 6.60 7.24

rJul-11 6.60 7.40

rAug-11 6.60 7.23

rSep-11 6.60 7.21

rOct-11 6.60 7.13

rNov-11 6.60 7.40

rDec-11 6.60 7.34

rJan-12 6.60 7.20

rFeb-12 6.60 7.11

rMar-12 6.60 7.27

Patient Experience


18 weeks RTT Incomplete 95th percentile

20

24

28

32

36

40

44

48

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 28.00 23.78

gMay-11 28.00 20.70

gJun-11 28.00 21.27

gJul-11 28.00 22.58

gAug-11 28.00 23.78

gSep-11 28.00 22.62

gOct-11 28.00 22.35

gNov-11 28.00 24.88

rDec-11 28.00 45.17

rJan-12 28.00 43.21

rFeb-12 28.00 39.48

rMar-12 28.00 40.80

Patient Experience


18 weeks RTT Incomplete Median

7.0

7.5

8.0

8.5

9.0

9.5

10.0

10.5

11.0

11.5

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 7.20 8.62

rMay-11 7.20 9.10

rJun-11 7.20 8.38

rJul-11 7.20 9.17

rAug-11 7.20 10.55

rSep-11 7.20 10.10

rOct-11 7.20 9.75

rNov-11 7.20 9.61

rDec-11 7.20 11.18

rJan-12 7.20 10.91

rFeb-12 7.20 11.49

rMar-12 7.20 10.38

Paper 02


2011/12 Month - 12


Patient Experience

Reportable Cancellations

0.4

0.6

0.8

1.0

1.2

1.4

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 0.80 0.79

gMay-11 0.80 0.57

gJun-11 0.80 0.49

gJul-11 0.80 0.54

gAug-11 0.80 0.50

gSep-11 0.80 0.54

gOct-11 0.80 0.61

gNov-11 0.80 0.60

gDec-11 0.80 0.67

gJan-12 0.80 0.69

gFeb-12 0.80 0.70

gMar-12 0.80 0.76

Patient Experience

Delayed Discharges

0

1

2

3

4

5

6

7

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


aApr-11 3.50 3.90

gMay-11 3.50 3.40

aJun-11 3.50 3.60

gJul-11 3.50 0.80

gAug-11 3.50 1.50

gSep-11 3.50 2.10

gOct-11 3.50 3.25

aNov-11 3.50 4.23

aDec-11 3.50 6.41

gJan-12 3.50 1.33

aFeb-12 3.50 3.55

gMar-12 3.50 2.00

Paper 02


2011/12 Month - 12


Resources

Sickness Absence

2.6

2.8

3.0

3.2

3.4

3.6

3.8

4.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 3.00 2.70

gMay-11 3.00 2.67

aJun-11 3.00 3.30

aJul-11 3.00 3.03

rAug-11 3.00 3.61

aSep-11 3.50 3.59

aOct-11 3.50 3.81

aNov-11 3.50 3.88

gDec-11 3.50 3.33

gJan-12 3.50 3.32

gFeb-12 3.50 3.49

aMar-12 3.00 3.49

Resources

Staff Turnover

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

10.0

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


gApr-11 10.00 8.78

gMay-11 10.00 8.69

gJun-11 10.00 8.10

gJul-11 10.00 7.50

gAug-11 10.00 7.53

gSep-11 10.00 7.72

gOct-11 10.00 7.69

gNov-11 10.00 7.51

gDec-11 10.00 7.57

gJan-12 10.00 7.00

gFeb-12 10.00 6.36

gMar-12 10.00 5.61

Resources

Staff Appraisal

60

64

68

72

76

80

84

88

92

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


aApr-11 90.00 78.20

aMay-11 90.00 78.34

aJun-11 90.00 82.94

aJul-11 90.00 84.32

aAug-11 90.00 84.55

aSep-11 90.00 78.72

aOct-11 90.00 76.20

aNov-11 90.00 74.75

rDec-11 90.00 68.12

rJan-12 90.00 62.84

rFeb-12 90.00 64.62

aMar-12 90.00 74.56

Paper 02


2011/12 Month - 12


Efficiency

Activity - Surgery

Surgical Division Activity - Inpatient Contract

850

900

950

1000

1050

1100

1150

1200

1250

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 994.00 966.00

gMay-11 1,007.00 1,014.00

aJun-11 1,081.00 916.00

rJul-11 1,094.00 912.00

rAug-11 969.00 915.00

gSep-11 1,031.00 1,033.00

gOct-11 1,056.00 1,058.00

gNov-11 1,109.00 1,121.00

gDec-11 1,028.00 1,055.00

gJan-12 1,095.00 1,109.00

aFeb-12 1,096.00 1,065.00

aMar-12 1,122.00 1,106.00

Efficiency

Activity - Surgery

Surgical Division Activity - Outpatient Contract

4400

4800

5200

5600

6000

6400

6800

7200

7600

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 5,306.00 5,544.00

gMay-11 5,372.00 6,295.00

gJun-11 5,770.00 6,254.00

aJul-11 5,837.00 5,491.00

gAug-11 5,580.00 6,319.00

gSep-11 5,912.00 6,740.00

gOct-11 6,045.00 6,372.00

gNov-11 6,045.00 6,798.00

aDec-11 5,647.00 5,274.00

gJan-12 5,978.00 6,537.00

gFeb-12 5,978.00 6,005.00

gMar-12 6,111.00 6,449.00

Efficiency

Activity - Medicine

Medicine Division Activity - Inpatient Contract

100

120

140

160

180

200

220

240

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 210.00 128.00

rMay-11 212.00 149.00

rJun-11 228.00 156.00

rJul-11 231.00 177.00

rAug-11 204.00 127.00

rSep-11 218.00 162.00

rOct-11 223.00 154.00

rNov-11 223.00 185.00

rDec-11 207.00 121.00

rJan-12 220.00 164.00

rFeb-12 220.00 141.00

rMar-12 225.00 179.00

Paper 02


2011/12 Month - 12


Efficiency

Activity - Medicine

Medicine Division Activity - Outpatient Contract

600

700

800

900

1000

1100

1200

1300

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


aApr-11 912.00 901.00

gMay-11 924.00 997.00

gJun-11 992.00 1,241.00

gJul-11 1,004.00 1,080.00

gAug-11 890.00 1,100.00

gSep-11 947.00 1,129.00

aOct-11 969.00 967.00

gNov-11 969.00 1,074.00

aDec-11 901.00 811.00

gJan-12 958.00 1,095.00

gFeb-12 958.00 1,044.00

gMar-12 981.00 1,197.00

Efficiency

New to Follow Up Ratio (Consultant Led Activity)

1.6

1.8

2.0

2.2

2.4

2.6

2.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2.30 2.13

gMay-11 2.30 2.18

rJun-11 2.30 2.61

aJul-11 2.30 2.34

gAug-11 2.30 1.93

gSep-11 2.30 1.98

gOct-11 2.30 2.17

gNov-11 2.30 2.02

gDec-11 2.30 2.26

gJan-12 2.30 2.19

gFeb-12 2.30 1.89

gMar-12 2.30 1.93

Efficiency

Demand Against Contract

Additions to Outpatient Waiting List

0

500

1000

1500

2000

2500

3000

3500

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2,000.00 2,151.00

aMay-11 2,000.00 2,319.00

aJun-11 2,000.00 2,523.00

rJul-11 2,000.00 3,190.00

aAug-11 2,000.00 2,384.00

rSep-11 2,000.00 2,714.00

aOct-11 2,000.00 2,359.00

aNov-11 2,000.00 2,322.00

gDec-11 2,000.00 1,903.00

gJan-12 2,000.00 2,155.00

gFeb-12 2,000.00 2,084.00

aMar-12 2,000.00 2,420.00

Paper 02


2011/12 Month - 12


Efficiency


Outpatient Waiting List (Consultant Led Activity Only)

0

1000

2000

3000

4000

5000

6000

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 3,250.00 3,943.00

rMay-11 3,250.00 4,101.00

rJun-11 3,250.00 4,645.00

rJul-11 3,250.00 4,939.00

rAug-11 3,250.00 5,216.00

rSep-11 3,250.00 5,224.00

rOct-11 3,250.00 5,642.00

rNov-11 3,250.00 5,208.00

rDec-11 3,250.00 5,730.00

rJan-12 3,250.00 5,588.00

rFeb-12 3,250.00 5,138.00

rMar-12 3,250.00 4,944.00

Efficiency


Inpatient Waiting List Total

0

500

1000

1500

2000

2500

3000

3500

4000

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 3,250.00 3,490.00

gMay-11 3,250.00 3,470.00

aJun-11 3,250.00 3,582.00

aJul-11 3,250.00 3,582.00

aAug-11 3,250.00 3,581.00

rSep-11 3,250.00 3,780.00

aOct-11 3,250.00 3,730.00

aNov-11 3,250.00 3,732.00

aDec-11 3,250.00 3,544.00

gJan-12 3,250.00 3,460.00

gFeb-12 3,250.00 3,161.00

gMar-12 3,250.00 3,235.00

Efficiency

Daycase Rates

38

40

42

44

46

48

50

52

54

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 44.00 46.19

gMay-11 44.00 48.13

gJun-11 44.00 49.94

gJul-11 45.00 46.84

gAug-11 45.00 48.84

gSep-11 45.00 50.52

gOct-11 46.00 51.93

gNov-11 48.00 50.05

gDec-11 48.00 52.96

gJan-12 50.00 51.37

aFeb-12 52.00 49.32

aMar-12 53.00 48.61

Paper 02


2011/12 Month - 12


Efficiency

Admission on Day of Surgery

66

68

70

72

74

76

78

80

82

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


gApr-11 72.00 73.67

gMay-11 72.00 74.04

gJun-11 72.00 72.81

gJul-11 72.00 74.40

gAug-11 72.00 74.65

gSep-11 72.00 75.56

gOct-11 72.00 76.16

gNov-11 74.00 80.25

gDec-11 74.00 79.60

gJan-12 76.00 80.56

gFeb-12 78.00 79.53

gMar-12 80.00 81.52

Efficiency

Theatre Efficiency

Theatre Efficiency

84

86

88

90

92

94

96

98

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12


aApr-11 95.00 92.21

gMay-11 95.00 95.54

aJun-11 95.00 85.74

aJul-11 95.00 90.22

aAug-11 95.00 85.86

gSep-11 95.00 97.12

gOct-11 95.00 95.95

gNov-11 95.00 95.55

aDec-11 95.00 93.13

gJan-12 95.00 98.39

gFeb-12 95.00 98.43

gMar-12 95.00 95.36

Efficiency

Theatre Efficiency

Cases Per Session

2.10

2.15

2.20

2.25

2.30

2.35

2.40

2.45

2.50

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


Apr-11 2.40 no data

May-11 2.40 no data

Jun-11 2.40 no data

aJul-11 2.40 2.14

aAug-11 2.40 2.17

aSep-11 2.40 2.21

aOct-11 2.40 2.27

aNov-11 2.40 2.31

gDec-11 2.40 2.48

aJan-12 2.40 2.29

aFeb-12 2.40 2.22

aMar-12 2.40 2.24

Paper 02


2011/12 Month - 12


Efficiency

Average Length Of Stay - Overall

1.8

2.0

2.2

2.4

2.6

2.8

3.0

3.2

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


gApr-11 2.60 2.60

gMay-11 2.60 2.54

gJun-11 2.60 2.23

gJul-11 2.60 2.41

gAug-11 2.60 2.53

gSep-11 2.60 2.26

gOct-11 2.60 2.49

gNov-11 2.56 2.31

gDec-11 2.52 2.22

gJan-12 2.48 2.10

gFeb-12 2.44 2.23

gMar-12 2.40 2.30

Efficiency

Average Length of Stay - Hips and Knees

Average Length of Stay Hips

4.0

4.4

4.8

5.2

5.6

6.0

6.4

6.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


aApr-11 4.50 4.79

rMay-11 4.50 4.70

rJun-11 4.50 4.63

rJul-11 4.50 4.55

rAug-11 4.50 5.40

rSep-11 4.50 5.53

rOct-11 4.50 4.92

rNov-11 4.45 4.71

rDec-11 4.40 4.63

rJan-12 4.35 5.22

rFeb-12 4.30 4.78

rMar-12 4.25 4.93

Efficiency

Average Length of Stay - Hips and Knees

Average Length of Stay Knees

4.0

4.4

4.8

5.2

5.6

6.0

6.4

6.8

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

Nu

mb

er


rApr-11 4.50 5.19

rMay-11 4.50 5.35

rJun-11 4.50 5.65

rJul-11 4.50 4.80

rAug-11 4.50 4.86

rSep-11 4.50 5.72

rOct-11 4.50 5.72

rNov-11 4.45 5.32

rDec-11 4.40 5.29

rJan-12 4.35 5.13

rFeb-12 4.30 4.67

rMar-12 4.25 4.93

Paper 02


2011/12 Month - 12


Efficiency

Bed Occupancy - Adult Orthopaedic Wards

0

20

40

60

80

100

Apr-1

0

May

-10

Jun-

10

Jul-1

0

Aug-1

0

Sep-1

0

Oct-1

0

Nov

-10

Dec

-10

Jan-

11

Feb-1

1

Mar

-11

Apr-1

1

May

-11

Jun-

11

Jul-1

1

Aug-1

1

Sep-1

1

Oct-1

1

Nov

-11

Dec

-11

Jan-

12

Feb-1

2

Mar

-12

%


rApr-11 87.00 76.65

rMay-11 87.00 74.50

rJun-11 87.00 77.99

rJul-11 87.00 76.02

rAug-11 87.00 80.45

rSep-11 87.00 80.00

rOct-11 87.00 81.00

aNov-11 87.00 84.54

rDec-11 87.00 76.42

rJan-12 87.00 81.80

rFeb-12 87.00 81.03

rMar-12 87.00 77.19

Paper 02


A) Key Facts 2011-12

B) Executive Summary

C) Monitor Risk Assessment/Ratio's D) Recommendations

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust Finance Report for period ending 31st March 2012

Recommendations:

The Board is asked to NOTE:

The Month 12 Financial Position.

We completed the year with the delivery of an additional £0.19m surplus to take our total for the year to £1.52m (pre impairment). This was in line with our revised forecast and ahead of original plan by £0.22m.

Income exceeded plan in month by £1.1m the majority of which was linked to additional activity delivered from our extended capacity working as we successfully completed additional contracted work for our Welsh Commissioners and recovered the shortfall of our Shropshire contract. In addition to this new RTA claim notifications were £0.25m higher than expected. We ended the year having earned an additional £1.9m than originally planned which includes £0.7m from additional RTA and private income. Year end agreements have been reached with all English Commissioners and the Welsh over performance is within the parameters of additional contracts agreed.

Pay costs increased once more linked to additional surgical capacity. The pay cost per spell did however reduce in month following review of a number of surgical areas. We ended the year having overspent against our original pay budget by £0.5m. Non pay expenditure rose sharply in month driven by a combination of increased surgical volumes and end of year provision re-assessments. We ended the year having spent an additional £1.3m than originally planned; this was however within the parameters of the additional income earned.

Further cost efficiencies of £0.34m were recognised in month This was higher than the monthly plan as adjustments were made to recognise the cost pressures from additional volumes of work delivered in the final quarter of the year. Cumulatively we have ended the year having identified efficiencies totalling £3.10m which is £0.03m in excess of the original target.

Cash balances reduced by £2m to £5.3m as a backlog of creditor payments was cleared and progress continued with the capital programme. This was slightly higher than the previous months forecast of £5m due to a greater clearance of debtors than had previously been anticipated.

Performance against our 30 day creditor payment target again fell short of the required levels as we continued to process a backlog of invoices following the disruption caused by the system upgrade. Cumulatively we have achieved 93% compliance against a target of 95%.

Capital expenditure for the month was £1m to take our total spend for the year to £4.89m which was £0.6m under plan. Most of the shortfall is linked to the remaining spend on the Main Entrance project that will be completed in the new year and funded by our agreed charitable contributions.

Our overall forecast risk rating remains unchanged at level 4 confirming that the Trust is performing at low financial risk.

UnitAnnual

Plan

Month

Plan

Month

Actual

Month

Variance

Month

% Var

YTD

Plan

YTD

Actual

YTD

Variance% Var YTD Risk

Annual

Forecast

Annual

Forecast

Risk

Income £m 81.81 7.04 8.17 1.14 16% 81.81 83.73 1.92 2% 83.73

Expenditure - Pay £m -45.55 -3.81 -4.10 -0.30 -8% -45.55 -46.08 -0.54 -1% -46.08

Expenditure - Non-pay £m -30.65 -2.67 -3.59 -0.92 -34% -30.65 -31.98 -1.33 -4% -31.98

EBITDA £m 5.62 0.56 0.48 -0.08 -14% 5.62 5.67 0.05 1% 5.67

Finance Costs £m -4.32 -0.36 -0.29 0.07 -19% -4.32 -4.15 0.16 -4% -4.15

Net Surplus £m 1.30 0.20 0.19 -0.01 -4% 1.30 1.52 0.22 17% 1.52

CIP delivered £m 3.07 0.30 0.34 0.04 13% 3.07 3.10 0.03 1% 3.10

Capital Expenditure £m 5.49 0.70 1.01 0.30 43% 5.49 4.89 -0.60 -11% 4.89

Cash £m 3.02 3.02 5.27 2.26 75% 3.02 5.27 2.26 75% 5.27

BPPC % 95% 95% 79% -16% -17% 95% 93% -2% -2% 93%

Annual

PlanYTD Plan

Annual

ForecastRisk Rating

EBITDA Margin 6.9% 6.9% 6.8% 3

EBITDA Achieved 100% 100.0% 100.9% 5

Return on Assets (ROA) 5.1% 5.1% 5.4% 4

I&E Surplus Margin 2.1% 2.1% 2.3% 4

Liquidity Ratio (Days) 28 28 30 4

100.9%

6.8%

YTD Actual

30

2.3%

5.4%

Paper 02


OU

TP

AT

IEN

TS

PR

IVA

TE

PA

TIE

NT

S &

OT

HE

R I

NC

OM

E


E) Income and activity analysis

Inp

ati

en

tsO

utp

ati

en

ts

The surgical activity recovery plan delivered an

additional 37 cases during the month with a rich

case mix as a number of complex spinal cases were

completed.

The above was however dampened by the ongoing

reduction in Metabolic Medicine inpatient activity with

a further loss of 53 episodes from plan. Overall

Medicine division income fell short of plan by £13k.

Outpatient activity increased in month with an additional 745

patients seen over planned levels. This was the highest month of

the entire year.

Private Patient income exceeded plan by £54k in month and ended

the year having over achieved by £206k.

Other income benefitted from an unusually high level of new RTA

claim notifications. This provided an unexpected additional £250k.

Provisions for non recovery have been made against expenditure in

line with our local assessment of write offs.

Private Patients Income

0

0.1

0.2

0.3

0.4

0.5

Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar

£m

This Year Plan Last Year Actual This year Actual

Other Income

0.0

0.2

0.4

0.6

0.8

1.0


£m


Outpatients - Activity

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000


Attendances


Outpatients - Income

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4


£m


Inpatients - Activity

0

200

400

600

800

1000

1200

1400

1600


Sp

ells


Inpatients - Income

0.0

0.5

1 .0

1 .5

2 .0

2 .5

3 .0

3 .5

4 .0

4 .5

A p r M a y Ju n e Ju ly A u g S e p O c t N o v D e c Ja n F e b M a r

£m


Inpatients - Income per Spell

2.5

2.6

2.7

2.8

2.9

3.0

3.1

3.2

3.3


£000s


Paper 02



F) Commissioner Performance G) Cost Improvement Programme

Income exceeded plan in month by £0.8m linked to extended capacity as we successfully completed additional contracted work for our Welsh Commissioners and recovered the shortfall of our Shropshire contract.

We ended the year having earned an additional £1.4m from our clinical activity than originally planned. Year end agreements have been reached with all English Commissioners and the Welsh over performance is within the parameters of additional contracts agreed.

The table above shows the respective Commissioner positions and includes full C-QUIN where applicable. A separate risk provision has been made (through expenditure) for outstanding risks.

Further cost efficiencies of £0.34m were recognised in month. This was higher than the monthly plan as adjustments were made to recognise the cost pressures from additional volumes of work delivered in the final quarter of the year.

Cumulatively we have ended the year having identified efficiencies totalling £3.10m which is £0.03m in excess of the original target. The most significant in month variances from plan are detailed below:

Tactical/Miscellaneous - Further inflationary benefits where price increases had been assumed above levels paid have been recognised this month. Additionally further contribution from our Telford & Wrekin Rheumatology partnership service and increased private work has been included.

Workforce Productivity - Increased spend on external consultants and bank and agency led to the under achievement of plan in month.

CommissionerAnnual

Plan £m

YTD

Plan £m

Actual

£m

Variance

£m

Risk

Rating

Shropshire County 27.3 27.3 27.2 -0.1

Betsi Cadwaladr 13.1 13.1 14.2 1.1

Powys 5.5 5.5 5.9 0.4

Telford & Wrekin 5.1 5.1 5.3 0.2

Specialised Commissioners 7.2 7.2 7.2 0.0

Other England Contracted 10.1 10.1 9.7 -0.4

Other Wales Contracted 0.8 0.8 0.7 -0.1

Non Contracted Activity 2.5 2.5 2.2 -0.3

Exclusions and other 0.7 0.7 1.3 0.6

Grand Total 72.3 72.3 73.7 1.4

Annual Plan

SchemesPlan Actual Variance Plan Actual Variance

£000s £000s £000s £000s £000s £000s £000s

Improving Operational Efficiency 964 132 216 84 964 851 -113

Workforce Productivity 970 83 -23 -106 970 796 -174

Realising the benefits of technology 156 16 4 -12 156 72 -84

Improved Contributions 70 6 6 1 70 73 3

Back office function productivity 414 40 33 -7 414 377 -37

Estates rationalisation/sustainability 141 12 3 -9 141 132 -9

Tactical/Miscellaneous 562 36 102 66 562 799 237

Contingency against slippage -204 -24 24 -204 204

Total 3,073 301 341 40 3,073 3,100 27

In Month Year to Date

Paper 02


Ma

np

ow

er

BA

NK

AN

D A

GE

NC

Y E

XP

EN

DIT

UR

EO

UT

OF

JO

B P

LA

N

Ov

ert

ime

KEY PAY METRICS


PA

Y E

XP

EN

DIT

UR

E

H) Pay Expenditure related Key Drivers/Financial Assumptions

Pay costs increased once more linked to additional surgical capacity. The pay cost per spell did however reduce in month following review of a number of surgical areas. We ended the year having overspent against our original pay budget by £0.5m; this was within the parameters of the extra income earned from increased volumes of work.

The graphs below track the monthly spend in the most volatile areas in greater detail.

Pay Expenditure - Plan vs Actual

3.00

3.20

3.40

3.60

3.80

4.00

4.20


£m

This Year Plan Last Year Actual This Year Actual

Pay Expenditure/Spell - Plan vs Actual

2.0

2.4

2.8

3.2

3.6

4.0


£m


Out of Job plan Expenditure/spell - Plan vs Actual

0

20

40

60

80

100

120

140

160

180


£0

00s


Overtime Expenditure - 2010/11 vs 2011/12

0

10

20

30

40

50

60


£000

s


Clinical agency and bank spend

0

20

40

60

80

100

120


£000s


Non-Clinical Agency/Bank Expenditure

0

20

40

60

80

100


£000s


Monthly Average

Pay Expenditure per WTE - Plan vs Actual

2.00

2.50

3.00

3.50

4.00

4.50


£0

00


WTE - Plan vs Actual

0

250

500

750

1,000

1,250

1,500

1,750

Apr May June July Aug Sep Oct Nov Dec Jan Feb MarThis Year Plan Last Year Actual This Year Actual

Out of Job Plan Expenditure - Plan vs Actual

0.00

0.05

0.10

0.15

0.20

0.25


£m


Paper 02


DR

UG

SIM

PL

AN

TS

NO

N-P

AY

EX

PE

ND

ITU

RE


I) Non-Pay Expenditure related Key Drivers/Financial Assumptions

KEY NON-PAY METRICS

Non pay expenditure rose sharply in month driven by a combination of increased surgical volumes and end of year provision re-assessments.

We ended the year having spent an additional £1.3m than originally planned. This was however within the parameters of the additional income earned from extra volumes of activity.

Implant costs were slightly ahead of plan in month and average when compared to the number of spells completed.

Drug costs increased sharply in month as a re-alignment between the Trust's pharmacy system and financial ledger was undertaken in month.

Non-pay Expenditure - Plan vs Actual

1.00

1.50

2.00

2.50

3.00

3.50

4.00


£m

This Year Plan £m Last Year Actual £m

This Year Actual £m

Non-pay Expenditure per Spell - Plan vs Actual

1000.00

1500.00

2000.00

2500.00

3000.00


£

This Year Plan (£/Spells) Last Year Actual (£/Spells)

This Year Actual (£/Spells)

Implants Expenditure - Plan vs Actual

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00


£m

This Year Plan £m Last Year Actual £m

This Year Actual £m

Implants Expenditure per Orthopaedic Spell - Plan

vs Actual

400

600

800

Apr M ay June July Aug Sep Oct Nov Dec Jan Feb M ar

£

This Year Plan (£/Spells) Last Year Actual (£/Spells)

This Year Actual (£/Spells)

Drugs Expenditure - Plan vs Actual

0.10

0.12

0.14

0.16

0.18

0.20

0.22

0.24

0.26

0.28

0.30


£m

This Year Plan £m Last Year Actual £m This Year Actual £m

Drugs Expenditure per Spell - Plan vs Actual

80

100

120

140

160

180

200

220

Apr June Aug Oct Dec Feb

£

This Year Plan (£/Spells) Last Year Actual (£/Spells) This Year Actual (£/Spells)

Paper 02



J) Balance Sheet Items Analysis

Cash balances reduced by £2m to £5.3m as a backlog of

creditor payments was cleared and progress continued

with the capital programme. This was slightly higher than

the previous months forecast of £5m due to a greater

clearance of debtors than had previously been anticipated.

As previously reported the closing cash balance is higher

than the original £3m plan mainly as a result of high over

perfromance in 2010/11 not being repeated. This increase

in cash balances has strengthened our liquidity and

financial risk rating score.

Surplus cash continues to be invested in line with the

parameters of our Treasury Management policy.

Performance against our 30 day creditor payment target was

79% and impacted by the clearance of a backlog of invoices

from earlier periods following the disruption caused by the

system upgrade. Cumulatively we achieved 93% compliance for

the year against a target of 95%.

The overall age profile of our creditors reduced linked to the

backlog clearance with the percentage of creditors older than 90

days now standing at 2.28%.

Recharge debtors reduced as systems returned to full functionality following the

problems that had peviously delayed inter Trust payments across the local health

economy.

Debtors older than 90 days increased slightly and remain above the 5% threshold

used by Monitor as part of their forecast financial risk metrics. Performance has been

measured to include sums owning from the CRU (Compensations Recovery Unit) and

without; the Trust is unable to influence the collection timeline of income owing from

the CRU.

Current year cash - Plan vs Actual

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00


£m

Plan This Year Actual £m

Creditor Days - Plan vs Actual

5

10

15

20

25

30

35


Days

Plan Last Year Actual This Year Actual

Percentage of Creditors > 90 days

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%


%

% value of trade & other payable over 90 days

Percentage of Debtors > 90 Days

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Month

Perc

en

tag

e

Total receivables Total Less CRU

DebtorDays Mar 11 - Mar 12

0

10

20

30

40

50

60

70

Ma

r

Ap

r

Ma

y

Ju

ne

Ju

ly

Au

g

Se

p

Oc

t

No

v

De

c

Ja

n

Fe

b

Ma

r

Month

Days

non clinical nhs clinical recharges

Paper 02


K) Capital Programme

L) Service Line Performance M) Key Financial Risks


Capital expenditure for the month was £1m to take our total spend for the year to £4.89m which was £0.6m under plan. Most of the shortfall is linked to the remaining spend on the Main Entrance project that will be completed in the new year and funded by our agreed charitable contributions.

The table above provides further detail of the status of each of our main capital schemes.

Our financial risks are routinely reviewed and updated each month. All risks associated with the out-turn of £1.5m reported have been provided for in full.

A new set of prospective risks for delivery of the 2012/13 plan will be reported against in the new financial year.

Current year Cap Ex - Plan vs Actual

0.00

1.00

2.00

3.00

4.00

5.00

6.00


£m

Cumulat ive Revised Plan This Year Actual £m

ProjectAnnual Plan £000s

Year to date Plan £000s

Completed £000s

Forecast Outturn £000s

Progress

Main Entrance 3,503 3,503 3025 3,025 Scheme nearing completion - carried into 2012/13Estates Backlog 907 907 850 850 All maintenance schemes completeMedical Equipment 180 180 167 167 CompleteIT Replacement 200 200 192 192 CompleteX-Ray Refurbishment 200 200 0 0 Scheme under evaluation post tenderOrthotics Manufacturing 200 200 0 0 Scheme deferredTheatre Cooling System 0 0 260 260 CompleteSheldon Ward redesign 0 0 60 60 Scheme nearing completion - carried into 2012/13Other Capital 300 300 340 340 Small minor works completeNHS Capital

Expenditure5,490 5,490 4,894 4,894

Capital Projects 2011/12

SLR Quarter 3 2011/12

2011-12 Q2 2011-12 Q3

£000s £000s

Surplus/(Loss) Surplus/(Loss)

Joint Surgery / Bone Tumour 570 615

Spinal Services -284 -151

Paediatric Services 218 156

Medicine -82 -167

Trading Directorate 82 127

Technical adjustment -175 -207

Total 329 373

Paper 02



N) Income and Expenditure Statement

ANNUAL

PLAN PLAN ACTUAL VARIANCE PLAN ACTUAL VARIANCE

NHS Clinical Income 72,300 6,248 7,024 776 72,300 73,751 1,451

Non NHS Clinical Income 3,757 308 634 326 3,757 4,602 844

Research & Development 699 58 27 (31) 699 666 (33)

Education & Training 1,538 122 151 29 1,538 1,558 21

Other Income 3,520 299 336 37 3,520 3,155 (366)

Operating Income, Total 81,814 7,035 8,171 1,136 81,814 83,732 1,918

Pay Costs (45,545) (3,808) (4,104) (296) (45,545) (46,083) (538)

Drugs (5,065) (434) (497) (63) (5,065) (5,368) (303)

Clinical Supplies (15,914) (1,341) (1,512) (171) (15,914) (16,420) (506)

Non Clinical Supplies (2,198) (235) (316) (81) (2,198) (2,319) (122)

Other Operating expenses (7,475) (662) (1,262) (600) (7,475) (7,870) (396)

Non pay costs, Total (30,651) (2,671) (3,586) (916) (30,651) (31,977) (1,326)

EBITDA 5,618 557 481 (76) 5,618 5,671 54

Interest Receivable 14 1 7 6 14 38 24

Interest Expense on loans and leases (37) (3) (2) 1 (37) (34) 3

Depreciation and Amortisation (3,049) (254) (243) 11 (3,049) (2,962) 87

PDC Dividend (1,246) (104) (54) 50 (1,246) (1,196) 50

Non-Operating Expenses, Total (4,318) (360) (292) 68 (4,318) (4,154) 164

Surplus/deficit before impairment 1,300 197 189 (8) 1,300 1,517 217

Impairment of assets 0 0 336 336 0 286 286

Net Surplus/deficit 1,300 197 526 329 1,300 1,804 504

IN MONTH YTD

Paper 02


O) Balance Sheet


April 2011

February

2012 March 2012

In month

movement

£'000 £'000 £'000 £'000

Non Current Assets (life of more than one year)

Fixed Assets 46,043 47,164 50,438 3,274 includes indexation of £2,166k

Non Current Receivables 231 362 529 167 new RTA claims notified

Total Non Current Assets 46,274 47,526 50,967 3,441

Inventories (Stocks) 1,535 1,525 1,453 (72) year end stock takes completed

Receivables 4,110 2,644 3,787 1,143

Cash at bank and in hand 3,859 7,305 5,273 (2,032)

Total Current Assets 9,504 11,474 10,513 (961)

Payables (Creditors) (6,456) (8,446) (8,082) 364 clearance of backlog creditors

Borrowings (DH Loans & accrued interest

+ finance lease commitments)(75) (73) (73) 0

Current Provisions for liabilities and

charges(262) (309) (477) (168)

Total Current Liabilities (6,793) (8,828) (8,632) 196

NET CURRENT ASSETS (LIABILITIES) 2,711 2,646 1,881 (765)

TOTAL ASSETS LESS CURRENT

LIABILITIES48,985 50,172 52,848 2,676

Non Current Borrowings (DH Loans +

finance lease commitment)(402) (357) (330) 27

Non Current Provisions for liabilities and

charges(426) (380) (380) 0

Total Creditors due after more than

one year(828) (737) (710) 27

TOTAL ASSETS EMPLOYED 48,157 49,435 52,138 2,703

Public dividend capital 31,220 31,220 31,220 0

Revenue Position 509 1,278 1,804 526In month surplus including impairment reversal

of £336k

Retained Earnings (Accumulated losses) 5,613 6,123 6,134 11

Revaluation Reserve 10,815 10,814 12,980 2,166

TOTAL TAX PAYER'S EQUITY 48,157 49,435 52,138 2,703

Taxpayers Equity

Current Assets

Current Liabilities

Non Current Liablities

Paper 02


P) Cash Flow Statement

``


Rolling Cashflow Forecast Mar-12

INCOME

April May June July August Sept Oct Nov Dec Jan Feb Mar Apr May June July August Sept Oct Nov Dec Jan Feb Mar

2011 2011 2011 2011 2011 2011 2011 2011 2011 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2012 2013 2013 2013

Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Actual Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

Clinical SLA Income 5,394 5,498 5,638 6,014 6,332 6,239 5,907 5,908 5,744 5,675 5,883 5,748 5,918 5,918 5,918 5,918 5,918 5,918 5,918 5,918 5,918 5,918 5,918 5,920

Clinical SLA Overperformance 60 215 320 262 203 -19 367

Clinical SLA Underperformance refunds -39 -686

Other NHS Income 561 693 751 954 580 767 642 678 725 898 351 1,173 650 650 650 650 650 650 650 650 650 650 650 650

Non NHS Income 504 544 375 694 469 673 474 644 550 362 575 628 550 550 550 550 550 550 550 550 550 550 550 550

Recharges 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125 125

Donated Capital 600

Total Cash receipts 6,605 7,075 7,209 8,049 7,709 7,785 7,148 7,355 7,144 7,060 6,934 7,674 7,524 7,243 7,243 7,243 7,243 7,243 7,243 7,243 7,243 7,243 7,243 7,245

EXPENDITURE

Payroll 2,195 2,229 2,250 2,179 2,144 2,170 2,172 2,246 2,221 2,296 2,267 2,288 2,250 2,250 2,250 2,250 2,250 2,250 2,250 2,250 2,250 2,250 2,250 2,250

Tax,NI,SPN 1,561 1,539 1,549 1,596 1,514 1,468 1,521 1,492 1,556 1,531 1,579 1,557 1,575 1,575 1,575 1,575 1,575 1,575 1,575 1,575 1,575 1,575 1,575 1,575

Theatre rental 816

Non-Pay via Accs Payable (Trade) 2,677 2,000 2,175 2,259 2,325 2,101 1,748 2,552 2,927 1,646 2,529 2,949 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400 2,400

Non-Pay via Accs Payable (NHS) 629 487 718 481 654 521 554 513 423 529 411 753 650 650 650 650 650 650 650 650 650 650 650 650

Capital (NHS) 175 284 188 62 271 378 136 427 24 499 585 1,563 246 213 213 213 213 213 213 213 213 213 213 213

Capital (Donated) 600

Investments -500 0 -2,000 4,500 -500 0 0 0 0 -4,000 2,000 -2,000

Loan Repayment 25 25 25 25

Loan Interest 8 7 8 8

PDC Dividend 623 623 623 623

Total Cash Payments 7,237 6,039 6,880 4,577 11,408 7,610 6,131 7,230 7,151 6,501 7,371 5,765 9,721 7,088 7,088 5,088 7,088 7,744 7,088 7,088 7,088 7,088 7,088 7,744

CASH BALANCE

Opening Balance 1,356 724 1,760 2,089 5,561 1,862 2,037 3,054 3,179 3,172 3,731 3,294 5,203 3,006 3,161 3,316 5,471 5,626 5,125 5,280 5,435 5,590 5,745 5,900

Cash Movement -632 1,036 329 3,472 -3,699 175 1,017 125 -7 559 -437 1,909 -2,197 155 155 2,155 155 -501 155 155 155 155 155 -499

Closing Balance 724 1,760 2,089 5,561 1,862 2,037 3,054 3,179 3,172 3,731 3,294 5,203 3,006 3,161 3,316 5,471 5,626 5,125 5,280 5,435 5,590 5,745 5,900 5,401

Total cash including investments

Add short term investments 2,500 2,000 2,000 0 4,500 4,000 4,000 4,000 4,000 4,000 4,000 0 2,000 2,000 2,000

Total Cash Holding 3,224 3,760 4,089 5,561 6,362 6,037 7,054 7,179 7,172 7,731 7,294 5,203 5,006 5,161 5,316 5,471 5,626 5,125 5,280 5,435 5,590 5,745 5,900 5,401

Previous month forecast cash holding 4,185 4,384 4,499 4,584 6,317 5,463 5,650 6,350 6,321 6,030 5,376 5,013 4,572 4,534 4,496 4,458 4,420 3,726 3,688 3,650 3,612 3,574 3,536

Variance -961 -624 -410 977 45 574 1,404 829 851 1,701 1,918 190 434 627 820 1,013 1,206 1,399 1,592 1,785 1,978 2,171 2,364

Drivers for variance from last month forecast:

creditor payments higher than plan -600

other nhs income higher than plan 600

non nhs income higher than plan 200

Actual Forecast

Paper 02


Appendix 1 - Declaration of performance against healthcare targets and indicators

These targets and indicators are set out in the 2011-12 Compliance Framework

Definitions can be found in the "2011/12 Compliance Framework"

Month 12Threshold/

agreed target

YTD Weighting

Achieved /

Not Met explanation

Clostridium Difficile -meeting the C.Diff objective 2 1.0 Achieved

MRSA - meeting the MRSA objective 0 1.0 Achieved

Cancer 62 Day Waits for first treatment (from urgent GP referral) >85% 1.0 AchievedReferral to treatment time, 95th percentile, admitted patients <23Wks 1.0 Failed to MeetReferral to treatment time, 95th percentile, non-admitted patients <18.3Wks 1.0 AchievedCancer 31 day wait from diagnosis to first treatment >96% 0.5 AchievedCancer 2 week (all cancers) >93% 0.5 AchievedCompliance with requirements regarding access to healthcare for people with a learning disability N/A 0.5 Achieved

Risk of, or actual, failure to deliver mandatory services Yes/No 4.0 No

CQC compliance action outstanding Yes/No 2.0 No

CQC enforcement notice currently in effect Yes/No 4.0 No

Moderate CQC concerns regarding the safety of healthcare provision Yes/No 1.0 No

Major CQC concerns regarding the safety of healthcare provision Yes/No 2.0 No

Yes/No 2.0 No

Calculated score 1.0 AMBER-GREEN

Monitor override 2/3 AMBER-RED

Target or Indicator (per 2011-12 Compliance Framework)

Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements

Paper 02


Paper 03

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 03 Directors Declarations of Interest.doc




Executive Responsible Margaret Surrage, Head of Board Governance (Trust

Secretary)


Category of Item Strategic Direction and

Development



Link to National Policy

Link to Trust’s Strategic Objectives


Executive Summary

The Directors Declaration of Interests is presented for the Directors consideration and to enable them to approve three

related entries in the Annual Report

Subject/Title Directors Declarations of Interest


For Discussion �

For Approval �


Legal Implications

Recommendation • That the Directors confirm that the register of interests

as shown at appendix 1 is accurate and complete

• That the Board confirms that the following Non

Executives Directors are considered to be independent

o Russell Hardy

o James Turner o Richard Clarke

o Peter Jones o Mervyn Dean

o Glen Lawes

1

Paper 03


• That the Board confirm that they consider that the

statement

“The Chairman has not declared any significant commitments which are considered material to his capacity to carry out his role” is accurate and should be recorded in

the Annual Report.

Acronyms and

Abbreviations

2

Paper 03


Russell Hardy � 4358 Chairman



DDIIRREECCTTOORRSS’’ DDEECCLLAARRAATTIIOONNSS OOFF IINNTTEERREESSTT

The Directors’ declarations of interest were brought to the Trust Board last June. The annual

exercise to refresh the register has been brought forward to fit in with the revised national reporting timetable. This will feed into the Annual report to meet three separate reporting

requirements as shown below.

Publication of the Register of Interests This requirement can be fulfilled by provided a link in the Annual Report to the declarations

on the Trust website, so it is important to ensure that the website is up to date.

Board members are asked to confirm that the details included at appendix 1 are accurate and

complete.

Independence of Non Executive Directors The Annual Report has to include the names of the NED’s which the Board considers to be

independent. To comply with this the Board is asked to review the declarations of interest

and confirm that it considers all of the NEDS to be independent. The provision from the FT governance handbook is copied below.

The board of directors should identify in the annual report each non executive director it considers to be independent. The board should determine whether the director is independent in character and judgement and whether there are relationships or circumstances which are likely to affect, or could appear to affect, the director’s judgement.

Chairman’s Commitments The Annual report must include a statement in relation to the other significant commitments

of the chairman and any changes to them during the year.

The proposed statement is “The Chairman has not declared any significant commitments which are considered material to his capacity to carry out his role”

The board is asked to review the Chairman’s declarations of interest and confirm that they

are in agreement with this statement.

3

Paper 03


Recommendation

The Board of Directors are asked to:

• Confirm that the register of interests as shown at appendix 1 is accurate and

complete

• Confirms that the following Non Executives Directors are considered to be

independent

o Russell Hardy

o James Turner o Richard Clarke

o Peter Jones o Mervyn Dean

o Glen Lawes

• Confirm that they consider that the statement:

“The Chairman has not declared any significant commitments which are considered material to his capacity to carry out his role” is accurate and

should be recorded in the Annual Report.

Margaret Surrage

Head of Board Governance (Trust Secretary)

4

Appendix 1

Directors Declarations of Interest as at April 2012

Non Executive DirectorsMr. R Hardy Chair of Hunters Moor Neuro Rehabilitation ltd

Governor of Nuffield Health

Chair of Multiple Sclerosis Trust

Trustee of UK Acquired Brain Injury Forum

Chair of the Strategic Orthopaedic Alliance

Mr R Clarke

Spouse owns a community pharmacy which is contracted to the

NHS Telford and Wrekin PCT, Richard provides accountancy

and other management services to the business on a self-

employed basis. His spouse also works for NHS Telford and

Wrekin PCT as a medicines management pharmacist, on a part-

time, self-employed basis. Governor of Newport High School

Academy Trust and "responsible officer" to the governing body

of the Academy Trust.

Mr. RM Dean Principal Auditor, Wrexham Borough council

Governor at Ysgol Rhiwabon (Ruabon High School)

Professor PW JonesEmeritus Professor of Statistics and a Senior Statistician at

Keele University Health Services Research Unit

Governor - Newcastle-Under-Lyme School

Member of NICE Technology Appraisal Committee

Funding from MRC, NIHR as co-investigator

Statistical adviser for Clinical Trials for Biocomposities

Member of the R&D Committee - Mid Cheshire Hospital

Foundation Trust

Member Rheumatoid Arthritis Commissioning Metrics Working

Group

Mr. G Lawes Board membership of:-

Shropshire Education & Conference Centre

Shropshire Tourism

Museums Libraries & Archives Council

Mr. JJ Turner Public Sector NED - Royal Navy Command Board; NED -

Welsh Government Board Private Sector NED – Aber

Instruments Ltd; Director -16 Gwendwr Board (Management)

Ltd; NED Boysand Boden Ltd; Voluntary Sector Director &

Trustee -Community Justice Interventions Wales; Director &

Trustee - Rekindle; Trustee - Castle United Charities; Chairman

& Trustee - Diocesan Board of Finance, Diocese of St Asaph;

Deputy Chairman & Trustee - Representative Body of Church in

Wales; Director & Trustee - Oriel Davies Gallery, Newtown

Executive DirectorsMrs. W Farrington Chadd NIL

Mr. JA Grinnell

Company secretary for wife's company "Playworld ltd" Company

provides children's play facilities - no potential conflict.

Mr. DJ James NIL

Professor IW McCall NIL

Mrs. N Bellinger NIL

Mrs. J Downey NIL

Ms. R Tyrrell NIL

Mrs. V Doyle NIL

Paper 04

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 04 Quarter 4 Board Assurance Framework.doc

BBooaarrdd ooff DDiirreeccttoorrss

2266tthh AApprriill 22001122


Executive Responsible Wendy Farrington Chadd, Chief Executive



Context Previous Board discussion The Q3 BAF was discussed at the January Board




Executive Summary

This paper presents the Board Assurance Framework for the fourth quarter of 2011/12. This reflects the assessment of

risk as at the end of the financial year.

Subject/Title Board Assurance Framework – Quarter 4


For Discussion �

For Approval �


Legal Implications

Recommendation That the Board notes the Board Assurance Framework.

Acronyms and

Abbreviations

BAF: Board Assurance Framework CIP: Cost Improvement Programme

Paper 04

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 04 Quarter 4 Board Assurance Framework.doc



RREEVVIIEEWW OOFF TTHHEE BBOOAARRDD AASSSSUURRAANNCCEE FFRRAAMMEEWWOORRKK 22001111--1122

1.0 Introduction

1.1 This paper presents the Board Assurance Framework for the fourth quarter of

2011/12. This reflects the assessment of risk as at the end of the financial year.

1.2 A refreshed Board Assurance Framework, based on 2012/13 objectives and risks will

be presented to the Board as part of the Annual Plan submission.

2.0 Changes made since the Board Assurance Framework was last reported to the Board

2.1 Since the January report the following changes have been made:

2.1.1 There has been one new risk added to the Board Assurance Framework: • 18 Week Referral to Treatment Target (RTT). This is a new risk area.

The action plan has been approved by the Board and the BRIC has

agreed to closely monitor progress against it.

2.1.2 Two risks have been reduced:

• The risk of slippage against the 2011/12 CIP programme. The CIP target

has been achieved. This risk will be replaced by a similar risk in 2012/13, concerning the current years CIP.

• The C Difficile target for 2011/12. The target of a ceiling of two cases

has been achieved. This will not be a future compliance risk as Monitor

has introduced a de minimus level of 12 cases.

3.0 Recommendation

3.1 That the Board approves the Board Assurance Framework.

Wendy Farrington Chadd Chief Executive

Board Assurance Framework Quarter 4

Version: 1.0 Last updated:

Link to IBP

Delivery of services as

demand for our services

increases

Increased referrals due

to failure of demand

management schemes

by commissioners

Director of

Operations

Demand for service exceeds contractual expectations

Cause: Increased referrals through patient choice

Effect: Breach of access targets. Failure to meet contractual

obligations.

I = 4 L = 4

16

40 Implementation of Hip & Knee scores

Implementation of new spinal pathway

Triaging of referrals

Improved use of Locums

Out of Job plan sessions with surgeons and anaesthetists have been secured

Improved use of Saturday lists

Capacity has been increased by locum appointments

BRIC / Executive Team Monthly performance report to Trust Board Activity delivery in 2010/11 & 2011/12 I = 4 L = 3

12



increases

Key Monitor

performance indicator

Director of

Operations

Delivery of the RTT Action Plan

Cause: Slippage on the delivery of the RTT Action Plan

Effect: Potential for increase in cost if external capacity or OJP sessions

used Risk to reputation

I = 4 L = 5

20

1217 Action plan in agreed by Board.

Monthly reports to Trust Board

In depth monitoring by BRIC

Plans agreed with Commissioners

Monitor regularly updated on the situation

Project team established to manage recovery plan

BRIC / Executive Team Monthly Board performance reports New risk I = 4 L = 4 16



increases

Director of

Operations

Failure to optimise capacity, which could lead to a shortfall in

meeting contractual and RTT obligations

Cause: Delay in the introduction of consultant job plans covering 6 day

operating, with appropriate staff support

Effect: Breach of access targets.

Failure to meet contractual obligations

I = 4 L = 4

16

1189 Improved use of Locums

Out of Job plan sessions with surgeons and anaesthetists have been secured

Improved use of Saturday lists

Capacity has been increased by locum appointments

BRIC / Executive Team Monthly performance report to Trust Board Activity delivery in 2010/11 & 2011/12 I = 4 L = 3

12

Maintain C-Difficile

target

Key Monitor

performance indicator

Director of

Nursing &

Governance

Target set for C-Difficile in 2011/12.

Cause: The DoH have set extremely challenging targets of less than or

equal to 2 cases for this year (2011/12). As at December 2011 two

cases have been reported.

Effect: Due to the nature of patients admitted, potentially this is

unachievable. New testing is much more sensitive, which may result in

a higher level of positive results.

I = 4 L = 5

20

1,161 Policies and Procedures are in place.

Staff are reminded of the Policies and procedures around Infection Control and to contact the

Infection Control Sister if clarification is needed.

Continual monitoring takes place

Additional staff Infection Control training provided by the Infection Control Team.

Increased infection control processes at pre-op.

Introduction of a new pre-op questionnaire.

Surgeons have received additional notice around C-Difficile procedures.

Quality & Safety Committee/

Executive Team

Monthly performance report to Trust Board Target met in 2011/12. (ceiling2 cases, actual 2 cases).

This will not be a high compliance risk for 2012/13 as a de

minimus of 12 cases has been set.

I = 4 L = 1

4

To redesign the patient pathway to facilitate improved patient outcomes and increased productivity

Continue to develop and

improve the patient

pathway, and flow

through the hospital

Revised patient

pathways / length of stay

reduction

Director of

Nursing and

Governance

Implementation of new patient pathways could result in disruption

to patient services or adversely impact on quality or safety.

Cause: Failure of internal governance or change management

processes.. Failure to recruit appropriately skilled staff.

Effect: Potential quality and safety breaches. Risk to business

continuity including the delivery of some key services. Inability to

deliver demand requirements. Risk to CIP delivery

I = 4 L = 4

16

1,127 Process for incident reporting;

Formal process for introducing new procedures;

HR Strategy and succession plans;

Training and development strategy;

Internal key principles to pathway improvements agreed and project group formed;

Steering group to lead implementation;

Working operational group.

Governance processes to manage identification of guidance.

Monitoring of patient safety measures.

Principle agreements in place for change.


Executive Team

QIPP Work Plans.

Monthly performance report to the Board.

Quarterly divisional reviews.

Steering Group to monitor progress.

Patient Experience KPI's, as reported to the Trust Board,

continue to be rated "green".

I = 4 L = 2

8

Monitor the national

economic climate and

the impact this may

have on local

commissioners

Economic Climate

pressures/ local

commissioner financial

pressures.

Director of

Finance

Financial challenges of the Economic Climate.

Cause: Reduction in Public Sector expenditure. Financial pressure on

the Trusts key commissioners. Financial problems experienced by other

providers in the Local Health Economy.

Effect: Inability of PCT/LHB to afford underlying growth in activity,

which could result in difficulties recovering payment for over

performance. Loss of income through increased demand management

measures. Requirement for increased cost reduction or higher efficiency

gains if income is reduced in any year.

I = 4 L = 4

16

858 The Trust, in collaboration with the SOA, is in communication with the DoH re PBR/

Operating Framework issues.

Plan assumes a reduction in funding over the next 5 years.

The 2012/13 Operating Framework key requirements are within the parameters of the IBP.

The majority of the 2012/13 contracts have been agreed which mitigates some of the risk of

loss of income

BRIC / Executive Team Monthly performance report to the Board.

Robust contract monitoring procedures in place.

Monthly contract meetings with Commissioners.

Impact of financial climate built into baseline.

Debt position reported to the Board and in detail every

quarter at Audit Committee.

CIP assumes reduced funding reported monthly to Board.

Financial surpluses delivered.

Planned 11/12 CIP over achieved.

Positive contractual negotiations and financial agreements

in place.

Long term sustainability model agreed with key English

commissioners aligned to Trust plans.

Downside scenarios as part of IBP demonstrate Trusts

financial viability.

Positive positioning from BCUHB seeing RJAH as

strategic partner.

FT authorisation demonstrates that Monitor have

assessed the Trust as being able to withstand the current

economic climate 2 year financial agreement in place

with BCU & Powys (11/12 to 12/13)

I = 4 L = 3

12

Emerging Risk Area. Emerging Risk Area. Chief Executive Impact of NHS restructuring on commissioning arrangements

Cause: "Liberating the NHS" reforms will restructure NHS

commissioning. The establishment of clusters and CCGs will cause

instability during transition

Effect: Need to rebuild commissioning relationships. ore complex

commissioning relationships.

I = 4 L = 4

16

1100 Transitional organisations are now in place for local, specialist and SHA clusters. New

relationships are being developed and this is seen as a key area of focus

BRIC / Executive Team Monthly Chief Executive updates to Trust Board. English Contracts have been signed I = 4 L = 3

12

Principal Risks (and Cause & Effect) Risk RatingRisk Reg

RefMitigating Actions/Controls

Sub-Committee/ reporting

committeePositive Assurance in last 18 monthsSources of Assurance

To develop a vibrant and viable

organisation where people achieve their full potential and success leads to investment in

services for patients

Residual Risk

Score

17/04/2012

Lead DirectorStrategic Aim Principal Objectives

To be the provider of choice for patients

through the provision of safe, effective and

high quality orthopaedic and related care.

Board Assurance Framework Quarter 4

Version: 1.0 Last updated:

Link to IBP Principal Risks (and Cause & Effect) Risk RatingRisk Reg

RefMitigating Actions/Controls

Sub-Committee/ reporting

committeePositive Assurance in last 18 monthsSources of Assurance

Residual Risk

Score

17/04/2012

Lead DirectorStrategic Aim Principal Objectives

Continue to work with

colleagues at the

Strategic Orthopaedic

Alliance on the national

tariff, to ensure it

reflects true costs

National tariff volatility Director of

Finance

The risk of instability arising from fluctuations in the annual

tariff.

Cause: Associated risk of instability arising from annual tariff

fluctuations. The impact could be compounded given the specialist

nature of the Trust.

Effect: The Trust would not be fully reimbursed for its activity, which

would result in a financial deficit.

I = 4 L = 4

16

1063 Working with colleagues in the Strategic Orthopaedic Alliance (SOA), the trust has agreed

prospective working arrangements with the DoH PBR Team, including a review of the Trust's

PLICs data. The

Trust participates in the National Sense check exercise to highlight any anomalies in the tariff

prior to it being issues. This had a positive impact on the 2011/12 tariff setting exercise.

SLR/ PLICs allows detailed understanding of cost and income interrelationships.

Approaches to the DoH have been successful on previous occasions. Trust participating in

National Spinal Taskforce review including focus on appropriate specialist tariffs. 2012/13

tariff roadtest has now been released & is currently being assessed.

BRIC / Executive Team Previous successful discussions with SOA/PbR Team.

Meeting with D Flory to discuss future input SOA can have

with PbR team.

Input into tariff setting assumptions.

Downside risk of unstable tariff modelled in IBP.

Participation in the National Sense checking exercise,

resulting in a positive impact on the 2011/12 & 2012/13

tariff setting exercises.

Continual review of the position.

I = 4 L = 3

12

Maintain business

continuity

Business Continuity -

Local Health Economy

incident planning

Director of

Nursing &

Governance

Risk of failure of key Trust systems due to a major incident.

Cause: Catastrophic failure of key Trust systems due to major incident

or acute business continuity issues.(HR,IT,Estate eg fire)

Effect: Potential impact on direct patient care delivery and safety of

staff. Trust systems (IT) fail leading to Trust key processes being

unable to support service delivery. Loss of activity for

a period of time and decreased through put and subsequent loss of

income and increased costs. Impact on Local Health Economy/ key

corporate objectives. Fire damage.

I = 5 L = 4

20

853

1190

Major incident plan includes business continuity and pandemic flu plans developed with LHE.

Major incident and business continuity plans tested on an annual basis.

Department level plans and operational plans in place.

Systems and controls in place to manage a variety of scenarios.

IT disaster recovery plans in place to support electronic systems failure.

Identified Trust lead for major incident and pandemic emergency planning.

Major incident policy has been updated and presented to the December 2011Trust Board.

Estate replacement programme targeting higher risk buildings (eg wooded framed)


BRIC/Executive Team

Regular testing of Trust level business continuity plans.

Departmental and operational plan in place.

Review of Trust plans to ensure remain up to date in light of

any new guidance received.

Quarterly reports to sub committees

Updated plan taken to December 2011 Trust Board.

Presentation on the Business Continuity Plans in

preparation for winter pressures given to the Board

(December 2011).

Desk top major incident exercise carried out March 2011.

Significant assurance from an Internal Audit review of

Business Continuity and Disaster recovery (March 2011).

External fire risk assessment report

I = 5 L = 2

10

Maintain financial

stability in line with the

Annual Plan, including

the delivery of CIPs

Undershoot on CIP

beyond 2011/12

Director of

Finance

Risk that the Trust fails to deliver the CIP programme in future

years

Cause: Inability to deliver the CIP in future years as the efficiencies

required from the tariff become more challenging.

Effect: Failure to meet financial plan. Deterioration in risk rating.

Possible deferral of capital programme due to cash flow issues.

Potential impact on the quality of service provision.

I = 4 L = 4

16

979 There are detailed plans in place for 2012/13 & 2013/14. Realistic thenmes have been

identified for the subsequent two years.

The Trust has a strong track record of challenging CIP delivery.

The Trust has robust processes embedded for the sign off of CIPs by the relevant managers.

The service line reporting and PLICs systems are providing more detailed information which

is enhancing the CIP/ QIPP programmes.

BRIC / Executive Team Monthly integrated performance report to the Board.

Regular updates to Executive Team.

Quarterly divisional reviews.

Audit Committee.

External audit.

Business Risk & Investment Committee.

SHA Financial Monitoring.

CIP Track record.

Divisional Performance Framework review meetings.

Divisional meetings minutes.

2009/10 CIP fully met.

Positive Internal and External Audits / Annual Accounts /

Annual Audit Letter.

Audit report providing significant assurance on Financial

Reporting.

FT authoristaion demonstrates that Monitor consider the

Trust to be financially stable

SLR reports.

Efficiency Strategy approved by the Board.

CIP over acheived in 2011/12 . CIPs and Annual plan agreed for 2012/13

I = 4 L = 3

12

Maintain financial

stability in line with the

Annual Plan, including

the delivery of CIPs

Undershoot on

2011/12 CIP

Director of

Finance

Undershoot on 2011/12 CIP.

Cause: Slippage in CIP schemes

Effect: Potential impact on outturn Potential impact on cash balance -

both of which could adversely affect the Monitor risk rating

I = 4 L = 4

16

1193 Alternative schemes have been identified to cover known slippage

Monthly & Quarterly divisional reviews include CIP progress. All

CIPs are agreed & signed off by managers Current CIP is being delivered in line with the plan

and forecast to be achieved at the year end. Trust Board is focussing on the key productivity

metrics which will achieve this. CIP

over acheived in 2011/12

BRIC / Executive Team CIP is reported to the Board on a monthly basis, with more

detailed deep dives undertaken on request.

2011/12 CIP schemes agreed.

Positive Internal and External Audits / Annual Accounts /

Annual Audit Letter.

Audit report providing significant assurance on Financial

Reporting.

FT authoristaion demonstrates that Monitor consider the

Trust to be financially stable

SLR reports.

Efficiency Strategy approved by the Board.

CIP over acheived in 2011/12

I = 4 L = 1

4

Maintain business

continuity

NHS wide industrial

action was not

envisaged when IBP

was produced

Associate Director

of Human

Resources

NHS wide Industrial Action

Cause: Inability to agree changes to NHS pensions at a national level.

Effect: Potential ongoing disruption to services, including targeted

action with key groups in the public sector.

Possible failure to meet targets or contractual obligations

I = 4 L = 4

16

1188 Existing contingency and Business Continuity plans are in place

SHA coordination of Business Continuity plans

National guidance has been issued

Associate Director of HR attendance at "Desktop" contingency planning exercise

Local industrial action protocol has been agreed.

BRIC / Executive Team Monthly monitoring report to SHA

Exception reporting to Board of Directors

Activity delivered on 30th November Day of Action I = 3 L = 4

12

Reduce staff sickness

to 2% by 2015

Staff sickness absence Associate Director

of Human

Resources

Failure to manage absence and avoid causes of absence.

Cause: Sickness absence resulting in paid time off

Effect: Increased pressure on colleagues; cost of paid leave; potential

litigation and personal injury.

I = 4 L = 4

16

1004

Sickness Trigger points set and monitored monthly

HR performance management and support to Trust

OH service provision Health and Wellbeing Strategy

Constant monitoring and application of the Sickness Absence Management Strategy

Addressing main causes of absence (MSDs/ Stress/ Anxiety) through targeted action

Promoting the general health & well being of staff

BRIC / Executive Team Monthly performance report to Trust Board.

Quarterly detailed reports to BRIC.

Seeing reduction in overall sickness percentage and long

term issues eg: MSDs.

Launch of the Health and Wellbeing Strategy (Jan 2011).

Improvements in the Staff Survey 2010.

3.5% sickness target is on track to be achieved for

2011/12. Internal Audit review of sickness absence (June

2011) gave significant assurance

I = 4 L = 2

8

Acronyms and abbreviations

ALE IM&T Information Management and Technology QIPP Quality Improvement Programme

BAF Board Assurance Framework KPI Key Performance Indicators RJAH Robert Jones and Agnes Hunt Orthopaedic and District NHS Trust

BRIC Business Risk and Investment Committee KSF Knowledge Skills Framework RTT Referral to Treatment

CHC LHB Local Health Board SCPCT Shropshire County Primary Care Trust

CEO Chief Executive Officer LHE Local Health Economy SHA

CINCH LTFM Long Term Financial Model SLR

CIP MPET Multi Professional Education and Training levy SoS

CQC NHSLA NHS Litigation Authority OH

CQUIN OOH Out Of Hours

DIPC PALS Patient Advice and Liaison Service

ESR PEAT Patient Environment Action Teams

FT Foundation Trust PCT Primary Care Trust

HCAI Healthcare Acquired Infections PDR Personal Development Review

HDD Historic Due Diligence PPI Patient and Public Involvement

IIP Investors In People PROMS Patient Reported Outcome Measures

Community Health Council

Community Involvement in Care and Health

Auditors Local Evaluation

Director of Infection Prevention and Control

Strategic Health Authority

Service Line Reporting

Occupational Health

Secretary of State

Care Quality Commission

Commissioning for Quality and Innovation

Cost Improvement Plan

Paper 05

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 05 Quarter 4 Monitor Submission.doc


Chairman





Helen Ashcroft, Business Planning Manager Craig Macbeth, Deputy Director of Finance


Development





Objectives

�


Executive Summary

This paper provides assurance to the Trust Board in relation to

the key targets and declarations required by Monitor for the

Quarter 4 performance return.



Recommendation It is recommended that the Board approve: • The content of the Quarter 4 (Month 12) submission to

Monitor.

Subject/Title Quarter 4 Monitor Return


For Discussion �

For Approval �

1

Paper 05


BOARD OF DIRECTORS

MONITOR QUARTERLY RETURN

QUARTER 4 – MARCH 2012

1. Introduction

1.1 As a Foundation Trust the Organisation is required to provide Monitor with quarterly

returns detailing the Trust’s performance against the national targets and core

standards as outlined in Monitor’s Compliance Framework.

1.2 The return for the fourth and final quarter of 2011/12 is due on the 30th April 2012 and will detail performance to the end of March 2012, the twelfth month of the

2011/12 financial year.

1.3 This paper presents the Board with the details of the targets against which the Trust

is measured and provides assurance of the Trust’s position in relation to these targets as to the end of March 2012.

1.4 The content of the quarterly return is drawn from the Board’s monthly performance

scorecard which covers all of the Compliance Framework requirements.

2. Monitor quarterly return format and targets

2.1 The Monitor Quarterly return is split into four sections:

• Overarching declarations of achievement

• Compliance Framework targets and indicators (service performance)

• Details of Governor elections

• Financial position indicators

2.2 Overarching declarations

2.2.1 There are three overarching declarations against which the Trust must confirm if it is compliant or not. They are:

• In year Finance declaration:

“The Board anticipates that the Trust will continue to maintain a financial risk

rating of at least 3 over the next 12 months”

• In year Quality Board statement:

“The Board is satisfied that, to the best of its knowledge and using its own

processes and having had regard to Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on

serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS Foundation Trust has, and will keep in place,

effective arrangements for the purpose of monitoring and continually

improving the quality of healthcare provided to its patients”

2

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• In year governance declaration:

“The Board confirms that all targets and indicators have been met (after

application of thresholds) over the period and that sufficient plans are in place to ensure that all known targets and indicators which will come into

force during 2011-12 will also be met” and “Details of any elections held

(including turnout rates) and any changes in the Board or Board of Governors are included in that quarter’s return”.

2.3 Compliance Framework targets and indicators

2.3.1 Monitor’s return requires the Trust to confirm its service performance against the

main Compliance Framework targets relevant to the Trust as set out below.

• Clostridium Difficile – requirement to have no more than 2 C. Difficile cases during the financial year 2011/12

• MRSA - requirement to maintain a zero MRSA rate

• Maintenance of all national cancer targets including:

� Maximum one month wait from diagnosis to treatment

� Maximum waiting time of 31 days for second or subsequent treatments for

all cancers

� Maximum waiting time of 31 days from diagnostic to first treatment for all

cancers

� Maximum 62 day wait for first treatment either from urgent GP referral to

treatment or from Consultant screening to treatment

� All cancers 31 day wait from diagnosis to first treatment

� Maximum waiting time of 2 weeks from urgent GP referral to first

outpatient appointment for all urgent suspected cancer referrals

• Referral to treatment times for admitted patients of 23 weeks (95th percentile) –

18 weeks

• Referral to treatment times for non-admitted patients of 18.3 weeks (95th

percentile) – 18 weeks

• Learning Difficulties – achievement of the 6 criteria for meeting the needs of people with learning difficulties

2.4 Details of any Governor elections 2.4.1 The Trust must confirm details of any Governor’s elections which have taken place in

the reporting quarter alongside turnout rates. Details of any changes to the Board are

not reported in the return instead uploaded on an ‘as and when’ basis through the year.

2.5 Financial position indicators

2.5.1 The Trust must report on a series of indicators Monitor have developed as early warning indicators of financial risk. There are 10 indicators in total focusing

predominantly on liquidity performance of the Trust.

3

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3. RJAH assurance processes

3.1 The Trust Board is assured of its position with the quarterly submissions via the

existing reporting structures in place, supporting the sign off of the Trust

declarations. These include the integrated balanced scorecard, reports made directly to the Board and those reviewed by delegated sub committees of the Board.

3.2 Details of the Trust’s financial and compliance framework targets are reported

monthly via the integrated balanced scorecard whilst quality governance assurance is provided via the monthly performance report, the work of the Quality and Safety

Committee and through the Board Assurance Framework. In addition regular

feedback is received via Directors reports and from non executive patient safety walkabouts.

3.3 Internal audits have been carried out during the financial year by both the Trust’s

own Data Quality team and the Trust’s auditors to ensure data accuracy and to

provide rigor to the reporting framework. In addition a recent internal audit highlighted the Trust as having ‘significant assurance’ in relation to Monitor’s self

certification process.

3.4 All exceptions to the targets are formally reported via normal reporting routes and in addition highlighted in a quarterly submission preview paper such as this provided to

the Board in advance of the quarterly submission deadline.

3.5 Further assurance can be gained from the 2011/12 Board self assessment process

which concluded that the Board and its processes were fit for purpose. A Board development programme has been signed off.

4. The quarter 4 submission

4.1 The quarter 4 submission to Monitor will detail performance between January 2012

and the end of March 2012 and will be uploaded to Monitor on the 30th April 2012.

4.2 The Board declarations will be signed off by the Chief Executive Officer following

approval by the Trust Board via this paper.

4.3 Main points to note within the quarter 4 submission are:

4.4 Financial position declaration & indicators

4.4.1 Evidence to assure the Board that the Trust has met its financial targets for quarter 4 is contained within the Trust’s integrated performance paper.

4.4.2 The Trust is continuing to achieve an overall financial risk rating level of 4 as per its plan and forecasts to do so to the year end.

4.4.3 The Trust continues to have a debtors over 90 days higher than Monitor’s early

warning indicator, however Monitor have confirmed in their quarterly update that this is not considered a material issue and is not of concern.

4.5 Compliance Framework targets and quality indicators 4.5.1 Aligned with the monitoring of the financial position indicators the compliance

framework targets are reported to the Trust Board on a monthly basis via the

integrated performance scorecard paper.

4

Paper 05


4.5.2 As previously reported to the Board, the Trust undertook a review of its waiting list policy and management arrangements during quarter 4. This identified a gap in the

delivery of the 18 week Referral to Treatment (RTT) targets including Monitor’s preferred measure of the 95th percentile for admitted patients. Using Monitor’s own

risk assessment criteria the non delivery of this target gives the Trust an ‘amber

green’ RAG rating. This is detailed in appendix 1.

4.5.3 This issue has been highlighted in the Monitor return and has been discussed in full with Monitor during the quarter and a plan for delivery by the end of August 2012

agreed, (which will be further discussed later in the Board session). Due to the 18 weeks RTT targets being a prime Monitor target, Monitor has taken a decision to

override the ‘amber-green’ risk rating to ‘amber–red’ within the quarterly return.

4.5.4 All of the remaining compliance framework targets including infection control, cancer

and learning difficulties targets have been met for quarter 4.

4.5.5 The Trust successfully achieved the delivery of the exceptionally low C. Difficile target

of no more than 2 cases for the year and so has removed the risk of non delivery reported in previous quarterly submissions.

4.5.6 The Trust has maintained a level 2 performance for all Monitor key requirements

included in the Information Governance Statement of Compliance in the Department of Health’s Information Governance Toolkit.

4.5.7 The Trust has not received any Care Quality Commission (CQC) reviews and has no CQC actions outstanding.

4.6 Overarching declarations

4.6.1 Both the quarterly finance and quality board statements show in section 2.2.1 above

will be signed off to say that the Trust is fully compliant with Monitor’s requirements.

4.6.2 The quarterly governance declaration will however not be signed off, instead Monitor

require that we sign off the following declaration for the quarter due to the Trust’s position in relation to the referral to treatment targets described in section 4.5.2 and

4.5.3 above:

“For one or more targets the Board cannot make Declaration 1 and has provided relevant details on worksheet "Targets and Indicators" in this return. The Board

confirms that all other targets and indicators have been met over the period (after

application of thresholds) and that sufficient plans are in place to ensure that all known targets and indicator which that will come into force during 2011-12 will also

be met.”

4.7 Details of Governor elections & Board changes

4.6.1 The Trust has a full complement of Executive Directors in place and through the recent Board self assessment is assured that it has the required management

capacity, capability and experience in place necessary to deliver the Annual Plan and that the management structure can deliver the forward plan.

4.6.2 There have been three Executive Director appointments over the quarter; the permanent appointment of a Director of Nursing and Director of Operations and an

interim appointment of a Medical Director, all of which have been reported to Monitor by the Chief Executive Officer.

5

Paper 05


4.6.3 There have been no Governor elections or changes during the last quarter.

4.6.4 The register of conflicts of interest is maintained by the Head of Financial Governance

for both the Board and Members’ Council which is updated on an annual basis and no

material conflicts of interest exist at this time.

5. Recommendations

5.1 On the basis of the information supplied to the Trust Board via routine monitoring

processes and the information within this paper it is recommended that the Board

agree:

• The Quarter 4 submission to Monitor noting the current governance risk

rating of ‘amber–red’

• That the Chief Executive signs the relevant declarations within the return on

behalf of the Trust Board.

Wendy Farrington Chadd

Chief Executive

6

Appendix 1 - Declaration of performance against healthcare targets and indicators

These targets and indicators are set out in the 2011-12 Compliance Framework

Definitions can be found in the "2011/12 Compliance Framework"

Month 12Threshold/

agreed target

YTD Weighting

Achieved /

Not Met explanation

Clostridium Difficile -meeting the C.Diff objective 2 1.0 Achieved

MRSA - meeting the MRSA objective 0 1.0 Achieved

Cancer 62 Day Waits for first treatment (from urgent GP referral) >85% 1.0 AchievedReferral to treatment time, 95th percentile, admitted patients <23Wks 1.0 Failed to MeetReferral to treatment time, 95th percentile, non-admitted patients <18.3Wks 1.0 AchievedCancer 31 day wait from diagnosis to first treatment >96% 0.5 AchievedCancer 2 week (all cancers) >93% 0.5 AchievedCompliance with requirements regarding access to healthcare for people with a learning disability N/A 0.5 Achieved

Risk of, or actual, failure to deliver mandatory services Yes/No 4.0 No

CQC compliance action outstanding Yes/No 2.0 No

CQC enforcement notice currently in effect Yes/No 4.0 No

Moderate CQC concerns regarding the safety of healthcare provision Yes/No 1.0 No

Major CQC concerns regarding the safety of healthcare provision Yes/No 2.0 No

Yes/No 2.0 No

Calculated score 1.0 AMBER-GREEN

Monitor override 2/3 AMBER-RED

Target or Indicator (per 2011-12 Compliance Framework)

Unable to maintain, or certify, a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements

7

Paper 06

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 06 Statement of Going Concern.doc

BBooaarrdd ooff DDiirreeccttoorrss









Objectives


Executive Summary

As part of submitting its annual Accounts and Report, the

Board are required to declare that the Trust is a going concern. This paper outlines the evidence for support of this

statement.

Subject/Title Statement of Going Concern


For Discussion �

For Approval �


Legal Implications

Recommendation That the Committee approves the following statement to be included in the Annual Report “After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.”

Acronyms and Abbreviations

1

Paper 06





SSTTAATTEEMMEENNTT OOFF GGOOIINNGG CCOONNCCEERRNN

1. Introduction

As an NHS Trust as part of submitting our Annual Report and Accounts a going concern

assessment was reached by our external auditors. This is not the case as a Foundation Trust.

Monitor have clarified in their Annual Reporting Manual that there is no presumption of going concern status for NHS Foundation Trusts. Directors must decide each year whether or not it

is appropriate for the NHS Foundation Trust to prepare its accounts on the going concern basis, taking into account best estimates of future activity and cash flows.

The NHS Foundation Trusts should include a statement on whether or not the financial statements have been prepared on a going concern basis and the reasons for this decision,

with supporting assumptions or qualifications as necessary (NHS Foundation Trust Code of Governance F.1.2).

A typical disclosure, based on guidance from the Accounting Standards Board, would read:

“After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.”

2. Evidence

Through its Integrated Business Plan (IBP) and Annual Plan the Board has developed its

financial strategy to ensure the Trust continues to embed its financial stability and associated risk coverage.

The Trust has a strong track record in delivering surpluses and has over recent years been growing its cash balances which ended the 2011/12 financial year at £5.2m and are forecast

to end the 2012/13 financial year at £5.4m. The 2012/13 financial plan assumes a further surplus of £1.5m is delivered.

As part of the Trusts Financial Strategy one of the key objectives was to ensure the Trust had enough risk coverage in its cash reserves to manage 10 days liquidity requirements which

equated to £2m minimum balances. The Trusts current and future cash projections are well in excess of this target.

2

Paper 06


The IBP and Annual Plan sees the Trust continuing to make year on year surpluses and

delivering a level 4 Financial Risk Rating (FRR) and thus are perceived as low risk by Monitor.

As part of developing these plans the Trust took a prudent assessment of likely demand for services which were much lower than seen historically. Our key commissioners reviewed and

supported our activity assumptions. The Trust also used local and national intelligence to

assess cost increases over the next 5 years.

During the production of our IBP we ran a number of sensitivities to our assumptions to test our financial stability under a series of downside risk scenarios. As part of this process the

Board signed off a prioritised list of mitigating actions that would be taken under a downside scenario which enables the Trust to continue to make surpluses, meet a level 3 FRR and

continue to have healthy cash balances.

As part of the FT process the Trust has also been required to have in place a working capital

facility that allows access to up to £6m of funds to manage short term liquidity risks.

Through the Trusts risk management processes key financial risks are tracked by the Board

and where required are further scrutinised by the Business Risk and Investment Committee.

3. External Assurance

In previous years our External Auditors have drawn the conclusion that RJAH is a going concern. Since their last audit our finances and associated cash balances have strengthened

further.

All of our plans and risks were tested thoroughly last summer by Monitor in making their

assessment that we are financially viable as a going concern. In drawing this conclusion Monitor asked PWC and Independent Accountants to carry out a working capital review which

covered the period for the remainder of 2011/12 and 2012/13. This process focussed

specifically on monthly cash flow projections and in doing so tested our financial planning assumptions. These tests formed the basis of a further set of downside risks and their impact

on daily cash flow levels.

From this detailed due diligence PWC signed off that the Trust is a going concern and this

enabled the Board to sign a Board Memorandum to this effect in July 2011.

4. Recommendation

Based on the evidence and recent assurances the Board are recommended to sign off the following statement as part of the submission of the Annual Accounts and Report:

“After making enquiries, the directors have a reasonable expectation that the NHS foundation trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts.”

John Grinnell Director of Finance

3

Paper 07

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 07 Equality Delivery System 2012.doc Page 1 of 8




Executive Responsible Ruth Tyrrell, Associate Director of Human Resources

Paper prepared by (if

different from above)


For Discussion

For Approval √


Performance and Governance √


Link to National Policy √


√


Executive Summary

The Equality Delivery System (EDS) will replace the Trusts existing Equality and Diversity Strategy and Single Equality

Scheme.

By adopting the EDS, the Trust will be able to demonstrate that

it responds effectively to the public sector Equality Duty.

The EDS includes a description of how it will be applied within the Trust and includes a summary of the baseline assessment

which has been undertaken and draft equality objectives to be agreed.

Subject/Title Equality Delivery System 2012

Legal Implications EDS enables compliance with Equality Act 2010 – public sector Equality Duty


Recommendation The Trust Board are asked to

• support the adoption of the EDS within the Trust • agree the baseline assessment and equality objectives

outlined in the paper

Paper 07





TTHHEE EEQQUUAALLIITTYY DDEELLIIVVEERRYY SSYYSSTTEEMM 22001122

1 Background

1.1 In the past, the laws addressing equality and diversity developed along separate routes, and resulted

in separate legislation e.g. Equal Pay, Sex, Race, Disability and Age.

1.2 Between 2006 and 2010, whilst the separate legislation to address these areas remained, public

organisations were required to develop a Single Equality Scheme, which was in essence an action

plan to demonstrate how individual public bodies planned to meet the duties placed upon them by equality legislation.

1.3 The Trust has had an Equality and Diversity Strategy in place since 2006, and published its latest

updated strategy, including the Single Equality Scheme and action plan in 2010. The Trust has included evidence from a variety of sources within previous strategies, which is monitored by the

Equality and Delivery Steering group in order to analyse equality performance and setting priorities.

1.4 The NHS Equality and Delivery System (EDS) was formally launched on 11 November 2011. It is

designed to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The

EDS is all about making positive differences to healthy living and working lives.

1.5 The EDS covers all those people with characteristics protected by the Equality Act 2010. There are

nine characteristics in total:

• Age

• Disability

• Gender re-assignment

• Marriage and civil partnership.

• Pregnancy and maternity

• Race including nationality and ethnicity

• Religion or belief

• Sex

• Sexual orientation

2. Commitment to and adoption of the EDS

2.1 The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (the Trust) is supportive of the EDS and will apply the framework in order to continue the analysis what is required

by section 149 of the Equality Act 2010 (“the public sector Equality Duty”) in a way that promotes

localism and also helps to deliver on the NHS Outcomes Framework, and the NHS Constitution. It will also assist the Trust in continuing to meet Care Quality Commission’s (CQC) “Essential Standards of

Quality and Safety”.

2.2 The EDS does not replace legislative requirements for equality; rather it is designed as a

performance and quality assurance mechanism for the NHS and a means by which NHS organisations are helped to meet the requirements of the Equality Act (2010) and the NHS Act (2006). By

adopting the EDS, the Trust will be able to demonstrate that it responds effectively to the public sector Equality Duty and provide continued to assurance that our patients and staff are treated fairly.

Paper 07


2.3 The trust will however seek to use its foundation trust membership and elected governors as its

primary base of engaging with both staff and service users, and will seek to ensure that its membership is developed to reflect the population is serves.

3. How will the EDS work?

3.1 At the heart of the EDS are four goals, each divided into 18 outcomes which focus on the issues of

most concern to patients, carers, communities, NHS staff and Boards.

3.2 Against each of these outcomes performance is analysed, graded and action determined, which

inform both the long term strategy (4 years) and short term objectives, which will be included within the Trusts annual planning process.

Goal Narrative Outcome

1.1 Services are commissioned, designed and procured to meet the health

needs of local communities, promote well-being, and reduce health inequalities

1.2 Individual patients’ health needs are assessed, and resulting services

provided, in appropriate and effective ways

1.3 Changes across services for individual patients are discussed with them,

and transitions are made smoothly

1.4 The safety of patients is prioritised and assured. In particular, patients are

free from abuse, harassment, bullying, violence from other patients and staff,

with redress being open and fair to all

1. Better health

outcomes for all

The NHS should achieve

improvements in patient health,

public health and patient safety for

all, based on comprehensive

evidence of needs and results

1.5 Public health, vaccination and screening programmes reach and benefit all

local communities and groups

2.1 Patients, carers and communities can readily access services, and should

not be denied access on unreasonable grounds

2.2 Patients are informed and supported to be as involved as they wish to be in

their diagnoses and decisions about their care, and to exercise choice about

treatments and places of treatment

2.3 Patients and carers report positive experiences of their treatment and care

outcomes and of being listened to and respected and of how their privacy and

dignity is prioritised

2. Improved

patient access

and experience

The NHS should improve

accessibility and information, and

deliver the right services that are

targeted, useful, useable and used

in order to improve patient

experience

2.4 Patients’ and carers’ complaints about services, and subsequent claims for

redress, should be handled respectfully and efficiently

3.1 Recruitment and selection processes are fair, inclusive and transparent so

that the workforce becomes as diverse as it can be within all occupations and

grades

3.2 Levels of pay and related terms and conditions are fairly determined for all

posts, with staff doing equal work and work rated as of equal value being entitled

to equal pay

3.3 Through support, training, personal development and performance appraisal,

staff are confident and competent to do their work, so that services are

commissioned or provided appropriately

3.4 Staff are free from abuse, harassment, bullying, violence from both patients

and their relatives and colleagues, with redress being open and fair to all

3.5 Flexible working options are made available to all staff, consistent with the

needs of the service, and the way that people lead their lives. (Flexible working

may be a reasonable adjustment for disabled members of staff or carers.)

3. Empowered,

engaged and

well-supported

staff

The NHS should Increase the

diversity and quality of the working

lives of the paid and non-paid

workforce, supporting all staff to

better respond to patients’ and

communities’ needs

3.6 The workforce is supported to remain healthy, with a focus on addressing

major health and lifestyle issues that affect individual staff and the wider

population

4.1 Boards and senior leaders conduct and plan their business so that equality is

advanced, and good relations fostered, within their organisations and beyond

4.2 Middle managers and other line managers support and motivate their staff to

work in culturally competent ways within a work environment free from

discrimination

4. Inclusive

leadership at all

levels

NHS organisations should ensure

that equality is everyone’s

business, and everyone is

expected to take an active part,

supported by the work of specialist

equality leaders and champions

4.3 The organisation uses the “Competency Framework for Equality and

Diversity Leadership” to recruit, develop and support strategic leaders to

advance equality outcomes

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3.3 Engaging with Local Interest Groups

3.4 As a Foundation Trust, the intention is to engage with 4000+ trust members and their elected

governors to inform and develop the equality agenda, involving other local interest groups openly, where relevant. e.g. where there was insufficient representation within FT membership.

3.5 The Trust will use its representative memberships and staff to continuously consult and engage

upon the EDS.

3.6 The Trust will continue to develop the evidence it uses as part of the EDS in order to monitor

performance.

4. Local Authority and wider Collaboration

4.1 The Trust will share its EDS with the Local Health and Wellbeing Boards for comment and possible

action and will collaborate wherever possible with the wider Health Economy in order to share

experience and resources.

5. EDS Baseline assessment and agreement of grades

5.1 The Trust will work with Foundation Trust Governors, members, staff side organisations and other

organisations and local interest groups to agree a grading for each outcome. The grades are

primarily for use locally. For this reason, the Trust and its members will make the grades and their descriptions work at a local level.

6. Preparing equality objectives

6.1 On the basis of the baseline assessment and agreed grading, the Trust, in engagement with its members and local interests, will prepare

• priorities for next 4 years (long term strategy)

• its equality objectives for the coming planning period.

• linking both to organisational objectives

6.2 It is likely that the equality objectives will focus on those outcomes where most improvement is needed and kept to four or five, and be spread across the four EDS Goals. Because of the

provisions of the Equality Act, the Trust is responsible for finalising the equality objectives.

7. Integration of equality objectives into mainstream business planning

7.1 Actions arising from the equality objectives will be integrated into the Trusts mainstream business

plans for 2012/13 in the first instance an annually thereafter. The Associate Director of Human Resources will provide leadership and advice at a local level regarding the integration of objectives

into annual plans.

8. Publication of grades and equality objectives

8.1 Grades and equality objectives will be published as a separate Equality and Diversity annual

report and will be available on the Trusts website and circulated to all Foundation Trusts members. The annual report will be available in different formats and languages upon request.

9. Governance and partnership working

9.1 The Associate Director of Human Resources has executive responsibility for equality and diversity, and is responsible for the delivery of the EDS framework.

9.2 The Trust has an established Equality & Delivery Steering Group, which is formally accountable to

the Business Risk and Investment Committee (BRIC), which is a formal sub committee of the

Board.

Paper 07


9.3 The steering group meets quarterly, and is currently compiled of executive, senior management

(including training and development), trade union, staff and public governors, religious and disabled members.

10. Agreement and Launch of Equality Delivery System 2012

10.1 A baseline assessment was completed in partnership with the following groups using quantitative and qualitative evidence at a local workshop held on Friday 30th March 2012.

• Equality and Diversity Steering Group

• Executive Lead for Equality and Diversity

• Staff Side and Staff Representatives

• Public Governor representation

• Staff Governor representative

• Disabled patient representative

• Equality and Diversity Steering Group members

10.2 The assessment process was based on the NHS Grades Manual Guidelines (July 2010) and each

factor has been given a rating with each of the four goals given an overall rating as follows:

• Excelling – Purple

• Achieving - Green

• Developing – Amber

• Undeveloped – Red

11. Agreed Grades and Quality Objectives

11.1 The tables in appendix 1 summarise the overall grade for each goal, and state the objective the

Trust will work towards over a four year period, with annual reviews, for each objective. In total there are six objectives agreed (although national guidance is no more than four or five equality

objectives, at least one per EDS goal).

12. Recommendation and Agreement

12.1 The Trust Board are asked to support the adoption of the EDS within the Trust and agree the baseline assessment and equality objectives outlined in the paper.

Ruth Tyrrell Associate Director of Human Resources

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Appendix 1 Summary Baseline Assessment and Draft Equality Objectives 2012

EDS Goal 1 – Better health outcomes for all

Factor Rating

for each criteria

Overall Rating

for each goal

Objectives

1.1 Services are commissioned, designed

and procured to meet the health needs of

local communities,

promote well-being, and reduce health

inequalities

1.2 Patients’ health needs are assessed,

and resulting services provided, in

appropriate and effective ways”

1.3 across services for individual patients

are discussed with them, and transitions

are made smoothly

1.4 The safety of patients is prioritised

and assured. In particular, patients are

free from abuse, harassment, bullying,

violence from other patients and staff, with

redress being open and fair to all

1.5 Public health, vaccination and

screening programmes reach and benefit

all local communities and groups

1) To increase information and act upon it

through

a. collection of evidence from

groups with protected

characteristics via PALS, and

Ipad survey and act upon

results / evidence

b. reviewing and monitoring

patient data to identify key

disadvantaged groups and 9

protected characteristics

c. Using FT elected public governor

and member networks & patient

surveys to further understand

health needs of groups and take

action

2) Promote well being to all protected

groups through

a. well being events and health

promotion messages in our

outpatient clinics

b. Promote awareness &

benefits of public health

vaccination and screening

programmes to FT members

& service users

3) To develop our in-house support to

assist with patients who require support

due to dementia

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EDS Goal 2 – Improved patient access and experience

Factor Rating for each criteria

Overall Rating

for each goal

Objectives

2.1 Patients, carers and communities can

readily access services, and should not

be denied access on unreasonable

grounds

2.2 Patients are informed and supported

to be as involved as they wish to be in

their diagnosis and decisions about their

care, and to exercise choice about

treatments and places of treatment

2.3 Patients and carers report positive

experiences of their treatment and care

outcomes and of being listened to and

respected and of how their privacy and

dignity is prioritised

2.4 Patients’ and carers’ complaints about

services, and subsequent claims for

redress, should be handled respectfully

and efficiently

4) Demonstrate delivery through Quality

Accounts

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EDS Goal 3 – Empowered, engaged and well-supported staff)

Factor Rating for each criteria

Overall Rating

for each goal

Objectives

3.1 Recruitment and selection processes

are fair, inclusive and transparent so that

the workforce becomes as diverse as it

can be within all occupations and grades

3.2 Levels of pay and related terms and

conditions are fairly determined for all

posts,

with staff doing equal work and work rated

as of equal value being entitled to equal

pay”

3.3 Through support, training, personal

development and performance appraisal,

staff are confident and competent to do

their work, so that services are

commissioned or provided appropriately”

3.4 Staff are free from abuse,

harassment, bullying, violence from both

patients and their relatives and

colleagues, with redress being open and

fair to all

3.5 Flexible working options are made

available to all staff, consistent with the

needs of the service, and the way people

lead their lives

3.6 The workforce is supported to remain

healthy, with a focus on addressing major

health and lifestyle issues

that affect individual staff and the wider

population

5) Ensure application of national pay

frameworks and any local variances

comply with Equal Pay legislation

a. Undertaking an equal pay

survey

b. Review of banding & job

evaluation process

EDS Goal 4 – Inclusive leadership at all levels

Factor Rating

for each criteria

Overall Rating

for each goal

Objectives

4.1 Boards and senior leaders conduct

and plan their business so that equality is

advanced, and good relations fostered,

within their organisations and beyond

4.2 Middle managers and other line

managers support and motivate their staff

to work in culturally competent ways

4.3 The organisation uses the

Competency Framework for Equality and

Diversity Leadership

to recruit, develop and support strategic

leaders to advance equality outcomes

N/A

6) Inclusion of EDS in revised personal

objectives framework.

Paper 08

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 08 Monitor 2012-13 Compliance Framework.doc






Margaret Surrage Head of Board Governance (Trust Secretary)


Development





Objectives


Executive Summary

The 2012/13 Compliance Framework is attached and the key

changes to the Board Statements and targets for 2012/13 are highlighted.

Subject/Title Monitor 2012/13 Compliance Framework


For Discussion �

For Approval �


Legal Implications

Recommendation That the Board notes the 2012/13 Compliance Framework

Acronyms and

Abbreviations

Paper 08


Russell Hardy � 4358

CChhaaiirrmmaann



22001122//1133 CCOOMMPPLLIIAANNCCEE FFRRAAMMEEWWOORRKK

The Board reviewed Monitor’s consultation document on the proposed changes to the

Compliance Framework at its January meeting. The Trust responded, via the FTN, to the effect that it broadly supported the proposed changes, but were disappointed that there had

been no consideration of setting a de minimus level for the C Difficile target.

The 2013/13 Compliance Framework has now been published. This is attached. The most

significant change is the setting of a de minimus target for C Difficile of 12 cases, which will be measured against a trajectory of 1 case per month.

The other key changes from the 2011/12 framework are:-

Board Statements

• Quality: Clarifies that boards must assess against the Quality Governance Framework,

not merely have regard to it

• Finance: 2 new statements, one of which used to be in the annual monitoring

template. They are that the organisation will maintain

o a Financial Risk Rating (FRR) of at least 3 and

o that the trust shall at all times remain a going concern.

• Governance: The statements have been streamlined and simplified.

Targets from Operating Framework

The compliance framework has been updated to reflect the changes made to the Operating

Framework. The key change is to the waiting times targets. The metric has reverted back to

measuring the percentage of patients, both admitted and non admitted seen in 18 week from referral to treatment and a new metric had been added for patients waiting on an incomplete

pathway. The new metrics are shown in the table below.

Revised Waiting List Metrics

Maximum 18 week waiting time

Score Monitoring frequency

Admitted patients 90% 1.0 Quarterly

Non-admitted patients 95% 1.0 Quarterly

Patients on an

incomplete pathway

92% 1.0 Quarterly

All of the revised targets have been reflected in the draft Performance Scorecard for 2012/13, which is a later agenda item.

Paper 08


Recommendation

That the Board note the changes to the Compliance Framework, which will impact on both the Annual plan and the quarterly submissions to Monitor.

Wendy Farrington Chadd

Chief Executive

Compliance Framework 2012/13

30 March 2012

Monitor’s Compliance Framework sets out the approach Monitor will take to assess the compliance of NHS foundation trusts with their terms of Authorisation (“the Authorisation”) and to intervene

where necessary.

While both the environment within which NHS foundation trusts operate and the Compliance

Framework have evolved – to include, for example, mental health, community and ambulance trusts becoming NHS foundation trusts, amendments to indicators used to derive annual and in-year financial risk ratings and the introduction of service-line reporting for under-performing NHS foundation trusts – Monitor’s overall approach has remained

consistent.

This most recent version of the Compliance

Framework, published in March 2012, includes the following revisions:

changes to board statements to streamline and simplify the certifications and reduce their overall number;

a refinement of our approach to financial risk ratings by: incorporating the relative cost of capital; excluding the income from donated assets; and providing the flexibility for Monitor to make technical adjustments by removing material one-off income received in-year;

a revision to how we incorporate Care Quality Commission judgements in our governance risk ratings; and

the inclusion of relevant priorities from the Operating Framework for the NHS 2012/13, which was published on 24 November 2011, including new referral to treatment waiting time measures, which we recognise as a proxy for governance concerns.

The Health and Social Care Bill gained Royal Assent to become the Health and Social Care Act (2012) on 27 March 2012. This Compliance

Framework will apply until the commencement of Monitor’s new licensing regime in 2013, when the Authorisation ceases to apply. This Compliance

Framework forms the basis on which annual plan submissions and subsequent in-year reports should be made in 2012/13.

Monitor intends, where possible, to carry

forward failures and breaches under this

Compliance Framework into any future

oversight regime.

Monitor’s framework for monitoring compliance by NHS foundation trusts with their

terms of Authorisation and for intervening in the event of failure to comply

Foreword

Contents

5 Significant breach and intervention

4 Escalation

3 Risk assessment

2 Monitoring

1 Monitor’s regime

Appendices

4

Introduction

1. The NHS is moving from a centrally managed system to one which is more responsive both to the needs of the patient and service user and the wishes of the local community. NHS foundation trusts are at the heart of this move.

2. While NHS foundation trusts remain public institutions, they are neither subject to direction by the Secretary of State for Health nor the performance management requirements of the Department of Health. They set their own strategies and make their own decisions within the framework of contracts with their purchasers and other bodies’ legal and regulatory regimes. They have an independent board of governors which appoints the chair and other non-executive directors, and which also approves the appointment of the chief executive. They can borrow commercially, retain surpluses and invest to serve local needs.

3. NHS foundation trusts are free to determine how they can most effectively improve patient services through innovation, investment and local engagement. Financially secure NHS foundation trusts will be given an increased ability to borrow. These freedoms create a significant opportunity to continue to reshape and improve the quality and safety of the delivery of healthcare in England.

4. NHS foundation trusts can:

improve quality through innovation and adoption of better practices, including bringing to England models of care that have worked in other countries;

invest in new patient care facilities and enter into partnerships with commissioners1 to improve the delivery of high quality care and develop long-term care facilities;

set local pay agreements;

form partnerships with the private sector and other hospitals, or specialise in selected services;

subject to competition approval, acquire or merge with other service providers; and

set local targets in consultation with their members or in contracts with commissioners.

5. These freedoms carry important responsibilities. The board of directors of each NHS foundation trust (“the

board”) is accountable for its success

or failure and must ensure that the trust operates effectively, efficiently and economically. While NHS foundation trusts can retain surpluses, they can also fail and Monitor has the power, in specific circumstances, to give notice to

1 Primary Care Trusts, local health boards for NHS foundation trusts with cross-border arrangements with Welsh commissioning bodies, and clinical commissioning groups where established.

1 Monitor’s regime

5

the Secretary of State for Health to make an order de-authorising an NHS foundation trust.2

6. In contrast, boards of governors are expected to focus less on day-to-day compliance and more on ensuring that NHS foundation trusts listen and respond to the needs and preferences of stakeholders, especially local communities. Governors’ statutory

roles include:

appointing, removing and deciding the terms of office of the chair and other non-executive directors;

approving the appointment of the chief executive;

receiving the annual report and accounts and auditor’s report at a

general meeting;

appointing and removing the auditor; and

expressing a view on the board’s plans

for the NHS foundation trust, in advance of the plan’s submission to

Monitor (Chapter 2).

7. Monitor expects NHS foundation trusts, in conjunction with their stakeholders, to set their own aspirations for improvement and innovation. This includes determining the balance between improvement in current provision and innovation through the development of new services.

8. Monitor authorises NHS foundation trusts on the basis that they are well-governed, financially robust, legally constituted in accordance with the National Health Service Act 2006 (“the

2 De-authorisation does not form part of Monitor’s Compliance Framework; for further information refer to the NHS Act (2006) as amended by section 16 of the Health Act 2009.

Act”)3 and meet the required quality threshold. Monitor has designed the Compliance Framework to ensure that NHS foundation trusts maintain their viability, including:

staying solvent;

being well-governed (from both a financial and quality perspective);

operating effectively within their constitutions;

engaging with patients, service users and commissioners;

providing all the services that they are required to deliver by law; and

complying with the other conditions set out in the Authorisation.

9. Nationally, Monitor works in partnership with a number of stakeholders, such as the Department of Health and the Care Quality Commission, to regulate the healthcare system. Monitor does not get involved in determining healthcare strategy or operational policies in NHS foundation trusts.

10. Where trusts are breaching their Authorisation, and this is regarded as ‘significant’ under the provisions of the

Act, Monitor may take regulatory action in the form of intervention (Chapter 5).

Regulatory principles

11. The following principles shape Monitor’s approach to regulation:

Self-regulation: boards of directors are responsible for ensuring that their trust complies with its Authorisation and statutory obligations at all times;

3 All legislation referred to in this document is available at www.legislation.gov.uk

6

Proportionality: the risk of a significant breach of the Authorisation determines the intensity of Monitor’s regulatory

activities;

Transparency: Monitor will use a transparent method for assessing risks to compliance, as set out in the Compliance Framework;

Trust-based approach: Monitor’s

regulatory framework is based on a philosophy of ‘no surprises’ and open

communication, including accurate information and robust certifications. Monitor expects NHS foundation trusts to disclose issues speedily and candidly and will seek to adopt a collaborative approach to resolving serious issues before considering intervention. A failure to keep Monitor adequately informed in relation to a material issue of non-compliance may itself reflect poor governance;

Confidentiality: Monitor will not, unless it has a statutory obligation to do so, disclose confidential information without prior agreement;

Minimal duplication of regulation: Monitor will not usually act where other bodies have a lead regulatory role unless they have exhausted their powers and an NHS foundation trust still risks a breach of its Authorisation. Where material care quality concerns exist at a trust, Monitor will co-ordinate its regulatory activities with the Care Quality Commission; and

Minimal information requirements:

Monitor aims to minimise the information requirements it places on NHS foundation trusts. Its requirements should in any case be a sub-set of the information which a board requires to discharge its functions effectively.

Approach

12. Effective self-governance sits at the heart of the Compliance Framework.

The board takes primary responsibility for compliance with the Authorisation. The chair of an NHS foundation trust should ensure that the board monitors the performance of the trust effectively and satisfies itself that appropriate action is taken to remedy problems as they arise.

Diagram 1: Monitor’s regulatory regime

7

The Compliance Framework is largely aimed at satisfying Monitor that boards are receiving robust assurance where appropriate and are discharging their responsibilities effectively.

13. The requirements placed on NHS foundation trusts are set out in their Authorisation. The role of the Compliance Framework is to set out how Monitor:

(i) monitors trusts’ performance against

their annual plans;

(ii) assesses the risk of trusts breaching their Authorisation; and

(iii) where necessary, responds in a proportionate manner to ensure trusts return to compliance in a timely fashion.

14. Monitor does this by requiring all boards to certify ongoing compliance with their Authorisation, subsequently using performance against governance indicators, financial performance, exception reports and third party information to test that certification.

The key elements of Monitor’s

regulatory regime are set out in Diagram 1 on page 6.

Requirements of foundation trusts

15. NHS foundation trusts are required to provide board statements (as set out in Appendix C3) certifying ongoing compliance with their Authorisation and other legal requirements. Such requirements include, but are not limited to:

putting in place, maintaining and complying with arrangements for the purpose of improving the quality of healthcare provided by and for that trust – having assessed against

Monitor’s Quality Governance

Framework (Appendix H), complaints and serious incidents;

delivering healthcare services to specified standards under agreed contracts with their commissioners;

maintaining registration with the Care Quality Commission and addressing conditions associated with registration;

operating effectively, efficiently and economically and as a going concern;

complying with healthcare targets and indicators;4

governing themselves in accordance with best practice, maintaining the organisation’s capacity to deliver

mandatory services;

growing a representative membership;

cooperating with the Care Quality Commission and a range of NHS and non-NHS bodies which may have a remit in relation to the provision of healthcare services;

disclosing information to Monitor and third parties according to the detailed requirements set out in their Authorisation;

dealing openly and cooperatively with Monitor, including regarding potential or actual breaches of compliance with their Authorisation, or any serious reputational issues;

complying with statutory requirements, their Authorisation, their constitution, their contracts with commissioners and guidance issued by Monitor;

4 As set out in Appendix B.

http://www.monitor-nhsft.gov.uk/home/our-publications/browse-publication-date/quality-governance-framework


8

following the Principles and Rules for Co-operation and Competition (PRCC) and taking such action as may be required by Monitor, advised by the Co-operation and Competition Panel (CCP), to address a breach of the PRCC; and

having regard to the NHS Constitution.

Monitor’s regulatory process

16. Monitor’s regulatory process is set out in Diagrams 2 and 3, and consists of:

(i) monitoring;

(ii) risk assessment;

(iii) escalation; and

(iv) significant breach and intervention.

Monitoring

17. To monitor ongoing compliance with their Authorisation, Monitor relies first on the information we receive directly from NHS foundation trusts through annual plans, in-year submissions and exception reports.

If NHS foundation trusts can demonstrate a track record of compliance with their Authorisation, and present a low risk of breaching it, Monitor may reduce the intensity of its monitoring.

18. Monitor does not directly assess compliance in areas where other bodies have the lead regulatory role, but expects NHS foundation trusts to report any issues that indicate such risks. Typically, Monitor relies on a third party to notify it when it conducts an

Diagram 2: monitoring and risk assessment

9

investigation or identifies an issue that could indicate a breach of the Authorisation. Third parties include other statutory regulators as well as commissioners of healthcare services, and are set out in more detail in Appendix A.

Risk assessment

19. Monitor uses a combination of financial information and performance against a selected group of national measures as the primary basis for assessing the risk of trusts breaching their Authorisation – see Diagram 2.

Monitor’s risk-based framework assigns two risk ratings – financial and governance – to each NHS foundation trust on the basis of its annual plan and in-year performance against that plan. Monitor uses these ratings to guide the intensity of monitoring and to signal to

the NHS foundation trust Monitor’s degree of concern with specific issues identified and the risk of breach of the Authorisation. Where issues arise, Monitor may wish to test the basis of board statements made.

20. Monitor may take into account the findings, judgement and/or guidelines of any relevant third party in determining risk ratings and/or whether a breach of the Authorisation has occurred. Monitor expects NHS foundation trusts to respond to any such issues.

21. Where NHS foundation trusts are carrying out major transactions, as defined by Monitor’s tests (see

Appendix F), Monitor will assess the risk to a trust’s Authorisation the transaction represents and communicate this to the trust.

Diagram 3: escalation, significant breach and intervention

10

Escalation

22. Where an NHS foundation trust is experiencing major financial or governance problems, Monitor will initially consider whether the trust is potentially in significant breach and, if so, will escalate the trust. The escalation process assesses whether the failure is likely to be significant under the provisions of section 52 of the Act. Monitor will make this assessment on a case-by-case basis.

Significant breach and intervention

23. Where trusts are in significant breach, oversight will be more intensive and Monitor may take action swiftly to ensure services to patients are safeguarded. The legislation gives Monitor extensive powers to intervene in the event that an NHS foundation trust is in significant breach.

24. Monitor will generally only intervene in relation to issues being dealt with by third parties when their relevant powers have been exhausted and the NHS foundation trust is still in significant breach of its Authorisation.

In cases where the Care Quality Commission indicates that it has material concerns regarding an NHS foundation trust’s registration with Care Quality Commission standards, Monitor will work with the Care Quality Commission to establish the most appropriate course of action to return the trust to compliance with those standards in a suitable timeframe.

25. Monitor will publicise all significant breaches and may decide to make public any other failures to comply with the Authorisation whether or not they

are significant. Monitor has a legal obligation to publish information about formal interventions.

Other aspects of Monitor’s regime

Guidance for foundation trusts and

governors

26. Monitor has published mandatory guidance and best practice advice which form part of the overall regulatory framework. Where appropriate these have been cross-referenced in this document. A list of publications is set out in Appendix G.

Information disclosure

27. Monitor’s policy on disclosing

information it receives regarding NHS foundation trusts is guided by a number of core principles:

non-disclosure of commercially sensitive information supplied by NHS foundation trusts without prior agreement, subject to compliance with relevant legislation, including the Freedom of Information Act 2000;

non-disclosure of any other confidential information supplied by NHS foundation trusts without prior agreement (unless there is a statutory obligation or a significant overriding public interest); and

protection of the interests of patients and staff, including for example adherence to the Data Protection Act 1998 and other relevant law and guidance.

Third parties

28. The Authorisation covers other obligations where a broad range of third parties interact with NHS

11

foundation trusts (see Appendix A), such as legislative requirements relating to an NHS foundation trust’s

constitution, health and safety, and employment matters.

29. Several bodies have statutory standard-setting, inspection, monitoring, and in some cases, enforcement powers, while others have no statutory powers. Monitor expects NHS foundation trusts to meet their statutory obligations towards all such bodies and abide by their duty to cooperate with NHS bodies and local authorities as set out in the Authorisation and the Act.

Induction seminars

30. Monitor runs induction seminars, setting out the fundamentals of our regulatory regime, for newly appointed chairs and chief executives of NHS foundation trusts who have not had prior experience of Monitor’s assessment process. If a chair or chief executive of a foundation trust has not attended, or is not scheduled to attend, this seminar within six months of their appointment, boards are required to inform Monitor as to when they will or, if this is not the case, the basis on which attendance is not required.

12

Monitoring

31. Monitor requires NHS foundation trusts to submit information both annually and during the year. The information and analyses that Monitor requests from NHS foundation trusts are those which should already be required by a well-managed board. This information ought to be easily extractable from material that boards routinely receive as part of their oversight of business performance, risk and governance.

32. This chapter describes what foundation trusts must submit to Monitor and how Monitor uses the information it receives from third parties.

How Monitor uses information from foundation trusts

33. Monitor uses NHS foundation trusts’

annual plans, in-year submissions and relevant third party reports to assign risk ratings for finance and governance (see Chapter 3).

34. Monitor then uses these ratings to assess risk to compliance with the Authorisation, guide the intensity of monitoring and signal to the NHS foundation trust the degree of concern with the specific issues identified and evaluated.

35. In-year monitoring is designed to:

measure and assess actual performance against the annual plan; and

assess the risk of NHS foundation trusts breaching their Authorisation.

In cases where in-year monitoring reveals a potentially significant breach of the Authorisation, NHS foundation trusts may be subject to escalation in order to determine whether the breach is actually significant. Trusts in significant breach may be subject to statutory intervention. Monitor’s

escalation and intervention procedures are described in more detail in Chapters 4 and 5. Diagram 4 describes the 2012/13 annual planning and monitoring cycle.

Annual submissions

36. Foundation trusts are required to submit the following annually:

a plan (“annual plan”) for Monitor’s

annual plan review, including board statements (see page 18); and

audited annual report and accounts.

2 Monitoring

13

The annual plan

37. An NHS foundation trust’s annual plan

includes its main strategic priorities, forecast financial and service performance and details of any major risks to compliance with its Authorisation and how these will be addressed. An overview of the contents of the annual plan and an annual monitoring checklist are included in Appendix C and further guidance can be found on Monitor’s website. The annual plan must be approved by the NHS foundation trust board and have regard to the views of the board of governors.

38. Monitor uses the information provided in the annual plan primarily to assess:

the forward risk of a financial breach of a trust’s Authorisation; and

the forward risk of a governance breach of a trust’s Authorisation.

39. Monitor publishes financial and governance risk ratings reflecting trusts’ annual plan submissions.

Although calculated in the same manner as Monitor’s in-year risk ratings, these reflect the views of trust boards and do not necessarily reflect Monitor’s own assessment of risk to the

trust’s compliance with its

Authorisation.

40. The effectiveness with which NHS foundation trusts plan for the future will form an important part of Monitor’s

assessment of actual and potential risk to the Authorisation. Where there are apparent weaknesses in the planning processes, or where plans demonstrate significant risks to the Authorisation, Monitor’s review of plans will necessarily be more intense and may involve a review of financial planning, financial viability, overall governance or quality governance at the trust.

41. Monitor is required to publish each NHS foundation trust’s annual plan. Each trust should indicate, when they submit the annual plan, which detailed information is considered confidential and therefore not intended for publication. The annual plan will be published on Monitor’s NHS foundation

Diagram 4: the annual planning and monitoring cycle

http://www.monitor-nhsft.gov.uk/information-nhs-foundation-trusts/planning-and-reporting-processes/annual-planning

14

trust directory on our website, at the same time as the annual risk ratings are published.

42. Diagram 5 outlines the main elements of the annual plan. Where a trust’s

annual plan leads to a published financial risk rating of 1 or 2, the trust may, at Monitor’s discretion, be

required to provide a monthly analysis of income and of earnings before interest, taxes, depreciation and amortisation (“EBITDA”), by service-line for the previous year and for the first year of its financial projections.

Further details on the annual plan format and required submission templates are in Appendix C and guidance on the preparation of the annual plan can be found on Monitor’s website.

43. NHS foundation trusts will be expected to submit their annual plan for 2012/13 by 31 May 2012. The report on the past financial year will therefore be based on unaudited annual accounts.

44. In addition to the annual plan, some NHS foundation trusts displaying material variances between annual plan and year-to-date performance at quarter two may, following quarter two, be required to submit a six-month update of financial projections in-year. This reforecast will reflect on the priorities of the annual plan, but with explanations required only for any significant variances, key risks to the Authorisation and action plans to rectify the position.

45. Monitor will, in exceptional circumstances, allow an NHS foundation trust to reforecast or make a

Diagram 5: the annual plan

15

material change to the financial projections submitted in the annual plan.

Circumstances where such a reforecast may be permitted include material adverse performance against the original annual plan, the completion of a major investment in-year or a significant change to the service development strategy.

Annual report and accounts

46. NHS foundation trusts are required to submit their audited annual report and accounts (which must be laid before Parliament before its summer recess) to Monitor. These should be accompanied by a reconciliation (where necessary) between the net surplus or deficit as per the audited accounts with that reported in the annual plan.

This reconciliation should include an explanation of any material differences.

In-year reporting requirements

47. NHS foundation trusts provide three types of information during the year:

(i) in-year (generally quarterly)

submissions, including:

board statements on service performance and financial risk (see Appendix D and page 18);

forward financial indicators (Diagram 7);

financial information (Appendix D); and

results of elections in the previous quarter.

(ii) exception reports, which may relate to any in-year issue affecting compliance with the Authorisation (Diagram 8 and

Diagram 6: in-year submissions

16

Appendix D); and

(iii) ad hoc reports, at Monitor’s request,

which may include follow up on specific issues relating to the Authorisation identified either in the annual plan or through in-year monitoring.

In-year submissions

48. In-year submissions report on financial performance5 in the most recent quarter, year-to-date performance against annual plan and future service performance. Their content is summarised in Diagram 6 and set out in more detail in Appendix D. Monitor provides relevant templates to foundation trusts for the purpose of these submissions.

49. Monitor uses the information in the

5 Monitor expects that the in-year financial returns are prepared on a consistent basis with the foundation trust’s

accounting policies as set out in its financial statements. Failure to do so may result in an override being applied to the financial risk rating.

regular reports as the basis for assigning financial and governance risk ratings (see Chapter 3 for further information).

50. In-year submissions are usually required quarterly. Where trusts are displaying a materially reduced level of risk, Monitor may, at its discretion, require finance and governance submissions on a six-monthly, rather than quarterly, basis for foundation trusts that meet the following criteria:

have maintained a financial risk rating of 5 for four quarters;

have maintained a governance risk rating of green for four quarters; and

have been authorised for at least two years.

Diagram 7: indicators of forward financial risk

17

Likewise, if an NHS foundation trust’s risk ratings change in-year to reflect an increased level of risk, Monitor may require more frequent monitoring.

Indicators of forward financial risk

51. Each quarter Monitor requires trusts to submit a limited set of indicators of forward financial risk to highlight the potential for any future material financial breaches of the Authorisation (see Diagram 7). Where trusts inform Monitor that one or more of these indicators are present at a trust, Monitor will consider whether a meeting with the trust to discuss them is appropriate. Following this meeting, Monitor may request the preparation of plans or the provision of other assurances as to an NHS foundation trust’s capacity to mitigate any potential

risk. These indicators do not of themselves affect Monitor’s risk ratings or trigger formal escalation.

Exception reports

52. NHS foundation trusts must report to Monitor any actual or prospective material changes which may affect their ability to comply with any aspect of their Authorisation and which have not been previously notified to Monitor. Examples of exception reports are set out in Diagram 8.

53. Exception reports should, as applicable, describe:

the issue that has arisen, the area(s) of the Authorisation to which it applies, and the magnitude of the issue, including the timeframe in which it will come into effect or, if it has already done so, when it occurred;

where relevant, the proposed actions to address the issue(s), and the criteria and process to determine the effectiveness of these actions;

Diagram 8: examples of exception reporting

18

a list of the third parties that the NHS foundation trust intends to notify of the issue(s) as well as a proposal of the support required from Monitor (if any);

where an application is made to vary the Authorisation, the information set out in Appendix E;

for UK healthcare investments, divestments or other transactions comprising > 10% of the assets, income or capital of the NHS foundation trust6 the information set out in Appendix F: material transactions; and

for UK healthcare investments, divestments or other transactions comprising > 25% of the assets, income or capital of the NHS foundation trust7 the information set out in Appendix F: significant transactions.

54. Exception reports should be submitted to Monitor at the time that a relevant issue arises. Cases of a serious and sudden change or an issue or matter which may significantly impact the Authorisation should be notified immediately to Monitor in writing. This also applies to serious reputational issues.

Serious incidents and complaints

55. NHS foundation trusts are required to report to Monitor any Serious Incidents Requiring Investigation (SIRIs) which breach or risk breaching the Authorisation. Serious complaints should also be reported in a timely manner to Monitor.

6Or >5% if non-healthcare related and/or international

7 Or >12.5% if non-healthcare related and/or international; or if a trust is in significant breach, any investment/divestment comprising >10% of the assets, income or capital of the trust.

Board statements

56. NHS foundation trust boards are required to provide board statements both in the annual plan (Appendix C) and in-year (Appendix D) certifying ongoing compliance with their Authorisation. Monitor regards the monitoring of compliance against the board statements as a key element of its governance regime. Where there are grounds to question the basis of these statements, Monitor may require further evidence regarding the quality of governance at the trust in question. Monitor may reflect any certification failures in the governance risk rating (see Diagram 11). Board statements cover the following areas:

quality;

financial performance; and

governance (which includes service performance, appropriate board roles and structures and risk and performance management).

Quality

57. Quality is a key responsibility of the board and is primarily monitored by third parties, in particular by the Care Quality Commission. Monitor does not intend to duplicate existing regulation in this area.

58. However, Monitor considers that maintaining and improving quality is an important indicator of governance at a trust. For the purposes of these certifications, ‘quality’ comprises:

patient safety;

clinical effectiveness; and

patient experience.

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59. Boards will make three quality-related board statements to Monitor to:

certify that, to the best of their knowledge and using their own processes, they are satisfied that their NHS foundation trust has and will keep in place effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to patients (“Board Statement

1”);

certify annually that, to the best of their knowledge and using their own processes, they are satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements; and

certify that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust meet the relevant registration and revalidation requirements.

NHS foundation trusts will be undertaking Organisational Readiness Self-Assessments (ORSA) prior to the introduction of revalidation. Monitor expects the results of the ORSA to inform this certification.

For the full text of the statements, see Appendix C3.

60. In order to make Board Statement 1 annually, boards are expected to have assessed the trust against Monitor’s

Quality Governance Framework (Appendix H) and be able to:

describe their own objectives for improving quality;

identify metrics to monitor quality in terms of clinical outcomes, patient or service user safety and experience, and expected levels of performance;

ensure they have in place systems, processes and procedures to monitor, audit and improve quality, including meeting their own objectives, healthcare targets and indicators and complying with all relevant legislation, and that relevant risks or shortfalls are identified, understood and mitigated;

maintain effective governance systems to monitor and report on cleanliness, patient safety and experience in a timely fashion;

consider serious incidents and patterns of complaints; and

maintain a programme of internal audit review and independent assurance that supports the certification process.

61. Where there is evidence that a board may not be meeting quality of healthcare requirements,8 Monitor is likely to explore the basis for a board’s

certification, including requiring the trust to commission an independent review of processes and procedures in place at the NHS foundation trust.

Financial performance

62. Foundation trusts must be well-led (from both a finance and quality perspective) and financially robust so that they are able to deliver excellent care and value for money. As part of the annual plan (and in-year submissions for the first bullet below), boards are required to certify that they are satisfied that plans are in place to ensure that the trust will:

continue to maintain a financial risk rating of at least 3 over the next 12 months; and

8 For example, through Care Quality Commission concerns or adverse reports from third parties regarding clinical quality or patient safety.


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remain at all times a going concern, as defined by relevant accounting standards in force from time to time.

63. In order to certify on financial performance, Monitor would expect boards to:

have a full understanding of the current and future financial position, and how it relates to the external environment in which the trust operates and the strategy of the trust;

maintain systems to monitor and regularly report on financial performance to the board and be confident of the basis of preparation and accuracy of the financial performance information being reported;

review and challenge financial performance on an ongoing basis;

use forecasting and extrapolation of current and historical trends to help predict future financial performance; and

have a full understanding of the basis on which the certification is given.

64. Where there is evidence that a board may not be meeting Monitor’s financial risk requirements, Monitor is likely to explore the basis for a board’s certification.

Governance

Effective risk management

65. In the first instance, Monitor will rely on the board’s certification as included in

Appendix C3. However, a failure by a board to identify effectively and address risks to ensure continued compliance with its Authorisation will be taken into account when assessing governance risk.

66. In such cases, Monitor may want to explore the basis for the certification. Exception reports of failures by NHS foundation trusts or third party concerns may also be taken into account.

Service performance

67. As part of both the annual plan and in-year submissions, boards are required to certify that they are satisfied that plans in place are sufficient to ensure service performance, explicitly:

ongoing compliance with all existing healthcare targets and indicators (after application of thresholds – Appendix

B); and

prospective compliance with known healthcare targets and indicators due to come into force in the future.

68. In order to certify on service performance Monitor would expect boards to:

have a full understanding of the basis on which healthcare targets are measured as included in the Compliance Framework;

be confident that they are receiving accurate information as to current and expected levels of performance against each of the healthcare targets and any performance risks;

use forecasting and extrapolation of historic trends to help predict future performance;

satisfy themselves that systems are in place to ensure risk to delivery has been properly assessed;

maintain systems to monitor and regularly report on performance;

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have an understanding where performance issues have occurred, or are predicted, as to how action plans will deliver the required improvements to meet each healthcare target, indicator and any requirements of the Care Quality Commission;

require internal audit and, as appropriate, commission other independent advice to provide adequate assurance; and

review and, as appropriate, challenge performance on an ongoing basis.

69. If there is a significant difference between an NHS foundation trust’s

certifications in board statements and actual delivery against service performance obligations,9 Monitor is likely to explore the basis for the board’s certification.

Appropriate board roles, structures and

capacity

70. In the first instance, Monitor will rely on the board’s statements (Appendix C3) as to the board and management skills and experience to discharge their functions and deliver trust plans. Where there is evidence that there has been a failure by a board to discharge its functions effectively, Monitor reserves the right to explore the basis for the certifications.

71. Monitor will also look for evidence that a collaborative and productive relationship exists between the board of governors and the board of directors and that members of the board understand and have the competencies to ensure that an NHS foundation trust

9 For instance, ongoing breaches of governance indicators despite certification of anticipated compliance, or breach of a full-year target in-year.

continues to meet the requirements of its Authorisation.

72. For the full text of all 16 board statements, see Appendix C3.

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Risk assessment

73. Monitor uses information in the annual plan and quarterly and ad hoc submissions to evaluate an NHS foundation trust’s risk of failure to

comply with its Authorisation.

74. Other information may also be used where appropriate. The risk ratings that Monitor assigns to NHS foundation trusts are characterised by their:

limited scope. Monitor’s regulation is

designed to ensure that NHS foundation trusts do not significantly breach their Authorisation and the risk ratings are for that purpose alone. They are not a comment on the overall performance of NHS foundation trusts;

forward-looking nature. The risk ratings are intended to indicate how likely it is that an NHS foundation trust is, or will be, in significant breach of its Authorisation; and

limited target audience. The main audiences for Monitor’s risk ratings are

foundation trust boards of directors and governors and senior staff and, to a lesser extent, commissioners. Monitor recognises that our risk ratings will inevitably be of interest to other stakeholders, but they are designed primarily for regulatory purposes.

75. Risk ratings are communicated to Monitor’s Board on a quarterly basis

together with an explanation of the basis for the ratings. If Monitor identifies material compliance issues at an NHS foundation trust through its in-year monitoring, it will inform the trust and indicate whether there is a need for any specific follow-up action. Monitor will also publish a summary and analysis of the quarterly risk ratings on our website. Where necessary, Monitor will change risk ratings in-quarter to reflect any situations at specific foundation trusts (e.g. Care Quality Commission inspections).

Financial risk rating

76. When assessing financial risk, Monitor will assign a risk rating using a scorecard that compares key financial metrics on a consistent basis across all NHS foundation trusts. The risk rating is intended to reflect the likelihood of a financial breach of the Authorisation.

77. The financial indicators used to derive the financial risk rating in both the annual planning process and in-year monitoring are described in Diagram 9 and incorporate four key criteria:

(i) achievement of plan;

(ii) underlying performance;

(iii) financial efficiency; and

(iv) liquidity.

78. Each financial criterion is rated 1 (high risk) to 5 (low risk) and compared with

3 Risk assessment

23

* EBITDA: Earnings before interest, taxes, depreciation and amortisation. EBITDA (and other financial metrics) may be adjusted by Monitor for any ‘one-off’ non-recurring revenue, costs or ‘investment adjustments’.

** Defined as (I&E surplus less PDC dividend, interest, PFI financing and other financial lease costs) divided by (total debt + total balance sheet PFI and finance leases + taxpayers’ equity). The full definition can be found in the Monitor’s quarterly and annual templates.

*** The liquidity ratio is defined as cash plus trade debtors (including accrued income) minus (trade creditors plus other creditors plus accruals) plus unused, committed and available working capital facility where there is no outstanding event of default (up to a maximum of 30 days and excluding overdraft agreements) expressed as the number of days operating expenses (excluding depreciation) that could be covered.

a grid of standard values. The weightings for each financial criterion and thresholds for each rating category are shown in Diagram 9.

79. Achievement of plan for the purposes of Monitor’s annual plan review will be

evaluated by comparing the percentage of the previous year’s planned EBITDA achieved. The financial criteria for underlying performance, financial efficiency and liquidity will all be scored by comparing year one of the projections with the relevant rating category thresholds.10

Once a preliminary score of 1 to 5 has

10 If there are material differences between the audited accounts and the unaudited financial information provided in the annual plan, the risk rating will be recalculated. Such a scenario could result in a change in the achievement of plan criteria, but could also lead to reconsideration of the forward-looking aspects of the rating.

been generated for each financial criterion, the relevant weighting is applied to derive an aggregate, whole number rating of 1 (highest risk) to 5 (lowest risk) for financial risk.11 A series of over-riding rules will then be applied. These rules are listed in Diagram 10. On authorisation, an NHS foundation trust’s financial risk rating will be either

a 3 or 4 unless there are exceptional circumstances.

Technical adjustments may be made to a trust’s financial risk rating by

removing exceptional, one-off (not non-recurrent) income received in-year where this materially distorts its

11 The general principle of rounding applies.

Diagram 9: deriving the financial risk rating

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1. At Monitor’s discretion, for trusts authorised for at least 2 years, and after four consecutive quarters rated 5 for finance risk and green for governance risk

2. Deficit: defined as an I&E deficit predicted in the annual plan, but after adding back any ‘one-off’ non-recurring revenue, costs or ‘investment adjustments’

3. PDC (Public Dividend Capital), except in those cases where a foundation trust has provided Monitor with a statement from the Department of Health in which it states that it has (pre)agreed to a delay in payment until specific technical issues are resolved

4. PBC (Prudential Borrowing Code), except in those cases where the trust has approval from Monitor for an exemption to the PBC limit either on Authorisation, as part of the annual plan submission, or as part of a specific separate request

5. Assessment of immediate financial risks and suggested mitigating actions

underlying financial position. Where this results in a rating of 2 or lower, a trust may be considered for escalation.

Diagram 10 also details the monitoring implications of each financial risk rating.

Transactions

80. Monitor expects that many NHS foundation trusts will use their freedoms to invest in expanding their healthcare activities. While such major investments, including acquisitions or mergers, will be expected to deliver a medium or long-term healthcare and financial benefit, they may have a negative short-term impact on an NHS foundation trust’s financial risk rating.

81. To ensure that risk ratings do not

disincentivise longer term investment for the benefit of patients Monitor may, at its sole discretion, agree an investment adjustment prior to calculation of a risk rating for a transaction (see Appendix F).

Assessing risk in the annual plan

82. In reviewing annual plan submissions, Monitor may:

identify a limited number of key criteria, against which it will check if the NHS foundation trust’s annual plan

assumptions are reasonable, benchmarked against past performance, other NHS foundation trusts and relevant national guidance;

consider how closely the NHS foundation trust performed against its

Diagram 10: financial risk rating

25

1. Consideration for escalation can occur as soon as the full year breach is recorded. 2. As the indicator must be met in each month during the quarter, trusts are required to report, by exception, any month in which they have

breached the RTT measure. Where trusts consequently report failures in the first or second months of a quarter, and have failed the measure in each of the previous two quarters, Monitor may consider whether to escalate the trust in advance of the end of the third quarter. This also applies where a trust fails the relevant measure in each year spanning any three quarters from 2011/12 going into 2012/13.

plan in the previous year. Monitor will also assess the scale of any variance between key plan parameters and the previous year’s actuals in order to test

the credibility of the projections; and

assess implications for compliance with the Authorisation during the year.

83. Where, for instance, there are material risks to the Authorisation or apparent weaknesses in the planning processes, Monitor will seek to understand the implications of these in more detail. This will result in further analysis (potentially by nominated third parties) and the potential for a meeting between Monitor and the board.

84. Where NHS foundation trust plans are subject to further analysis as part of the annual plan review, the annual plan risk

rating may remain provisional until completion of that review and the outcome of any subsequent meeting with the board.

85. In cases where there is any material variance between the in-year financial submissions and the relevant quarter of the annual plan, NHS foundation trusts will be required to provide a commentary explaining the reasons for the variance and the actions they propose to take to address it.

86. Likewise, where subsequent events in-year call into question the basis of assurances given in board statements in the annual plan, Monitor may require a review of governance at the NHS foundation trust.

Diagram 11: deriving the governance risk rating

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Financial risk ratings of 1 or 2

87. If an NHS foundation trust has a financial risk rating of 2 or less, or if the assessment of its committed working capital facilities and overall cash position indicate that it is at serious risk of not being able to continue providing mandatory services, Monitor will consider escalating the trust for consideration of whether it is in significant breach (see Chapter 4).

88. Where an NHS foundation trust’s

financial risk rating falls to 2 or 1 in-year, Monitor may require from the trust an analysis of income and EBITDA by service-line (for any service accounting for more than 5% of revenue) for the previous and current year. A well-governed trust should have a good understanding of its service-line incomes and costs for business planning and control purposes. Inability to provide this information in a timely manner is likely to be viewed as an indication of poor financial governance. Further information on service-line reporting and service-line management is available on Monitor’s website (as outlined in Appendix G for the relevant publications).

Prudential borrowing limit

89. In the event that an NHS foundation trust experiences a material decline in its in-year risk rating (a decline of two or more ratings when compared with its annual plan rating), as explained in the Prudential Borrowing Code for NHS

Foundation Trusts, Monitor can alter an NHS foundation trust’s Prudential Borrowing Limit accordingly.

Governance risk rating

90. Monitor assigns a governance risk rating to reflect the quality of

governance at a trust. Higher levels of governance risk may serve to trigger greater regulatory action and, ultimately, consideration as to whether an NHS foundation trust should be escalated (see Chapter 4).

91. The governance risk rating is not designed to capture every potential indicator of governance risk. Monitor may therefore adjust the rating where other governance concerns come to light. Typical examples are set out later in this chapter.

92. Monitor includes five elements within the governance risk rating (Diagram 11 provides further detail):

(i) Service performance: trusts are required to provide a board statement certifying that they are satisfied that plans in place are sufficient to ensure they meet the performance thresholds against Monitor’s governance indicators (see Appendix C3). These are largely derived from the Department of Health Operating Framework for the NHS in

England and can be found in Appendix

B.

(ii) Third parties: Monitor will incorporate the views of the Care Quality Commission and the NHS Litigation Authority in the governance risk rating:


registration: trusts are required to maintain full and ongoing registration with the Care Quality Commission. Should an NHS foundation trust fail to maintain registration, or comply on a timely basis with the requirements of any regulatory actions required of it by the Care Quality Commission, it risks being in significant breach of its Authorisation. The scores for a major impact on service users and enforcement action by the Care Quality

27

Commission are described in Diagram

11.

Monitor will remove these scores when the Care Quality Commission confirms:

any major impact on patients has been mitigated; or

the trust has met the requirements of all outstanding enforcement actions.

As set out in Diagram 13, Monitor may adjust a trust’s governance risk rating

where concerns with potential governance implications are raised by the Care Quality Commission but are not reflected in either major impacts on service users or enforcement actions.

NHS Litigation Authority Clinical

Negligence Scheme for Trusts

(CNST) levels: as part of their overall report on governance standards, trusts subscribing to the NHS Litigation Authority’s CNST are required to certify that they expect to maintain a published CNST level of 1.0 and then, by exception, to declare in-year if this is not the case.12

Trusts not enrolled with the NHS Litigation Authority are required to certify that appropriate, alternative indemnity arrangements, equivalent to a CNST level of 1.0, are in place in respect of clinical negligence where the provision or non-provision of services may result in a clinical negligence claim. Where trusts can make this statement, they will not be scored negatively for choosing not to participate in the CNST.

(iii) Mandatory services: trusts are required to provide a board statement certifying that they will at all times remain compliant with their

12 For all CNST schemes to which the trust subscribes.

Authorisation. This includes trusts being able to continue to provide the mandatory services required by Schedules 2 and 3 of their Authorisation, and then, by exception, to declare in-year if this risks not being the case.

Any proposed changes to mandatory service provision by NHS foundation trusts will require a variation of the Authorisation – see Appendix E. Monitor may consider a specific risk where the proposed service change has a material impact on the NHS foundation trust’s business plan.

(iv) Other certification failures: where NHS foundation trust boards have failed to certify accurately against the required elements of their board statements, and this failure is material, Monitor may consider applying an override to the trust’s governance risk rating.

Examples of such adjustments would include:

Financial governance: where trusts have a financial risk rating of 1 or 2 and there are associated concerns over financial governance, the governance risk rating may be adjusted accordingly.

Cooperation with NHS bodies and

local authorities: NHS foundation trusts have a duty under the Act to cooperate with a range of NHS bodies and with local authorities. Monitor would not expect to become involved in certain non-cooperation issues, for example relating to minor contract disputes, local capacity planning or the operation of patient choice, and expects such issues to be resolved through the appropriate existing mechanisms. Monitor may, however, consider and evaluate certain types of exception reports of non-cooperation when assessing

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governance risk, including a failure to undertake in good faith discussions to reach agreement with commissioners of a legally binding contract to deliver mandatory goods and services.

Information governance: NHS foundation trusts are required to meet the relevant requirements of the Information Governance Toolkit, as set out by the Department of Health.

Monitor considers a robust information governance assurance framework to be a fundamental component of good governance. However, we regard the achievement of these specific requirements as a contractual matter for foundation trusts and their commissioners. As is Monitor’s general

practice, where another agency takes

the regulatory lead – in this case, the Information Commissioner – Monitor will not generally take action unless and until other bodies have exhausted their powers and the foundation trust still risks breaching its Authorisation.

Co-operation and Competition Panel: NHS foundation trusts are required to comply with the PRCC and the CCP is responsible for investigating and addressing potential breaches of the PRCC. Where NHS foundation trusts are concerned, the CCP will advise Monitor. Monitor will decide how to act on this advice and whether to require any actions included in this advice, or other actions, from an NHS foundation trust. Failure to implement Monitor’s

requirements will lead to a red rating for

1. Consideration for escalation can occur as soon as the full year breach is recorded. 2. As the indicator must be met in each month during the quarter, trusts are required to report, by exception, any month in which they

have breached the RTT measure. Where trusts consequently report failures in the first or second months of a quarter, and have failed the measure in each of the previous two quarters, Monitor may consider whether to escalate the trust in advance of the end of the third quarter. This also applies where a trust fails the relevant measure in each year spanning any three quarters from 2011/12 going into 2012/13.

Diagram 12: governance red-rating overrides

29

governance risk and is a significant breach of the Authorisation.

(v) Other factors: in some cases, where NHS foundation trusts are not meeting requirements of other bodies, Monitor may regard this as a failure of governance and reflect this in the trust’s

governance risk rating.

Adjustments and overrides to the

governance risk rating

Persistent failure of the same 1.0-

weighted indicator

93. Where a trust has failed to address a failure of a 1.0-weighted governance indicator (as set out in Appendix B), Monitor will consider red-rating the trust and escalation for consideration of significant breach. Diagram 12 sets out the criteria for each indicator.

Transactions

94. Monitor expects NHS foundation trusts to use their freedoms to invest in expanding their services, innovating and providing better care. While such investments, including acquisitions or mergers, will be expected to deliver a medium or long-term healthcare and financial benefit, they may have a negative impact on trusts’ governance risk ratings.13

95. To ensure that our regime is flexible enough to facilitate this, Monitor may, at its discretion, apply an adjustment to a trust’s governance risk rating in

situations where a transaction has a negative impact on the overall level of service provision by a trust and where plans are in place to mitigate this

13 E.g. through absorbing an organisation with an underperforming A&E unit, or long referral-to-treatment waiting times.

impact over a specified timeframe. See Appendix F for more detail.

Serious incidents

96. A failure by an NHS foundation trust to have in place adequate processes or procedures to identify, learn from and, on a timely basis, report to Monitor relevant Serious Incidents Requiring Investigation, serious complaints or other incidents may be reflected in its governance risk rating.

Other third parties

97. Diagram 13 sets out examples of how the governance risk ratings reflect governance concerns, how these are monitored and Monitor’s action as a

result.

98. If Monitor receives reports or other evidence from relevant third parties (such as the Health Protection Agency) that highlight concerns with potential governance implications, and these reports are substantiated through discussion with the trust, Monitor may increase its risk rating to reflect this. Once a trust has resolved an issue and demonstrated sustained improvement, Monitor may remove the increased risk rating.

Growing a representative membership

99. Monitor will directly assess whether an NHS foundation trust is complying with its Authorisation to grow a representative membership. If this is not the case, Monitor will assess whether boards’ membership plans are likely to ensure compliance in the future. Material failure may result in Monitor applying an override to the governance risk rating.

The submissions will also assist us to collate information to support evidence

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on the development and effectiveness of local engagement with members and local accountability within NHS foundation trusts. The specific criteria are outlined in Appendix C2.

Accurate and timely information

100. Monitor’s assessment of NHS foundation trusts’ compliance with their

Authorisation is based on the provision of accurate and timely information. An inability to provide such information, or a material misstatement of performance or in-year financial information, potentially represents a breach of the Authorisation and a serious governance issue.

101. In such cases, Monitor may apply an override to a trust’s risk rating to

take account of the scale of information failure – i.e. how many returns were affected and for how long – and the drivers of such failure.

102. Where the information not disclosed may otherwise have triggered Monitor’s escalation process (see

Chapter 4) Monitor may red-rate the trust and assess whether to escalate the trust for consideration of significant breach.

Red risk ratings for governance

103. If an NHS foundation trust has a red governance risk rating, Monitor will consider whether the trust should be escalated. In making this decision Monitor may undertake further analysis and request information, including action plans, in order to understand:

the background to and reasons for the breach;

whether the breach is or may be significant;

what actions are envisaged and required to rectify the breach (and

Diagram 13: governance risk rating

31

mitigate the risk of the breach reoccurring);

the extent of any additional independent advice required; and

if intervention is or may become necessary in order to rectify a significant breach:

- what intervention actions are required; and

- what the risks and possible outcomes are of an intervention.

Further information is set out in Chapter 4: Escalation.

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Escalation

104. Monitor’s risk assessment process is

designed to flag situations where an NHS foundation trust is failing, or declares a risk of failing, to comply with its Authorisation.

105. Where Monitor’s risk assessment

processes indicate a potential significant breach, Monitor will consider the context and circumstances of the breach(es) in question. If, in Monitor’s

judgment, the breach is likely to be significant, Monitor will escalate the trust in order to assess:

whether the breach is actually significant; and

whether subsequent intervention under section 52 of the Act is required (see Chapter 5).

106. During escalation, Monitor will generally require a greater level of interaction with, and information from, the trust.

Triggers for escalation

107. Monitor uses a number of triggers to establish whether a trust should be considered for escalation. These include:

a red governance risk rating;

a financial risk rating of 1 or 2;

reports raising significant concerns about clinical quality, patient safety or service performance or investigations/ inspections by the Care Quality Commission or another similar body;

a failure to make the appropriate board statements (see Appendix C); or

other significant risks to compliance with the Authorisation not otherwise captured.

108. Escalation is not automatic. Monitor will consider whether the trigger reflects a potentially significant breach of the Authorisation before deciding to escalate. In coming to this decision Monitor will consider, among other things:

the information on the breach already available via in-year monitoring;

the context and circumstances of the breach; and

any other information readily available from the trust or third parties.

If, following this process, Monitor believes the trust is likely to be in significant breach, or requires further information to come to this decision, then Monitor will escalate the trust for formal consideration of significant breach.

The escalation process

109. Escalation is designed to provide a clear evidence base regarding whether

4 Escalation

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a trust is in significant breach and, if so, the need for intervention. The escalation process allows Monitor to ascertain:

the quality of governance and/or the financial viability of the NHS foundation trust in breach;

whether the breach in question may be significant;

if so, whether the NHS foundation trust has the capability and resources to return to compliance in an appropriate timeframe; and

whether the use of Monitor’s formal

powers of intervention is necessary.

Monitor can provide illustrative examples only of what it is likely to consider significant in assessing a

potential or existing breach of the Authorisation. These are set out in Diagram 14.

110. Once an NHS foundation trust has been escalated, Monitor is likely to require additional information in order to understand (i) the nature of the breach and (ii) the likelihood that the trust’s plans to rectify it will be successful. Monitor will gather this evidence through a number of means, including:

meetings with, or information submissions from, senior management;

formal escalation meeting(s) with the board; and

where relevant, seeking the views of third parties, e.g. the Care Quality

Diagram 14: examples of significant breach

34

Commission and commissioners.

In addition, Monitor may seek a number of actions from the trust, including:

the preparation, presentation and commitment to deliver an adequate recovery plan;

the commissioning of external advice to support a return to compliance with the Authorisation; and

the commissioning of an independent report on the circumstances and other matters underpinning the breach. Monitor will agree the scope of such a report.

Trusts in breach on grounds of finance

111. For NHS foundation trusts that are escalated on financial grounds, Monitor may require the board to commission a report by independent advisers which will:

confirm the factual background to the breach of the Authorisation;

consider integrated monthly financial forecasts prepared by the NHS foundation trust, including preparation and analysis of key risks and sensitivities;

define and establish objective monthly measures by which an NHS foundation trust can demonstrate that it is tracking to financial recovery and is unlikely to return to financial distress within the next 12 months;

consider and report on the management resources required to deliver its financial recovery plans; and

deal with other relevant matters on a case-by-case basis.

Trusts in breach on grounds of

governance

112. For trusts that are escalated on governance or other grounds, Monitor is likely to review its information needs from the trust on a case-by-case basis, but is likely to seek to:

confirm the factual background to the breach of the Authorisation;

consider a recovery plan prepared by the trust to address the breach(es), including preparation and analysis of key risks and sensitivities;

agree objective measures by which the foundation trust can demonstrate it is tracking to addressing the breach(es); and

consider management and organisational capability and any other factors concerning a return to compliance.

Determining significance

113. In determining the significance of a breach, Monitor will assess each trust’s

situation giving due consideration to issues including:

urgency or time-critical nature of the situation, in particular regarding patient care;

degree to which factors causing the breach were, or remain, outside the board’s control or influence;

effectiveness of steps taken by the board to understand and then address the risk of breach, including its assurance processes;

likelihood that any breach will be resolved successfully and then not repeated;

35

risk to mandatory services;

risk to financial viability; or

evidence that the skills required to address the issue on a sustainable basis are present.

Formal escalation meeting and

significant breach decision

114. If, having received the relevant evidence, Monitor considers the NHS foundation trust as likely to be in significant breach of its Authorisation, Monitor will hold a formal escalation meeting with the trust board.

115. Following the escalation meeting, Monitor will write to the board of the trust stating whether or not, in its preliminary view, the NHS foundation trust is likely to be in significant breach and inviting any further relevant information before making a final determination.

116. Monitor will subsequently write to the NHS foundation trust confirming Monitor’s decision as to whether the trust is in significant breach or not, and if so, any use of Monitor’s intervention

powers.

Meeting escalation triggers but not in

significant breach

117. Where an NHS foundation trust has met Monitor’s escalation triggers (see

Chapter 4) but the breach is not regarded as significant, Monitor may draw this to the attention of the trust board, seek confirmation that remedial action is in hand and then track delivery of the board’s plan to rectify the breach.

118. In cases where a trust has met the criteria for a red governance risk rating (see Diagram 13) but where Monitor is satisfied the trust is not currently at risk

of being in significant breach, Monitor will revise the trust’s risk rating:

where the trust’s cumulative service

performance score has triggered the red rating for governance, Monitor will reduce this to amber-red; or

where Monitor has applied a red-rating override for three quarters’ successive

failure of a 1.0 weighted measure, Monitor will reduce the governance risk rating to amber-red. Monitor reserves the right to reduce the rating to amber-green where, in its judgement, the evidence supports this reduction.

119. Monitor will review subsequent performance on at least a quarterly basis. If a trust subsequently fails to address the issues and continues to meet the escalation triggers, Monitor may escalate the trust for consideration of significant breach at a future date.

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Significant breach and

intervention

120. If Monitor is satisfied that an NHS foundation trust is in significant breach or is likely to repeat an earlier significant failing, Monitor has the discretion to use specific powers of intervention, allowing it to:

require the NHS foundation trust to do, or not to do, specific things within a set period; and

remove any or all of the directors or members of the board of governors and appoint interim directors or members of the board of governors.

121. Monitor will generally use these powers to ensure the continued delivery of mandatory services and a timely and sustained return to compliance with the Authorisation. Any such intervention will only be taken following:

consideration of the views of the NHS foundation trust board;

consideration by Monitor’s Board; and

assurance of the absence of material mitigating circumstances.

Once an NHS foundation trust is deemed to be in significant breach, Monitor will also write to the trust’s governors, lead commissioners and Members of

Parliament informing them of the decision. Monitor will simultaneously publish the significant breach decision on its website.

Enhanced monitoring

122. Irrespective of whether Monitor uses its statutory powers, it is likely to require trusts found in significant breach to prepare and deliver plans to return to compliance with their Authorisation at the earliest possible opportunity. Trusts in significant breach will be subject to an enhanced level of monitoring and greater regulatory interaction with Monitor while doing so.

123. As described in Chapter 4, Monitor will in all cases write to the NHS foundation trust board setting out the reason(s) the trust is in significant breach of its Authorisation. In addition, Monitor will set out its requirements of the trust. These may include, for example:

the parameters by which Monitor will measure a return to compliance;

the timeframe to deliver these parameters;

the context in which Monitor may be minded to use its statutory powers; and

the actions which Monitor may require in the event that it decides to use its statutory powers of intervention.

124. Monitor will require prompt action and full compliance from trusts in

5 Significant breach and

intervention

37

significant breach with whatever actions and timetable we may specify.

125. Should further significant breaches of its Authorisation come to light, Monitor will write to the trust setting out the basis of these breaches and its requirements of the trust in relation to these.

126. For trusts in significant breach of their Authorisation on financial grounds, Monitor may set clearly defined monthly measures over, for example, a six to nine month period. Monitor will use these metrics to test that:

the trust is on course to an underlying operational recovery;

this recovery will be sustained; and

the trust is unlikely to return to a financially distressed position in the foreseeable future.

127. Where a trust is in significant breach of its Authorisation on grounds of governance, Monitor will assess the parameters by which it will consider any sustainable return to compliance on a case-by-case basis. For example, the trust may be required to provide evidence from independent clinical experts as to the efficacy of the trust’s

measures to address the breach.

128. In addition, Monitor may require an NHS foundation trust to make monthly or more regular submissions (including activity data), instead of quarterly reporting. This may typically include:

progress against agreed recovery action plans and milestones;

updates and explanation of key variances; and

where liquidity concerns exist, detailed cash flow forecasts.

129. Where the breach has occurred as a result of third party concerns – for example the Care Quality Commission – Monitor is likely to require the trust to provide evidence that it is complying, on a sustainable basis, with any statutory requirements of that third party14 as a minimum requirement for any de-escalation from significant breach.

130. In all cases, and even where Monitor has not initially intervened, failure to meet the specified objective measures of recovery may give rise to Monitor using its statutory powers of intervention.

Intervention

131. Monitor will intervene based on the information and evidence it receives if, in its judgment:

the NHS foundation trust is significantly breaching its Authorisation;

any appropriate third party powers have been exhausted;15 and

the use of Monitor’s statutory powers is

necessary to address the significant breach and return an NHS foundation trust to compliance with its Authorisation.

132. Examples of the ways in which Monitor may invoke its statutory powers of intervention include:

14 Some third parties who may become involved in clinical issues, such as the regulators of health professionals, have extensive statutory powers. It is unlikely that Monitor will become involved in cases involving such parties.

15 With the exception of the Care Quality Commission, with whom Monitor will coordinate its regulatory actions, including any use of its powers of intervention.

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requiring the board to seek external advice, commission an independent review and/or to apply best practice:

– for example: cases where current operational or clinical management practice may be a contributory factor;

appointing interim directors or other advisers to oversee implementation of an agreed action plan:

– for example: cases where Monitor considers that the board in its current form requires additional, skilled personnel to provide leadership or the resource to address rapidly the specified issues;

suspending all or some of the powers of directors and assigning them to specified individuals, or removing directors or governors:

– for example: cases where the performance of individual executives or directors has, in Monitor’s

considered view, directly contributed to the significant breach; and

requiring that an NHS foundation trust makes alternative arrangements to secure the safe care of patients while a problem is rectified:

– for example: cases where only contracting with another provider may ensure provision of services of a sufficient standard.

133. In cases of significant breach, the notice containing any formal directions issued, or other actions taken under section 52 of the Act, must be published in the public register on Monitor’s website maintained under

section 39 of the Act.

134. If, following intervention by Monitor to address a significant breach of the Authorisation on financial grounds, short-term stability has been achieved (i.e. the cash position of the NHS foundation trust has been improved and services are being delivered at normal rates), subsequent action will depend on Monitor’s assessment of the

NHS foundation trust’s long-term financial viability.

Removal from significant breach

135. An NHS foundation trust will be removed from significant breach only once Monitor is satisfied that the failures which gave rise to the significant breach have been addressed and resolved on a sustainable basis.

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Appendix A – third

parties with roles in

relation to NHS

foundation trusts

This list is indicative and not exhaustive.

Where appropriate, it is split into third

parties with a remit specific to healthcare,

and those with a more general remit. The

lists may change from time to time.

Bodies with statutory

enforcement powers

Bodies with statutory enforcement powers include, for example, the Health and Safety Executive, the regulators of health professionals such as the General Medical Council and the fire authorities. Monitor does not reasonably expect to be involved in the resolution of issues covered by such bodies, except where persistent failures may indicate fundamental governance failings and a breach of the Authorisation.

Statutory remit specific to

healthcare


The Care Quality Commission registers all care providers in England, including NHS foundation trusts, and monitors providers’

compliance with its standards on an ongoing basis. The Care Quality Commission has a range of enforcement powers available to it to address failure to maintain compliance with these requirements. In the case of an NHS foundation trust failing to meet these standards, the Care Quality Commission will liaise with Monitor and, taking account of their respective powers, Monitor and the Care Quality Commission will work

together to ensure these requirements are met.

Health Protection Agency

The Health Protection Agency is a statutory body set up to: identify and respond to health hazards and emergencies; anticipate and prepare for emerging and future threats; alert and advise the public and Government on health protection; provide specialist health protection services; and support others in their health protection roles.

Human Fertilisation and Embryology

Authority

The Human Fertilisation and Embryology Authority is a non-departmental government body that regulates and inspects all UK clinics providing IVF, donor insemination or the storage of eggs, sperm or embryos.

Regulators of individual health

professionals

Currently, there are nine regulators of individual health professionals, covering a range of professions. They are the:

(i) General Chiropractic Council;

(ii) General Dental Council;

(iii) General Medical Council;

(iv) General Optical Council;

(v) General Osteopathic Council;

(vi) General Pharmaceutical Council;

(vii) Health Professions Council;

(viii) Nursing and Midwifery Council; and

(ix) Pharmaceutical Society of Northern Ireland.

Each has the power to demand the release of information where it relates to a hearing about the fitness to practice of a health professional.

40

Some regulators may also have powers in relation to the accreditation of courses, education or training for health professionals wishing to register.

General statutory remit

Charities Commission

The Charities Commission is a statutory regulator and registrar for charities in England and Wales.

Equality and Human Rights

Commission

The Equality and Human Rights Commission is an independent statutory body established to promote and monitor human rights, and to protect, enforce and promote equality across the nine ‘protected’ grounds – age, disability, gender, race, religion and belief, pregnancy and maternity, marriage and civil partnership, sexual orientation and gender reassignment.

Environment Agency

The Environment Agency is the leading public body for protecting and improving the environment in England and Wales. It grants licences for waste management services, including clinical waste.

Fire Authorities

Fire Authorities are responsible for fire fighting and fire safety and may require NHS foundation trusts to make changes to buildings or operations to prevent fires.

Health and Safety Executive

The Health and Safety Executive is responsible for the regulation of almost all the risks to health and safety arising from work activity.

Human Tissue Authority

The Human Tissue Authority (HTA) is a regulator that licenses organisations that store and use human tissue for, for example, research, teaching, treatment, and post-mortem examination and gives approval for organ donations from living people. The HTA, as the Competent Authority for England and Wales for the EU Organ Donation Directive, will set standards for the quality and safety of transplant organs across the UK and will develop the first formal regulatory framework and its implementation into legislation by August 2012.

Information Commissioner

The Information Commissioner oversees and enforces compliance with the Data Protection Act 1998 and Freedom of Information Act 2000.

Public Accounts Committee

The Public Accounts Committee is a parliamentary committee with the power to call any accounting officer of a public body (including NHS foundation trusts) before it.

Secretary of State for Health

NHS foundation trusts are not generally subject to direction by the Secretary of State for Health. However, the Secretary of State has specific duties in respect to safety and security in connection with the provision of high security psychiatric services, and may issue directions which will be applicable to NHS foundation trusts.

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Bodies with a statutory role

but no enforcement powers

Bodies that have a statutory role in setting or monitoring compliance with healthcare standards, but no direct enforcement powers, include commissioners and overview and scrutiny committees.

Remit specific to healthcare

Commissioners

Commissioners specify in detail the delivery and performance requirements of NHS foundation trusts, and the responsibilities of each party, through legally binding contracts with NHS foundation trusts.

NHS foundation trusts are required to meet their obligations to commissioners under their contracts. Any disputes about contract performance should be resolved in discussion between commissioners and NHS foundation trusts, or through their dispute resolution procedures (see guidance in Appendix G).

Commissioners should raise with Monitor serious and persistent concerns regarding an NHS foundation trust’s willingness to

attempt to agree contracts or ability to remain compliant with its Authorisation. NHS foundation trusts should similarly keep Monitor informed where disputes or potential disputes with commissioners may have an impact on an NHS foundation trust’s ability to remain

compliant with its Authorisation. Monitor does not expect to be involved in specific contractual disputes.

Primary care trusts (“PCTs”) commission secondary care services from NHS trusts, NHS foundation trusts and independent sector treatment centres, controlling 80% of the NHS budget. Each is responsible for monitoring compliance by NHS foundation

trusts with their contractual obligations. PCTs play a crucial role in the management of the quality of care delivered, as measured by national and local agreements, through contractual arrangements with providers.

The independent NHS Commissioning Board, currently a Shadow Special Authority, will be established as a statutory body from October 2012. Its roles will include both the delivery of its own commissioning functions and ensuring that all NHS commissioning is coordinated, comprehensive and effective, supported by clinical networks and senates. It will also take on the safety functions of the National Patient Safety Agency (NPSA).

PCTs will be abolished by April 2013 and the NHS Commissioning Board will start considering applications for the establishment and authorisation of Clinical Commissioning Groups (CCGs) from October 2012. Formed by GP practices, these will be responsible for commissioning the majority of healthcare services. Transitional PCT Clusters will support the development of these successor organisations.

Health and Wellbeing Boards

Each top tier and unitary authority will have its own Health and Wellbeing Board. Each will be a forum for health and social care service representatives to collaborate to understand local needs and agree priorities in order to address the broader determinants of health and wellbeing and reduce health inequalities for their local population. Boards will operate in shadow form during 2012/13 and take on their statutory functions from April 2013.

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Public Health England

Public Health England (PHE) will be established as part of the Department of Health. It will be responsible for the delivery of improvements in public health outcomes and incorporate functions from the Health Protection Agency from April 2013, the National Treatment Agency for Substance Misuse, Public Health Observatories and cancer registries and will work closely with local authorities. PHE will take on full responsibilities, budgets and powers from April 2012 and public health budgets will be allocated directly to local authorities from April 2013.

NHS Blood and Transplant

NHS Blood and Transplant is a special health authority with responsibility for providing a range of essential health services, including blood and tissue related services across England and transplant related services across the whole of the UK.

Parliamentary and Health Service

Ombudsman

The Parliamentary and Health Service Ombudsman investigates complaints made by or on behalf of people who may have suffered because of unsatisfactory treatment or service by the NHS.

Co-operation and Competition Panel

(CCP)

The CCP investigates potential breaches of the PRCC, and makes independent recommendations to strategic health authorities, the Department of Health and, in relation to NHS foundation trusts, Monitor, on how such breaches may be resolved. On receipt of advice from the CCP, Monitor will decide what, if any, action is required on the part of the NHS foundation trust(s) concerned. From April

2012, Monitor will incorporate the CCP and its functions.

NHS Information Centre for Health and

Social Care

The NHS Information Centre is a special health authority that collects, analyses and presents national data and statistical information about health and social care. NHS foundation trusts are required to report information specified by Schedule 6 of their Authorisation to the NHS Information Centre.

Overview and scrutiny committees of

local authorities

The overview and scrutiny committees of local authorities inquire into all “matters of local concern”, including, for example, health inequalities and access to services in the NHS. NHS foundation trusts must consult with the relevant overview and scrutiny committees before making any material changes to service offerings that will result in a change to mandatory services, and must provide the overview and scrutiny committees with any information requested. A number of overview and scrutiny committees, some non-local, may take an interest in provision where NHS foundation trusts offer a tertiary referral service on a regional or national basis.

Local Involvement Networks (LINks)

and HealthWatch England

The role of LINks is to give local communities a voice in commissioning health and social care. The Local Government and Public Involvement in Health Act 2007 which established LINks sets out their role and function and also gives the Secretary of State power to make regulations, imposing duties on commissioners and certain providers of health and social care services.

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HealthWatch England will be established in October 2012 as a sub-committee of the Care Quality Commission. LINks will evolve into local HealthWatch bodies that will: continue LINks’ current role in shaping the planning and delivery of local health and social care services; help people make choices; and provide an advocacy service regarding complaints. HealthWatch England will be able to advise the Secretary of State for Health, the NHS Commissioning Board, local authorities, Monitor and the Care Quality Commission about concerns raised by local HealthWatch bodies for possible investigation.

General remit

Ofsted

Ofsted is the inspectorate for children and learners in England. It is Ofsted’s job to

contribute to the provision of better education and care through effective inspection and regulation.

HM Inspectorate of Prisons

HM Inspectorate of Prisons for England and Wales is an independent inspectorate which reports on conditions for and treatment of those in prison, young offender institutions and immigration detention facilities.

National Audit Office (NAO)

The NAO is an independent body headed by the Comptroller and Auditor General and scrutinises public spending on behalf of Parliament. The NAO audits the accounts of all government departments and agencies as well as a wide range of other public bodies, and reports to Parliament on the economy, efficiency and effectiveness with which government bodies have used public money.

Bodies with no statutory role

but a legitimate interest

Finally, there are bodies with no statutory powers over NHS foundation trusts which may have a legitimate interest in their operations. Monitor expects that NHS foundation trusts will generally cooperate with such bodies and a failure to cooperate may, under certain circumstances, constitute a breach of the Authorisation and grounds for intervention.

These bodies include nationally recognised accreditation services, such as Clinical Pathology Accreditation (UK) Ltd, committees, working groups and forums advising the Department of Health on topics across health and social care such as the National Specialised Commissioning Group, some arm’s length

bodies such as the National Institute for Health and Clinical Excellence (NICE), and the medical Royal Colleges.

Monitor expects such bodies to influence NHS foundation trusts through the advice they give and NHS foundation trusts to report to Monitor any issues raised by such bodies that could indicate a significant breach of their Authorisation. Monitor will review any reports of non-cooperation, failure to take account of relevant advice (e.g. safety alerts from the NPSA and the organisations to which its functions are transferred) or serious or persistent concerns from such third parties with the NHS foundation trust and make its own judgment on how to proceed. Monitor may choose to intervene if it believes this to be necessary.

Clinical Pathology Accreditation (UK)

Ltd

Clinical Pathology Accreditation (UK) Ltd is a private organisation which provides a nationally recognised accreditation service for clinical laboratories.

http://www.pals.nhs.uk/CmsContentView.aspx?ItemId=2116

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Committees, working groups and

forums advising the Department of

Health on topics across health and

social care

There are about 40 groups which advise the Department of Health on a range of topics across health and social care. Of these, about half may work with foundation trusts from time to time and include: the NHS-wide Clearing Service; the National Specialised Commissioning Group; and the Specialist Advisory Committee on Antimicrobial Resistance.

Confidential enquiries

Confidential enquiries research the way patients are treated, to identify ways of improving the quality of care. They publish reports summarising key findings and recommendations arising from the information they gather. They aim to identify changes in clinical practice that will improve quality of care and ultimately improve patients’ outcomes.

There are three enquiries, each undertaking research in different areas:

• The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness examines all incidences of suicide and homicide by people in contact with mental health services in the UK. It also examines cases of sudden death in the psychiatric in-patient population;

• The Centre for Maternal and Child Health Enquiries carries out national confidential enquiries into maternal and child health and a range of other related audit and research related activities designed to improve maternal and child health in the UK; and

• The National Confidential Enquiry into Patient Outcome and Death assists in

maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, undertaking confidential surveys and research, and publishing the results of such activities.

Medical Education England

Medical Education England is a non-departmental public body that provides independent, expert advice on education and training and workforce planning in the fields of medicine, dentistry, pharmacy and healthcare science.

National Patient Safety Agency

The NPSA coordinates the reporting of, and learnings from, mistakes and problems that affect patient safety. It also incorporates the National Clinical Assessment Service (NCAS), which provides a support service where there are concerns over the performance of an individual doctor or dentist.

The NPSA is due to be abolished in July 2012. However, its functions – such as patient safety, NCAS, the National Research and Ethics Service and the National Reporting and Learning Service (NRLS) – will continue in other ways. NHS organisations should continue to submit their patient safety incident reports to the NRLS to support ongoing learning

NHS Business Services Authority

The NHS Business Services Authority is responsible for policy and operational matters relating to prevention, detection and investigation of fraud and corruption in the NHS.

NHS Litigation Authority

The NHS Litigation Authority is responsible for handling negligence claims made against NHS bodies in England. It

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helps to manage clinical risks (via the Clinical Negligence Scheme for Trusts) and non-clinical risks (via the Risk Pooling Scheme for Trusts) and manages claims and litigation for both.

Royal Colleges

Royal Colleges aim to ensure high quality care for patients by improving standards and influencing policy and practice in modern healthcare. They set standards for clinical practice, conduct examinations, define and monitor education and training programmes for their members, support clinicians in their practice of medicine, and advise the Government, public and the profession on healthcare issues. They include the:

• Royal College of Anaesthetists;

• Royal College of General Practitioners;

• Royal College of Midwives;

• Royal College of Nursing;

• Royal College of Obstetricians and Gynaecologists;

• Royal College of Ophthalmologists;

• Royal College of Paediatrics and Child Health;

• Royal College of Pathologists;

• Royal College of Physicians;

• Royal College of Psychiatrists;

• Royal College of Radiologists;

• Royal College of Speech and Language Therapists; and

• Royal College of Surgeons.

Universities and postgraduate

deaneries

NHS foundation trusts may offer professional education or training in conjunction with universities or other professional bodies. The accreditation process for such education or training may include a requirement for inspection and monitoring of provision.

For NHS foundation trusts with cross-border activities in Wales, the list also includes the Welsh Assembly, local health boards, Health Commission Wales and Healthcare Inspectorate Wales.

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Appendix B –

Governance

indicators

Monitor uses a limited set of national measures to assess the quality of governance at NHS foundation trusts. These cover acute, mental health and ambulance measures. As set out in Diagram 11 in Chapter 3, Monitor uses performance against these indicators as a component of the service performance score used to calculate governance risk ratings.

NHS foundation trusts failing, or in their quarterly monitoring submissions declaring a risk of failing, to meet these national measures will have the relevant weighting added to their service performance score.

Except where otherwise stated, any trust commissioned to provide services will be subject to the relevant governance indicators associated with those services.

Table 1 on page 45 sets out the indicators, thresholds, weightings and monitoring periods.

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Table 1: targets and indicators, thresholds, weightings and monitoring periods for 2012/13

Area Indicator Threshold (1) Weighting

Monitoring

Period

Safety Clostridium (C.) difficile – meeting the C. difficile objective (2) 0 1.0 Quarterly

Safety Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective (3) 0 1.0 Quarterly

Quality All cancers: 31-day wait for second or subsequent treatment (4), comprising:

1.0 Quarterly

surgery 94% anti-cancer drug treatments 98% radiotherapy 94%

Quality All cancers: 62-day wait for first treatment (5) from: 1.0 Quarterly urgent GP referral for suspected cancer 85% NHS Cancer Screening Service referral 90%

Patient Experience

Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted (6) 90% 1.0 Quarterly

Patient Experience

Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted (6)

95% 1.0 Quarterly

Patient Experience

Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway (6) 92% 1.0 Quarterly

Quality All cancers: 31-day wait from diagnosis to first treatment (7) 96% 0.5 Quarterly

Quality Cancer: two week wait from referral to date first seen (8), comprising: 0.5 Quarterly

all urgent referrals (cancer suspected) 93% for symptomatic breast patients (cancer not initially suspected) 93%

Quality A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge (9)

95% 1.0 Quarterly

Effectiveness Data completeness: community services (10), comprising: Referral to treatment information

Referral information Treatment activity information

The inclusion of further data items may be introduced later in 2012/13, comprising:

Patient identifier information

Patients dying at home/care home

50% 50% 50%

50%

50%

1.0

Quarterly

Quality Care Programme Approach (CPA) patients (11), comprising: 1.0 Quarterly receiving follow-up contact within seven days of discharge 95% having formal review within 12 months 95%

Quality Minimising mental health delayed transfers of care (12) ≤7.5% 1.0 Quarterly

Quality Admissions to inpatients services had access to Crisis Resolution/Home Treatment teams (13) 95% 1.0 Quarterly

Quality Meeting commitment to serve new psychosis cases by early intervention teams (14) 95% 0.5 Quarterly

Effectiveness Data completeness: identifiers (15) 97% 0.5 Quarterly

Effectiveness Data completeness: outcomes for patients on CPA (16) 50% 0.5 Quarterly

Quality Category A call – emergency response within 8 minutes (17) 75% 1.0 Quarterly

Quality Category A call – ambulance vehicle arrives within 19 minutes (17) 95% 1.0 Quarterly

Patient experience

Certification against compliance with requirements regarding access to healthcare for people with a learning disability (18) N/A 0.5 Quarterly

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Notes on table 1:

(1) Monitor will not utilise a general rounding principle when considering compliance with these targets and standards, e.g. a performance of 94.5% will be considered as failing to achieve a 95% target. However, exceptional cases may be considered on an individual basis, taking into account issues such as low activity or thresholds that have little or no tolerance against the target, e.g. those set between 99-100%. Where targets comprise multiple thresholds, each threshold must be individually met to avoid incurring a score.

Indicators have been sourced from the Operating Framework unless otherwise specified.

(2) Will apply to any inpatient facility with a centrally set C. difficile objective.16 Where an NHS foundation trust with existing acute facilities acquires a community hospital, the combined objective will be an aggregate of the two organisations’ separate objectives. Both avoidable and unavoidable cases of C. difficile will be taken into account for regulatory purposes.

Where there is no objective (i.e. if a mental health NHS foundation trust without a C. difficile objective acquires a community provider without an allocated C. difficile objective) we will not apply a C. difficile score to the NHS foundation trust’s governance risk

rating.

Monitor’s annual de minimis limit for cases of C. difficile is set at 12. However, Monitor may consider scoring

16

Should the Department of Health move to a bed rate based target, we may align our regime to reflect this development.

cases of <12 if the Health Protection Agency indicates multiple outbreaks.

See (2) / (3) for the circumstances in which we will score NHS foundation trusts for breaches of the C. difficile objective.

(3) Will apply to any inpatient facility with a centrally set MRSA objective. Where an NHS foundation trust with existing acute facilities acquires a community hospital, the combined objective will be an aggregate of the two organisations’

separate objectives.

Those NHS foundation trusts that are not in the best performing quartile for MRSA should deliver performance that is at least in line with the MRSA objective target figures calculated for them by the Department of Health. We expect those NHS foundation trusts without a centrally calculated MRSA objective as a result of being in the best performing quartile to agree an MRSA target for 2012/13 that at least maintains existing performance.

Where there is no objective (i.e. if a mental health NHS foundation trust without an MRSA objective acquires a community provider without an allocated MRSA objective) we will not apply an MRSA score to the trust’s

governance risk rating.

Monitor’s annual de minimis limit for cases of MRSA is set at 6.

See (2) / (3) for the circumstances in which we will score NHS foundation trusts for breaches of the MRSA objective.

(2) / (3) Monitor will score NHS foundation trusts for breaches of the C.

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difficile and MRSA objectives as follows:

Where the number of cases is less than or equal to the de minimis limit, no formal regulatory action (including scoring in the governance risk rating) will be taken;

If a trust exceeds the de minimis limit, but remains within the in-year trajectory17 for the national objective, no score will be applied;

If a trust exceeds both the de

minimis limit and the in-year trajectory17 for the national objective, a score will apply; and

If a trust exceeds its national objective above the de minimis limit, Monitor will apply a red rating and consider the trust for escalation.

If the Health Protection Agency indicates that the C. difficile target is exceeded due to multiple outbreaks, while still below the de minimis, Monitor may apply a score.

Monitor considers it a matter of routine reporting for trusts to report any risk to achieving its targets, including those relating to infection control.

(4) 31-day wait: measured from cancer treatment period start date to treatment start date. Failure against any threshold

represents a failure against the overall

target. The target will not apply to trusts having five cases or less in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single patient breach over

17 Assessed at: 25% of the annual objective at quarter 1; 50% at quarter 2; 75% at quarter 3; and 100% at quarter 4 (all rounded).

the quarter.18 Will apply to any community providers providing the specific cancer treatment pathways.

(5) 62-day wait: measured from day of receipt of referral to treatment start date. This includes referrals from screening service and other consultants. Failure against either

threshold represents a failure against

the overall target. The target will not apply to trusts having five cases or less in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any community providers providing the specific cancer treatment pathways.

National guidance states that for patients referred from one provider to another, breaches of this target are automatically shared and treated on a 50:50 basis. These breaches may be reallocated in full back to the referring organisation(s) provided Monitor receives evidence of written agreement to do so between the relevant providers (signed by both Chief Executives) in place at the time the NHS foundation trust makes its quarterly declaration to Monitor.

In the absence of any locally-agreed contractual arrangements, Monitor encourages trusts to work with other providers to reach a local system-wide agreement on the allocation of cancer target breaches to ensure that patients are treated in a timely manner. Once an agreement of this nature has been reached, Monitor will consider applying

18 I.e. if a trust has ten cancer (surgery) patients in a quarter and one breaches the waiting time target (thus scoring 90%) Monitor will generally not score. But if a trust has 20 patients and two breach the target (failing the target with more than one breach) Monitor generally will apply the score.

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the terms of the agreement to foundation trusts party to the arrangement.

(6) Performance is measured on an aggregate (rather than specialty) basis and NHS foundation trusts are required to meet the threshold on a monthly basis. Consequently, any failure in one month is considered to be a quarterly failure for the purposes of the Compliance Framework. Failure in any month of a quarter following two quarters’ failure of the same measure represents a third successive quarter failure and should be reported via the exception reporting process.

Will apply to consultant-led admitted, non-admitted and incomplete pathways provided. While failure against any

threshold will score 1.0, the overall

impact will be capped at 2.0. The measures apply to acute patients whether in an acute or community setting. Where an NHS foundation trust with existing acute facilities acquires a community hospital, performance will be assessed on a combined basis.

Monitor will take account of breaches of the referral to treatment target in the 2011/12 Compliance Framework when considering consecutive failures of the referral to treatment target in the 2012/13 Compliance Framework. For example, if a trust fails the 2011/12 admitted patients target at quarter 4 and the 2012/13 admitted patients target in quarters 1 and 2, it will be considered to have breached for three quarters in a row.

(7) Measured from decision to treat to first definitive treatment. The target will not apply to trusts having five cases or fewer in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single

patient breach over the quarter. Will apply to any community providers providing the specific cancer treatment pathways.

(8) Measured from day of receipt of referral – existing standard (includes referrals from general dental practitioners and any primary care professional).19 Failure against either threshold

represents a failure against the overall

target. The target will not apply to trusts having five cases or fewer in a quarter. Monitor will not score trusts failing individual cancer thresholds but only reporting a single patient breach over the quarter. Will apply to any community providers providing the specific cancer treatment pathways.

(9) Waiting time is assessed on a site basis: no activity from off-site partner organisations should be included. The 4-hour waiting time indicator will apply to minor injury units/walk in centres.

(10) Data completeness levels for trusts commissioned to provide community services, using Community Information Data Set (CIDS) definitions, to consist of:

Referral to treatment times – consultant-led treatment in hospitals and Allied Healthcare Professional-led treatments in the community;

Community treatment activity – referrals; and

Community treatment activity – care contact activity.

19 Specific guidance and documentation concerning cancer waiting targets can be found at http://nww.connectingforhealth.nhs.uk/nhais/cancerwaiting/documentation

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While failure against any threshold will

score 1.0, the overall impact will be

capped at 1.0. Failure of the same measure for three quarters will result in a red-rating.

We reserve the right to include two further data items later in 2012/13, comprising:

Patient identifier information; and

Patients dying at home.

While failure against either of these two

thresholds will score 0.5, the overall

impact will remain capped at 1.0.

Numerator: all data in the denominator actually captured by the trust electronically (not solely CIDS-specified systems).

Denominator: all activity data required by CIDS.

(11) For CPA patients (failure against

either threshold represents a failure

against the overall target).

7-day follow up:

Numerator: the number of people under adult mental illness specialties on CPA who were followed up (either by face-to-face contact or by phone discussion) within seven days of discharge from psychiatric inpatient care.

Denominator: the total number of people under adult mental illness specialties on CPA who were discharged from psychiatric inpatient care.

All patients discharged to their place of residence, care home, residential accommodation, or to non-psychiatric care must be followed up within seven days of discharge. Where a patient has

been transferred to prison, contact should be made via the prison in-reach team.

Exemptions from both the numerator and the denominator of the indicator include:

patients who die within seven days of discharge;

where legal precedence has forced the removal of a patient from the country; or

patients discharged to another NHS psychiatric inpatient ward.

Guidance on what should and should not be counted when calculating the achievement of this target can be found on Unify2.20

For 12 month review (from Mental Health Minimum Data Set v4-0, MHMDS):

Numerator: the number of adults in the denominator who have had at least one formal review in the last 12 months.

Denominator: the total number of adults who have received secondary mental health services during the reporting period (quarter) who had spent at least 12 months on CPA (by the end of the reporting period OR when their time on CPA ended).

(12) For full details of the changes to the CPA process, please see the implementation guidance Refocusing

the Care Programme Approach on the Department of Health’s website. For minimising mental health delayed transfers of care:

20 Unify2 is the system for reporting and sharing NHS and social care performance information.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083647


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Numerator: the number of non-acute patients (aged 18 and over on admission) per day under consultant and non-consultant-led care whose transfer of care was delayed during the quarter. For example, one patient delayed for five days counts as five.

Denominator: the total number of occupied bed days (consultant-led and non-consultant-led) during the quarter.

Delayed transfers of care attributable to social care services are included.

(13) This indicator applies only to admissions to the foundation trust’s

mental health psychiatric inpatient care. The following cases can be excluded:

planned admissions for psychiatric from specialist units;

internal transfers of service users between wards in a trust and transfers from other trusts;

patients recalled on Community Treatment Orders; or

patients on leave under Section 17 of the Mental Health Act 1983.

The indicator applies to users of working age (16-65) only, unless otherwise contracted. An admission has been gate-kept by a crisis resolution team if they have assessed the service user before admission and if they were involved in the decision-making process, which resulted in admission.

For full details of the features of gate-keeping, please see Guidance

Statement on Fidelity and Best Practice

for Crisis Services on the Department of Health’s website. As set out in this guidance, the crisis resolution home treatment team should:

a) provide a mobile 24 hour, seven days a week response to requests for assessments;

b) be actively involved in all requests for admission: for the avoidance of doubt, ‘actively involved’ requires

face-to-face contact unless it can be demonstrated that face-to-face contact was not appropriate or possible. For each case where face-to-face contact is deemed inappropriate, a declaration that the face-to-face contact was not the most appropriate action from a clinical perspective will be required;

c) be notified of all pending Mental Health Act assessments;

d) be assessing all these cases before admission happens; and

e) be central to the decision making process in conjunction with the rest of the multidisciplinary team.

(14) Quarterly performance against commissioner contract. Threshold represents a minimum level of performance against contract performance, rounded down.

(15) Patient identity data completeness metrics (from MHMDS) to consist of:

NHS number;

Date of birth;

Postcode (normal residence);

Current gender;

Registered General Medical Practice organisation code; and

Commissioner organisation code.




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Numerator: count of valid entries for each data item above.21

Denominator: total number of entries.

(16) Outcomes for patients on CPA (from MHMDS). Note: Monitor is

assessing the completeness of data to

make assessments of employment and

accommodation status. Thresholds in

Table 1 above reflect minimum

required levels of data completeness in

order to assess performance against

the indicators in question, not

performance itself:

Employment status:

Numerator: the number of adults in the denominator whose employment status is known at the time of their most recent assessment, formal review or other multi-disciplinary care planning meeting, in a financial year. Include only those whose assessments or reviews were carried out during the reference period. The reference period is the last 12 months working back from the end of the reported quarter.

Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the reported quarter.

Accommodation status:

Numerator: the number of adults in the denominator whose accommodation status (i.e. settled or non-settled accommodation) is

21 For details of how data items are classified as VALID please refer to the data quality constructions available on the Information Centre’s website:

www.ic.nhs.uk/services/mhmds/dq

known at the time of their most recent assessment, formal review or other multi-disciplinary care planning meeting. Include only those whose assessments or reviews were carried out during the reference period. The reference period is the last 12 months working back from the end of the reported quarter.

Denominator: the total number of adults (aged 18-69) who have received secondary mental health services and who were on the CPA at any point during the reported quarter.

Having a Health of the Nation Outcome Scales (HoNOS) assessment in the past 12 months:

Numerator: The number of adults in the denominator who have had at least one HoNOS assessment in the past 12 months.

Denominator: The total number of adults who have received secondary mental health services and who were on the CPA during the reference period.

(17) For patients with immediately life-threatening conditions.

(18) Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All (DH, 2008):

a) Does the NHS foundation trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients?

http://www.ic.nhs.uk/services/mhmds/dq

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b) Does the NHS foundation trust provide readily available and comprehensible information to patients with learning disabilities about the following criteria:

treatment options; complaints procedures; and appointments?

c) Does the NHS foundation trust

have protocols in place to provide suitable support for family carers who support patients with learning disabilities?

d) Does the NHS foundation trust have protocols in place to routinely include training on providing healthcare to patients with learning disabilities for all staff?

e) Does the NHS foundation trust have protocols in place to encourage representation of people with learning disabilities and their family carers?

f) Does the NHS foundation trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports?

Note: NHS foundation trust boards are required to certify that their trusts meet requirements a) to f) above at the annual plan stage and in each quarter. Failure to do so will result in the application of the service performance score for this indicator.

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Appendix C - Annual

plans

NHS foundation trusts are required to make the following submissions as part of their annual plans:

• Annual plan commentary (Appendix C1);

• Membership report (Appendix C2);

• Board statements on quality, finance and governance (including risk, service performance, compliance with their Authorisation and board roles, structures and capacity) (Appendix C3);

• Financial projections (Appendix C5); and

• Annual update to Schedule 2 (mandatory goods and services) and Schedule 3 (mandatory education and training).

The annual plan includes forward planning information (as required under paragraph 27 of Schedule 7 to the Act), which Monitor will publish, as required by section 39(2)(e) of the Act.

Appendix C1 – Annual plan commentary

Foundation trusts’ plan submissions are

expected to include an overall plan commentary, including:

articulation of strategy over plan period and delivery milestones;

summary of national and local factors;

summary financial commentary;

financial plans, considering:

o income;

o service developments;

o activity and costs;

o workforce; and

o capital programmes (including estates strategy).

Clinical plans, considering:

o quality accounts; and

o measures to improve clinical quality.

Regulatory requirements, including:

o cooperation and competition issues; and

o compliance with terms of Authorisation.

Leadership arrangements and any succession plans over plan period.

The commentary is expected to highlight the key initiatives in each area, with timetables for delivery and risks and mitigating actions included.

Appendix C2 - Membership report

The membership report should include:

data and commentary on membership size and movement by each public, staff and, where appropriate, patient or service user constituency, for the last year and estimates for the coming year – with reference to the table of analysis of membership size and movements;

an analysis of current membership of the public constituency and comparison with eligible membership by age, gender, ethnicity and socio-economic groupings;

an analysis of current membership of the patient or service user constituency by age;

election turnout rates by each public, staff and, where appropriate, patient or service user constituency;

confirmation that all elections to the board of governors are held in accordance with the election rules (election results are

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requested separately under the quarterly monitoring process); and

explanation of the membership plan for the future, outlining steps:

- taken in the past twelve months to ensure a representative membership in each constituency and evaluation of the outcome of these steps; and

- planned in the next twelve months to ensure membership of each constituency is representative.

Strategies should make reference to the table of analysis of current membership.

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Appendix C2 – Membership report

Membership size and movements

Public constituency 2011/12 2012/13 (estimated)

At year start (April 1) New members Members leaving At year end (March 31) Staff constituency 2011/12 2012/13 (estimated)

At year start (April 1)

New members

Members leaving

At year end (March 31)

Patient constituency 2011/12 2012/13 (estimated)

At year start (April 1)

New members

Members leaving

At year end (March 31)

Analysis of current membership

Public constituency Number of members Eligible membership

Age (years):

0-16

17-21

22 +

Ethnicity:

White

Mixed

Asian or Asian British

Black or Black British

Other

Socio-economic groupings22

:

ABC1

C2

D

E

Gender analysis

Male

Female

Patient constituency Number of members Eligible membership

Age (years):

0-16

17-21

22 +

22 Socio-economic data could be completed using profiling techniques (e.g. postcode) or other recognised methods. To the extent socio-economic data is not already collected from members, it is not anticipated that NHS foundation trusts will make a direct approach to members to collect this information

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Appendix C3 – Board statements

The board is required to confirm the following statements on an annual basis.23

No supporting details are required unless compliance cannot be confirmed.

For quality, that:

1. The board is satisfied that, to the best of its knowledge and using its own processes and having assessed against Monitor’s

Quality Governance Framework (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients (“Board

Statement 1”).

2. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements.

3. The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements.

For finance that:

4. The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.

5. The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time.

23 Statements 4 and 11 also require quarterly confirmation.

For governance that:

6. The board will ensure that the trust remains at all times compliant with its terms of authorisation and has regard to the NHS Constitution.

7. All current key risks to compliance with the trust’s Authorisation have been identified

(raised either internally or by external audit and assessment bodies) and addressed –

or there are appropriate action plans in place to address the issues – in a timely manner.

8. The board has considered all likely future risks to compliance with its Authorisation and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.

9. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.

10. An Annual Governance Statement is in place pursuant to the requirements of the NHS Foundation Trust Annual Reporting

Manual, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

11. The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B; and a commitment to comply with all known targets going forwards.

http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/our-publications/browse-category/guidance-foundation-trusts/mandat-1

http://www.monitor-nhsft.gov.uk/home/news-events-and-publications/our-publications/browse-category/guidance-foundation-trusts/mandat-1

http://www.hm-treasury.gov.uk/

http://www.hm-treasury.gov.uk/

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12. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit.

13. The board will ensure that the trust will at all times operate effectively within its constitution. This includes: maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; that all board positions are filled, or plans are in place to fill any vacancies; and that all elections to the board of governors are held in accordance with the election rules.

14. The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

15. The board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual plan; and the management structure in place is adequate to deliver the annual plan.

16. For an NHS foundation trust engaging in a major Joint Venture, or Academic Health Science Centre (AHSC), the board is satisfied that the trust has fulfilled, or continues to fulfil, the criteria in Appendix

C4.

Appendix C4

Where an NHS foundation trust:

i. that is part of a major Joint Venture or AHSC; or

ii. whose board is considering entering into either a major Joint Venture or an AHSC

meets the relevant triggers, it is required to certify to Monitor prior to entering into such an arrangement (and then once it has done so, each year thereafter), that it is satisfied it has or continues to:

• ensure that the partnership will not inhibit the trust from remaining at all times compliant with its Authorisation;

• have appropriate governance structures in place to maintain the decision making autonomy of the trust;

• conduct an appropriate level of due diligence relating to the partners when required;

• consider implications of the partnership on the trust’s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities;

• consider implications of the partnership on the trust’s governance risk rating having

taken full account of the impact on the seven elements of governance identified in the Compliance Framework;

• conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk;

• comply with any consultation requirements;

• have in place the organisational and management capacity to deliver the benefits of the partnership;

• involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services;

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• address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework);

• ensure appropriate commercial risks are reviewed;

• ensure that the Principles and Rules for Cooperation and Competition are considered and where appropriate the CCP is consulted;

• maintain the register of interests and no residual material conflicts identified; and

• engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans.

In addition, before entering into an accredited AHSC or other major Joint Venture, boards of NHS foundation trusts are required to certify that they have received external advice from independent professional advisers with appropriate experience and qualifications and that they have taken into account the best practice advice in Risk Evaluation for

Investment Decisions by NHS Foundation

Trusts or comment by exception where this is not the case.

Appendix C5 – Financial projections

NHS foundation trusts are required by 31 May to submit financial projections including an income statement, balance sheet and a cash flow statement. The templates for each NHS foundation trust, incorporating relevant historical data, will be made available well in advance of the submission date.

The financial information submitted needs to include the most recent actual year (against plan) and three years of projections. Furthermore, to facilitate in-year monitoring, the projections for year 1 must be on a quarterly basis (or monthly where an NHS foundation trust is on a monthly monitoring regime). Projections for years 2 and 3 should be on an annual basis.

To reflect the differing commissioning arrangements for acute, ambulance and mental health trusts, there are separate income and expenditure templates for each. The balance sheets and cash flow templates are the same for each. Instructions on how NHS foundation trusts can download templates can be found on Monitor’s website.

http://www.monitor-nhsft.gov.uk/home/our-publications/browse-category/guidance-foundation-trusts/mandatory-guidance/risk-evaluation-



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Annual monitoring checklist

Items covered by board statements

NHS foundation trusts are required to confirm all the board statements, as set out in Appendix C3. No supporting details are required unless compliance cannot be confirmed.

Non-exhaustive list of items requiring exception reporting

NHS foundation trusts must provide reports for risks to compliance with the Authorisation (including in relation to all the items on the following non-exhaustive list). These reports are required only by exception, i.e. if there is an issue. A more exhaustive list can be found in Diagram 8 in Chapter 2.

Finance

• Unplanned significant reduction(s) in income or significant increase(s) in costs;

• Requirement for working capital in breach of Prudential Borrowing Limits;

• Failure to comply with the NHS Foundation Trust Annual Reporting Manual; and

• Discussions with external auditors which may lead to a qualified audit report.

Governance

• Events suggesting material issues with governance processes and structures, e.g.:

o Removal of director(s) for abuse of office;

o Significant non-contractual dispute with an NHS body; and

o Relevant third party investigations e.g. fraud, any relevant Care Quality Commission reviews, investigations or studies.

• Risk of failure to maintain plans to ensure ongoing compliance with the Care Quality Commission’s registration requirements.

Mandatory services

• Proposals to vary mandatory service provision or dispose of assets (see Appendix E); and

• Loss of accreditation of a mandatory service.

In addition

• Explanations for qualified or missing certifications for any item from list above; and

• Breach of any Authorisation requirement.

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Appendix D – in-year submissions

NHS foundation trusts will be required to make the following in-year submissions on a quarterly or six-monthly basis during 2012/13:

• Quarterly financials (Appendix D1);

• Year-to-date financials (Appendix D1);

• Statement from the board certifying compliance with two specific board statements, including the underlying data that informs them, where appropriate (see Quarterly Monitoring Checklist).

• Exception reports to be provided to Monitor at any time a relevant issue arises (see Chapter 2);

• Results of any governor elections; and

• Reports on any changes in the board of directors or board of governors by completing Monitor’s online forms. These forms should be used across the year (not just quarterly) to update any director and governor details.

These submissions are described in the following sections of this Appendix.

Appendix D1 – Quarterly and year-to-

date financials

NHS foundation trusts are required to submit their actual quarterly financials, with commentary throughout the year as described in Chapter 2. Where reporting is on a six-monthly basis, the past two quarters should be submitted together.

In addition, trusts will submit information on the indicators of forward financial risk (see Diagram 7).

The final templates for each NHS foundation trust, incorporating relevant historical data for each quarter, will be made available well in advance of the submission date.

To reflect the differing commissioning arrangements for acute, ambulance and mental health trusts, Monitor will provide separate income and expenditure templates for each.

http://www.monitor-nhsft.gov.uk/home/information-nhs-foundation-trusts/planning-and-reporting-processes/-year-reporting/updating-you

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Quarterly monitoring checklist

Items covered by board statements

NHS foundation trusts are required to confirm the following board statements, as set out in Appendix C3. No supporting details are required unless compliance cannot be confirmed.

For finance that:

The board anticipates that the trust will continue to maintain a financial risk rating of at least 3 over the next 12 months.

For governance that:

The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B; and a commitment to comply with all known targets going forwards.

Non-exhaustive list of items requiring exception reporting

NHS foundation trusts must provide reports for risks to compliance with the Authorisation (including in relation to all the items on the following non-exhaustive list). These reports are required only by exception, i.e. if there is an issue. A more exhaustive list can be found in Diagram 8 in Chapter 2.

Finance

• Unplanned significant reduction(s) in income or significant increase(s) in costs;

• Requirement for working capital in breach of Prudential Borrowing Limits;

• Failure to comply with the NHS Foundation Trust Annual Reporting Manual; and

• Discussions with external auditors which may lead to a qualified audit report.

Governance

• Events suggesting material issues with governance processes and structures, e.g.:

o Removal of director(s) for abuse of office;

o Significant non-contractual dispute with an NHS body; and

o Relevant third party investigations e.g. fraud, any relevant Care Quality Commission reviews, investigations or studies.

• Risk of failure to maintain plans to ensure ongoing compliance with the Care Quality Commission’s registration requirements.

Mandatory services

• Proposals to vary mandatory service provision or dispose of assets (see Appendix E); and

• Loss of accreditation of a mandatory service.

In addition

• Explanations for qualified or missing certifications for any item from list above; and

• Breach of any Authorisation requirement.

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Appendix E – Applications to vary the

Authorisation

Exception reports that make a request for a variation to the Authorisation should cover:

Nature of the request

• A description of the variation to the Authorisation requested, identifying the area(s) of the Authorisation to which it applies.

• An estimation of the timeframe in which it will come into effect if approved.

• Details of the background and reasons for the request.

• Overview of implications of the application for a variation (both operational and financial).

Proposed action

• A summary of the proposed actions that are required to be put in place (if any).

• Required approvals to be received from other third parties (if required).

Next steps

• A list of the third parties that the NHS foundation trust has and intends to notify of the issue.

• Evidence of required approvals (if not already provided).

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Appendix F – Transactions

Monitor requires NHS foundation trusts to report proposed investments or divestments, including:

• projects funded through private finance initiatives (PFI);

• acquisition of PCT provider arms and/or their estates;

• contracts to provide services;24

• other investments or divestments; and

• changes in indemnity arrangements exceeding the thresholds shown in Diagram 15.

Monitor does not have any role in approving such plans unless the trust is being escalated or is in significant breach, but it will consider their impact on the NHS foundation trust’s risk

ratings and communicate this to trust boards.

The board will need to determine when such an investment or divestment should be reported to Monitor and the information required.

When reporting to Monitor, boards should ensure that any requests to make any related variations to the schedules of their terms of Authorisation are submitted at the same time, unless there are material mitigating factors.

Even where proposed transactions do not trigger the reporting requirements for investments or divestments set out below, boards are encouraged to take account of the best practice advice described in Risk

Evaluation for Investment Decisions by NHS

Foundation Trusts (“REID”) when evaluating the processes which they should undertake to ensure that reputational and financial risks are fully understood and governance obligations 24 These may or may not involve a transfer of assets but will be

treated as an investment for these purposes.

met. The types of transactions covered in REID include significant capital expenditure, acquisitions, joint ventures, equity stakes, major property transactions, mergers and alliances. The financing of such transactions may be through retained surpluses, equity, debt, sale and leaseback transactions, PFI and other financial instruments.

The timing for reporting major investments is also set out in REID. This requires boards to inform Monitor once they have completed their detailed review and before committing to an investment or divestment. When contemplating major investments or divestments, NHS foundation trusts may wish to inform Monitor prior to proceeding to the detailed review stage.

Based on their scale relative to the NHS foundation trust, major investments or divestments are categorised between ‘material’ and ‘significant’ transactions. The

relevant thresholds are set out in Diagram 16:

• for acquisitions and divestments of assets or businesses, data from the last year’s

audited accounts should be used; and

• for capital investments, the investment may be made over a number of years, with revenue attributable to the investment potentially only being achieved in future years. For the asset ratio, estimated capital spend will be compared with the audited asset values, and for income ratio the full year impact of projected revenue from the investment will be compared with projected foundation trust revenue in that year.

• Where a foundation trust chooses to cease membership of the NHS Litigation Authority’s various schemes, including

CNST, and enters into alternative indemnity arrangements, and this affects the capital (taxpayers’ equity) on the trust’s

balance sheet, this may trigger a




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transaction review according to the thresholds set out in Diagrams 15 and 16.

In addition:

• for any other transaction types, the data used for the transaction classification will be considered on a case-by-case basis. Foundation trusts should seek guidance from Monitor if there is any uncertainty;

• where there has been a material or significant transaction since the date of the last audited accounts, we will consider the data used for the transaction classification on a case-by-case basis; and

• in the case of an acquisition where there has been a material change in the financial position of either the foundation trust or the business being acquired since the last accounts date, and the ratio at that time is not considered representative of the contribution of the acquired business to the foundation trust, Monitor may, following discussions with the foundation trust, choose to recalculate the ratios on a pro-forma basis using current or future year data.

In all cases Monitor may, following discussions with the foundation trust, choose to recalculate the ratios using data from future years where we reasonably consider this to be an appropriate measure of the relative size of the transaction.

Material and significant transactions

The distinction between ‘material’ and

‘significant’ transactions, the two categories of

major investments or divestments, determines the extent of additional reporting required by Monitor. This will also determine how Monitor uses the information provided in assessing the potential impact of the investment or divestment on the level of risk of the resulting entity and the Authorisation.

An NHS foundation trust is required to receive formal notification from Monitor that it has complied with the requirements of the Compliance Framework before entering into a legally binding agreement with regard to a major investment.

Diagram 15: thresholds for reporting investments or divestments

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Material investments and divestments

Where a major investment (including contracts) or divestment is deemed to be ‘material’, based on the thresholds in Diagram

16, Monitor will, prior to financial and legal closure, require the board to certify that it is satisfied that it has:

• conducted an appropriate level of financial and market due diligence relating to the proposed investment or divestment;

• considered the implications of the proposed investment or divestment on the resulting entity’s financial risk rating, having taken full account of reasonable downside sensitivities;

• conducted appropriate inquiry about the probity of any partners involved in the proposed investment or divestment, taking into account the nature of the services

provided and likely reputational risk;

• conducted an appropriate assessment of the nature of services being undertaken as a result of the investment or divestment and any implications for reputational risk arising from these;

• received appropriate external advice from independent professional advisers with relevant experience and qualifications;

• taken into account the best practice advice in REID or commented by exception where this is not the case;

• resolved any accounting issues relating to the investment or divestment and its proposed treatment;

• addressed any legal issues associated with the transfer of staff (either via an acquisition, divestment or fixed term contract);

Diagram 16: categories for major investments/divestments

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• complied with any consultation requirements;

• established the organisational and management capacity and skills to deliver the planned benefits of the proposed investment or divestment;

• involved senior clinicians at the appropriate level in the decision-making process and received confirmation from them that there are no material clinical concerns in proceeding with the investment or divestment, including consideration of the subsequent configuration of clinical services;

• in the case of a contract of a specified period, ensured appropriate legal protection in relation to staff, including on termination of the contract; and

• ensured relevant commercial risks are understood;

• at the time of the acquisition, Board Statement 1 (see Appendix C3) regarding monitoring and improving care quality in the acquirer; and

• at the time of the acquisition, a Board Statement that plans are in place to be able to monitor and improve care quality in the new organisation within 6 months.

In addition:

• within 6 months of the transaction, boards are required to make Board Statement 1 (see Appendix C3) for the new organisation.

The board will also need to consider and certify that it has satisfied itself that a proposed ‘material’ investment or divestment

will meet the requirements of the PRCC.

If the board is not able to certify to Monitor that it is satisfied that the above matters have been addressed, it should explain why.

Diversification Where trusts undertake material transactions representing substantial diversification, Monitor will regard this as a ‘significant’

transaction for the purposes of quality governance assurance – see below.

Significant investments and divestments

Where a major investment (including contracts) or divestment is deemed to be ‘significant’, Monitor will require the board to

provide certification prior to financial closure in the same way as for a ‘material’ transaction.

This should be at the Final Business Case stage. However, in addition, as part of the detailed review phase, the board will be required to submit financial and other information to Monitor in enough detail to enable Monitor to undertake:

• in the case of an acquisition or divestment of a business (which is not a merger), a contract or underlying assets, a full risk evaluation of the resulting business following completion of the transaction; or

• in the case of a merger, a new assessment process of the combined business.

The purpose of the risk evaluation process in the circumstance where a major investment both:

• qualifies as a ‘significant’ transaction; and

• is an acquisition or divestment of a business, a contract or underlying assets,

is to consider how the proposed investment or divestment may affect the risk profile of the NHS foundation trust. This will inform Monitor whether any change should be reflected in the financial or governance risk rating.

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Monitor may also require the board to present to it the strategy behind its proposed investment or divestment and other matters which may impact on an NHS foundation trust’s overall risk profile.

On completion of the risk assessment, where the indicative financial risk rating is less than 3 or the governance risk rating is likely to be amber-red or red, Monitor will provide details of the risks identified. In these circumstances Monitor would not expect a board to enter into a binding contract without having first satisfied itself and Monitor that these risks can be mitigated.

Financial and quality governance

assurances for ‘significant’ transactions

Where any ‘significant’ transaction is being

undertaken, the board may be required, where appropriate, to prepare a post-transaction integration plan, a working capital board memorandum and appoint independent accountants to report on these. Further, Monitor may require an NHS foundation trust to prepare a financial reporting procedures board memorandum and appoint independent accountants to report jointly to Monitor and the board of the NHS foundation trust on this. This requirement will be considered on a case-by-case basis by Monitor in discussion with the NHS foundation trust and will take into account the specific risks of the investment or divestment proposed.

In addition to the above, Monitor may also require trusts undertaking ‘significant’

transactions to:

1. prepare plans for applying appropriate quality governance arrangements across the new organisation and submit these to Monitor; and

2. receive external assurance, in the form of an independent opinion, on the trust’s

post-transaction quality governance arrangements, and submit this to Monitor.

1 and 2 above may also apply to trusts undertaking material transactions displaying substantial diversification (see above).

Transactions involving NHS foundation

trusts meeting escalation triggers

Monitor will vary its approach to calculating risk ratings for transactions where there is a risk that the NHS foundation trust is in significant breach.

Where an NHS foundation trust has met one of Monitor’s escalation triggers, and Monitor is

currently considering whether to escalate, or has escalated that trust, Monitor will:

for material transactions, postpone receipt of trust certifications concerning the transaction in question; and

for significant transactions, postpone assigning a risk-rating to the transaction

until Monitor has determined whether the trust is, or is not, in significant breach.

Transactions involving NHS foundation

trusts in significant breach

Where an NHS foundation trust is in significant breach, Monitor will consider any material transaction as a significant transaction and consequently apply an associated risk rating. Monitor may require a credible recovery plan before preparing a risk rating for the transaction.

Investment adjustments

In order not to discourage NHS foundation trusts from undertaking transactions with short-term negative implications for Monitor’s

risk ratings, NHS foundation trusts may apply for investment adjustments.

An investment adjustment will be considered by Monitor on a case-by-case basis and may apply only in the following circumstances:

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• written application is made by the NHS foundation trust to Monitor requesting an investment adjustment and providing supporting information; and

• the relevant investment is a major investment.

Financial risk rating adjustments

For financial risk rating adjustments, trusts are required to provide evidence that:

• risks and potential rewards, and their likely timing, are demonstrated in accordance with REID; and

• the NHS foundation trust’s plan

supporting the investment identifies the potential risk adjusted costs and returns over the period of the investment.

In assessing a potential investment adjustment, Monitor may require a presentation from the NHS foundation trust setting out the basis on which it considers it appropriate, including detailed analysis of cash flows and associated risks.

Governance risk rating adjustments

Trusts seeking such an adjustment based on a revised performance threshold should, in the first instance, submit to Monitor, alongside the standard requirements for a transaction:

a proposed threshold trajectory for each governance indicator for the acquired business by quarter, returning to the target threshold within 13 months;

a proposed threshold trajectory for each indicator which the trust should be scored across the combined business, rather than separately; and

a rationale for the thresholds above.

Monitor will investigate the rationale before agreeing to any trajectory.

In addition, trusts seeking post-transaction NHS Litigation Authority CNST levels should indicate the proposed timeline and plans to achieve a CNST level of 1.0. Monitor will generally not provide a transaction adjustment related to risks triggered by Care Quality Commission concerns.

For further information, see Investment

adjustments: Guidance for NHS Foundation

Trusts.

Statutory merger

In the case of a statutory merger, Monitor will undertake a new assessment process of the combined entity as set out in Applying for a

Merger Involving An NHS Foundation Trust:

Guide for Applicants.

Disposal of protected assets

Guidelines for the disposal of protected assets are set out in Protection of Assets: Guidance

for NHS Foundation Trusts.

Joint ventures

NHS foundation trusts entering into major joint ventures, including AHSCs, that meet any of the triggers set out below are required to:

• as part of the annual plan each year, certify anticipated continued compliance with the requirements set out in Appendix C4; and

• by exception, to notify Monitor where an NHS foundation trust ceases to comply with the requirements set out in Appendix C4.

The relevant triggers are:

‘Control’ i.e.: where a separate decision making body has influence over the development and/or delivery of an NHS foundation trust’s strategy. Where the separate decision-making body is a legal entity, influence would normally be defined as at least 20% ownership.

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‘Financial conditions’: where an NHS foundation trust’s:

- assets within the vehicle are greater than 10% of its total assets (per the most recent quarterly monitoring submission); or

- share of income or expenditure from the partnership exceeds 10% of the foundation trust’s total income or expenditure respectively in any full financial year.

Legal arrangement – for ‘accredited’

AHSCs only, where an NHS foundation trust enters into a legal agreement establishing the legal arrangement of the partnership.

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Appendix G –

Monitor’s publications

While the Compliance Framework has formed the core of the regulatory framework for NHS foundation trusts since its initial publication in March 2005, additional documents also form part of Monitor’s regulatory regime.

Each of the mandatory guidance and best practice advice documents referred to below is available on our website: www.monitor-nhsft.gov.uk

Mandatory guidance

• Applying for a Merger Involving an NHS

Foundation Trust: Guide for Applicants explains the process to be followed in assessing a proposal for a merger involving one or more foundation trusts;

• Prudential Borrowing Code for NHS

Foundation Trusts determines the limit on the total amount of borrowing by NHS foundation trusts;

• Audit Code for NHS Foundation Trusts details the way in which auditors of NHS foundation trusts are to carry out their functions;

• Variation of the Terms of Authorisation: Guidance for NHS Foundation Trusts outlines how an NHS foundation trust can request a variation to its Authorisation;

• Protection of Assets: Guidance for NHS

Foundation Trusts defines protected assets and the procedure which needs to be followed when seeking disposal or de-classification of protected assets;

• Information Data Requests – Guidance

for NHS Foundation Trusts and

Sponsors explains the changed requirements relating to information

data requests to NHS foundation trusts. It gives an overview of Monitor’s

approach to information reporting from NHS foundation trusts, describes the duties of NHS foundation trusts to provide information and sets out the rights of requesters (sponsors) of information;

• NHS Foundation Trust Accounting

Officer Memorandum outlines the duties and responsibilities of the accounting officer of an NHS foundation trust;

• Investment adjustments: Guidance for

NHS Foundation Trusts provides guidance on applying for an investment adjustment and Monitor’s regulatory process for reviewing such applications;

• NHS Foundation Trust Annual

Reporting Manual provides guidance on financial and quality reporting requirements and is updated annually; and

• Contract dispute resolution: advice for

NHS foundation trusts summarises the dispute resolution procedure for NHS foundation trusts.

Best practice advice

• Effective Governance in NHS

Foundation Trusts details findings following Monitor’s requirement for

eleven NHS foundation trusts boards to commission independent advisers to review their certification process;

• The role of boards in improving patient

safety: patient care inevitably raises issues of safety. Safety measures can never be failsafe, but they can always be improved. The aim of this publication



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is to offer guidance to boards on helping to bring about these improvements.

• Roles and Responsibilities in the

Approval of NHS Foundation Trust

Private Finance Initiative Schemes sets out the roles and responsibilities of those involved in prospective NHS foundation trust private finance initiative schemes;

• Risk Evaluation for Investment

Decisions by NHS Foundation Trusts

(“REID”) outlines best practice principles for investment;

• The NHS Foundation Trust Code of

Governance sets out a common framework for the corporate governance of NHS foundation trusts. This is best practice advice although NHS foundation trusts are expected to observe in full the disclosure requirements or explain any non-compliance;

• Managing Operating Cash in NHS

Foundation Trusts promotes fiscal responsibility;

• NHS Foundation Trust Model Core

Constitution provides guidance to ensure that the constitution of an NHS foundation trust is in accordance with Schedule 7 to the Act;

• Transactions Manual for providers and

commissioners of NHS services provides a useful overview for the NHS as to the structure and approach to undertaking transactions;

• Transforming Community Services:

Transactions Guidance for NHS

foundation trusts provides guidance on Monitor’s process for reviewing these

transactions;

Where an NHS foundation trust is undertaking a transaction, it should, as

applicable, follow the guidance and best practice set out in the Compliance

Framework, REID and Applying for a

Merger Involving an NHS foundation

trust: Guide for Applicants, as appropriate; and

• Delivering sustainable cost

improvement programmes (“CIPS”), published jointly with the Audit Commission, looks at the evidence from across the NHS to identify important lessons. It provides examples of how NHS trusts and foundation trusts can deliver CIPs while improving patient care, patient satisfaction and safety.

Information on service-line reporting

(SLR) and service-line management

(SLM):

The SLM framework aims to support existing and applicant/aspirant foundation trusts in assessing SLM implementation. It provides an opportunity to highlight areas of good practice and identify areas of concern. The self-assessment tool can be used to plot a trust’s position and progress

against the framework.

Toolkit 1: Working towards service-line

management: a how-to guide sets out the processes and structures necessary to implement SLM within a trust setting using checklists, practical tools and examples of good practice;


management: organisational change

and performance management can be used by trusts that have already put in place SLR, to gather financial and operational data;

Toolkit 3: Guide to developing reliable

financial data for service-line reporting

describes a process of seven steps towards the implementation of SLR. It

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also describes how trusts can overcome some of the obstacles that may arise when introducing SLR, and includes an example work plan for implementation;


management: a toolkit for presenting

operational service-line data describes a range of SLR tools and shows how they can be used to present data about the performance of service-lines; and


management: using service-line data in

the annual planning process is not a comprehensive annual planning kit, but shows how SLR data can be incorporated into a trust’s business

planning cycle.

Guidance for NHS foundation trust

governors:

• Guide to Monitor for NHS foundation

trust governors: sets out what we do, how we regulate NHS foundation trusts and how governors can interact with us.

• Your Statutory Duties: A Reference

Guide for NHS Foundation Trust

Governors examines ways in which governors can deliver their statutory duties. It sets out these duties, and provides suggested process steps to deliver them. These process steps are advisory and reflect best practice.

• Current practice in NHS foundation trust member recruitment and engagement is a joint report produced by Monitor, Electoral Reform Research (part of Electoral Reform Services) and Membership Engagement Services.







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Appendix H –

Monitor’s Quality

Governance Framework

Quality governance is the combination of structures and processes at and below board level to lead on trust-wide quality performance including:

ensuring required standards are achieved;

investigating and taking action on sub-standard performance;

planning and driving continuous improvement;

identifying, sharing and ensuring delivery of best-practice;

and identifying and managing risks to quality of care.

Diagram 17 lists the four areas and ten questions underpinning Monitor’s Quality

Governance Framework, while samples of

good practice in each are set out in the diagrams below.

Diagram 17: Monitor’s Quality Governance Framework

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Strategy Example good practice: 1A: Does quality drive the trust’s strategy?

Quality is embedded in the trust’s overall strategy:

The trust’s strategy comprises a small number of ambitious trust-wide quality goals covering safety, clinical outcomes and patient experience which drive year on year improvement.

Quality goals reflect local as well as national priorities, reflecting what is relevant to patients and staff.

Quality goals are selected to have the highest possible impact across the overall trust.

Wherever possible, quality goals are specific, measurable and time-bound. Overall trust-wide quality goals link directly to goals in divisions/services (which

will be tailored to the specific service). There is a clear action plan for achieving the quality goals, with designated lead

and timeframes. Applicants are able to demonstrate that the quality goals are effectively communicated and well-understood across the trust and the community it serves. The board regularly tracks performance relative to quality goals.

1B: Is the board sufficiently aware of potential risks to quality?

The board regularly assesses and understands current and future risks to quality and is taking steps to address them. The board regularly reviews quality risks in an up-to-date risk register. The board risk register is supported and fed by quality issues captured in directorate/service risk registers. The risk register covers potential future external risks to quality (e.g. new techniques/technologies, competitive landscape, demographics, policy change, funding, regulatory landscape) as well as internal risks. There is clear evidence of action to mitigate risks to quality. Proposed initiatives are rated according to their potential impact on quality (e.g. clinical staff cuts would likely receive a high risk assessment). Initiatives with significant potential to impact quality are supported by a detailed assessment that could include: ‘Bottom-up’ analysis of where waste exists in current processes and how it can be

reduced without impacting quality (e.g. Lean). Internal and external benchmarking of relevant operational efficiency metrics (of

which nurse/bed ratio, average length of stay, bed occupancy, bed density and doctors/bed are examples which can be markers of quality).

Historical evidence illustrating prior experience in making operational changes without negatively impacting quality (e.g. impact of previous changes to nurse/bed ratio on patient complaints).

The board is assured that initiatives have been assessed for quality. All initiatives are accepted and understood by clinicians. There is clear subsequent ownership (e.g. relevant clinical director). There is an appropriate mechanism in place for capturing front-line staff concerns, including a defined whistleblower policy. Initiatives’ impact on quality is monitored on an ongoing basis (post-implementation). Key measures of quality and early warning indicators identified for each initiative. Quality measures monitored before and after implementation. Mitigating action taken where necessary.

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Capabilities and Culture

Example good practice:

2A: Does the board have the necessary leadership and skills and knowledge to ensure delivery of the quality agenda?

The board is assured that quality governance is subject to rigorous challenge, including full NED engagement and review (either through participation in Audit Committee or relevant quality-focused committees and sub-committees). The capabilities required in relation to delivering good quality governance are reflected in the make-up of the board. Board members are able to: Describe the trust’s top three quality-related priorities. Identify well- and poor-performing services in relation to quality, and actions the

trust is taking to address them. Explain how it uses external benchmarks to assess quality in the organisation

(e.g. adherence to NICE guidelines, recognised Royal College or Faculty measures).

Understand the purpose of each metric they review, be able to interpret them and draw conclusions from them.

Be clear about basic processes and structures of quality governance. Feel they have the information and confidence to challenge data. Be clear about when it is necessary to seek external assurances on quality e.g.

how and when it will access independent advice on clinical matters. Applicants are able to give specific examples of when the board has had a significant impact on improving quality performance (e.g. must provide evidence of the board’s role in leading on quality). The board conducts regular self-assessments to test its skills and capabilities; and has a succession plan to ensure they are maintained. Board members have attended training sessions covering the core elements of quality governance and continuous improvement.

2B: Does the board promote a quality-focused culture throughout the Trust?

The board takes an active leadership role on quality. The board takes a proactive approach to improving quality (e.g. it actively seeks to apply lessons learnt in other trusts and external organisations). The board regularly commits resources (time and money) to delivering quality initiatives. The board is actively engaged in the delivery of quality improvement initiatives (e.g. some initiatives led personally by board members). The board encourages staff empowerment on quality. Staff are encouraged to participate in quality/continuous improvement training and development. Staff feel comfortable reporting harm and errors (these are seen as the basis for learning, rather than punishment). Staff are entrusted with delivering the quality improvement initiatives they have identified (and held to account for delivery). Internal communications (e.g. monthly newsletter, intranet, notice boards) regularly feature articles on quality.

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Structures and Processes

Example good practice:

3A: Are there clear roles and accountabilities in relation to quality governance?

Each and every board member understands their ultimate accountability for quality. There is a clear organisation structure that cascades responsibility for delivering quality performance from ‘board to ward to board’ (and there are specified owners in-post and actively fulfilling their responsibilities). Quality is a core part of main board meetings, both as a standing agenda item and as an integrated element of all major discussions and decisions. Quality performance is discussed in more detail each month by a quality-focused board sub-committee with a stable, regularly attending membership.

3B: Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?

Boards are clear about the processes for escalating quality performance issues to the board: Processes are documented. There are agreed rules determining which issues should be escalated. These

rules cover, among other issues, escalation of serious untoward incidents and complaints.

Robust action plans are put in place to address quality performance issues (e.g. including issues arising from serious untoward incidents and complaints). With actions having: Designated owners and time frames. Regular follow-ups at subsequent board meetings. Lessons from quality performance issues are well-documented and shared across the trust on a regular, timely basis, leading to rapid implementation at scale of good-practice. There is a well-functioning, impactful clinical and internal audit process in relation to quality governance, with clear evidence of action to resolve audit concerns: Continuous rolling programme that measures and improves quality. Action plans completed from audit. Re-audits undertaken to assess improvement. A whistleblower/error reporting process is defined and communicated to staff; and staff are prepared if necessary to blow the whistle. There is a performance management system with clinical governance policies for addressing under-performance and recognising and incentivising good performance at individual, team and service line levels.

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3C: Does the board actively engage patients, staff and other key stakeholders on quality?

Quality outcomes are made public (and accessible) regularly, and include objective coverage of both good and bad performance. The Board actively engages patients on quality, e.g.: Patient feedback is actively solicited, made easy to give and based on validated

tools. Patient views are proactively sought during the design of new pathways and

processes. All patient feedback is reviewed on an ongoing basis, with summary reports

reviewed regularly and intelligently by the Board. The board regularly reviews and interrogates complaints and serious untoward

incident data. The board uses a range of approaches to ‘bring patients into the board room’

(e.g. face-to-face discussions, video diaries, ward rounds, patient shadowing). The board actively engages staff on quality, e.g.: Staff are encouraged to provide feedback on an ongoing basis, as well as through

specific mechanisms (e.g. monthly ‘temperature gauge’ plus annual staff survey). All staff feedback is reviewed on an ongoing basis with summary reports

reviewed regularly and intelligently by the board. The board actively engages all other key stakeholders on quality, e.g.: Quality performance is clearly communicated to commissioners to enable them to

make educated decisions. Feedback from PALS and LINks is considered. For care pathways involving GP and community care, discussions are held with

all providers to identify potential issues and ensure overall quality along the pathway.

The board is clear about Governors’ involvement in quality governance.

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Measurement Example good practice:

4A: Is appropriate quality information being analysed and challenged?

The board reviews a monthly ‘dashboard’ of the most important metrics. Good practice dashboards include: Key relevant national priority indicators and regulatory requirements. Selection of other metrics covering safety, clinical effectiveness and patient

experience (at least 3 each). Selected ‘advance warning’ indicators. Adverse event reports/serious untoward incident reports/patterns of complaints. Measures of instances of harm (e.g. Global Trigger Tool). Monitor’s risk ratings (with risks to future scores highlighted). Where possible/appropriate, percentage compliance to agreed best-practice

pathways. Qualitative descriptions and commentary to back up quantitative information. The board is able to justify the selected metrics as being: Linked to trust’s overall strategy and priorities. Covering all of the trust’s major focus areas. The best available ones to use. Useful to review. The board dashboard is backed up by a ‘pyramid’ of more granular reports reviewed by sub-committees, divisional leads and individual service lines. Quality information is analysed and challenged at the individual consultant level. The board dashboard is frequently reviewed and updated to maximise effectiveness of decisions; and in areas lacking useful metrics, the board commits time and resources to developing new metrics.

4B: Is the board assured of the robustness of the quality information?

There are clearly documented, robust controls to assure ongoing information accuracy, validity and comprehensiveness: Each directorate/service has a well-documented, well-functioning process for

clinical governance that assures the board of the quality of its data. Clinical audit programme is driven by national audits, with processes for initiating

additional audits as a result of identification of local risks (e.g. incidents). Electronic systems are used where possible, generating reliable reports with

minimal ongoing effort. Information can be traced to source and is signed-off by owners. There is clear evidence of action to resolve audit concerns: Action plans are completed from audit (and subject to regular follow-up reviews). Re-audits are undertaken to assess performance improvement. There are no major concerns with coding accuracy performance.

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4C: Is quality information being used effectively?

Information in Quality Reports is displayed clearly and consistently. Information is compared with target levels of performance (in conjunction with a R/A/G rating), historic own performance and external benchmarks (where available and helpful). Information being reviewed must be the most recent available, and recent enough to be relevant. ‘On demand’ data is available for the highest priority metrics. Information is ‘humanised’/personalised where possible (e.g. unexpected deaths shown as an absolute number, not embedded in a mortality rate). Trust is able to demonstrate how reviewing information has resulted in actions which have successfully improved quality performance.

Monitor, 4 Matthew Parker Street, London SW1H 9NP

Telephone: 020 7340 2400 Email: [email protected] Website: www.monitor-nhsft.gov.uk

© Monitor (March 2012)

Publication code: IRG 03/12

This publication can be made available in a number of other formats on request. Application for reproduction of any material in this publication should be made in writing to [email protected] or to the address above.

Paper 09

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Chairman



Helen Ashcroft, Business Planning Manager


Development

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Executive Summary

The paper provides details of the planned changes to the Trust

Balanced Scorecard for 2012/13.

The updates are driven externally by Monitor via their Compliance

Framework and though internal review.



Recommendation It is recommended that the Board:

Agree the proposed changes to the Balanced Scorecard metrics

for 2012/13 Note the planned data quality assurance processes

Subject/Title 2012/13 Trust Balanced Scorecard Report


For Discussion �

For Approval �

Paper 09


BOARD OF DIRECTORS

26TH APRIL 2012

2012/13 TRUST BALANCED SCORECARD REPORT

1. Introduction

1.1 As a Foundation Trust it is vital that the Board of Directors are provided with timely and accurate information on which it can assess the Organisation’s performance against a full

range of National targets and locally agreed measures. This is provided in an overarching

format to the Board via the Trust’s Integrated Balanced Scorecard.

1.2 At the start of each financial year the Trust reviews what should be included in the Balanced Scorecard to reflect any changes to both the National guidance and internal priorities for the

year ahead.

1.3 This paper details the planned changes to the metrics in the Balanced Scorecard for 2012/13.

The paper seeks to confirm the overall look of the Scorecard, clarify the targets to be monitored at a Trust Board level and provide detail of how ‘Red / Amber / Green’ (RAG)

tolerances have been formulated.

2. Scorecard format

2.1 At the start of 2011/12 the scorecard was significantly updated to provide the Board with a greater range of data in a user friendly format, with an overview Balanced Scorecard front

sheet supported by graphical and tabular information with further in depth written analysis as

appropriate.

2.2 It is proposed that this format continues to be used in 2012/13 with minor modifications during the year to bring the format of the financial information in line with that of the

qualitative sections.

2.3 The quadrants of the Balanced Scorecard front sheet for 2012/13 previously agreed by the

Board will remain unchanged and include:

External perception

Patient safety

Patient Experience

Resources

Efficiency

2.4 The metrics within each domain and their respective sub-metrics have been updated to provide an overview of Trust performance against a range of key drivers from internally

agreed priorities to local commissioner, Monitor and Department of Health requirements.

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2.5 The revised list of metrics is shown in table 1 below alongside the driver behind the metric Those metrics highlighted in red are new or revised for 2012/13:

Table 1: Scorecard quadrants and metrics

Quadrant Metric Sub-metrics KPI Driver

Monitor risk rating – Finance External perception Monitor risk rating – Quality Governance

Monitor

Infection control – overall Hospital acquired MRSA

Hospital acquired C. Diff

Surgical site infections – Hips

Surgical site infections - knees

Monitor

Monitor



Never events No. of never events Monitor

Serious incidents No. of serious incidents Department of Health

Unexpected deaths Total unexpected deaths (patients not on end of life care pathways)

Internal

Medicines management – overall

Medication errors – total number

Medication errors as % of activity Internal

Patient risk Patient falls

Hospital acquired VTE

Pressure ulcer assessments

Hospital acquired grade 2-4 pressure

ulcers

Hospital acquired catheter associated UTIs

2012/13 CQUIN

CQUIN - overall VTE risk assessments

VTE prophylaxis for at risk patients

Improved responsiveness to patient need

NHS safety thermometer

Dementia screening, risk assessment & referrals for emergency admissions

Theatre turnaround times

‘Making Every Contact Count’ strategy development, staff training & referrals

Patient satisfaction – Net promoter

question

Mental health training

Medicines management discharge

documentation (allergies, TTO drugs, renal function)

National CQUIN & Primary Care Trust

Patient Safety

Readmission rate to Trust Readmissions directly back into RJAH Department of Health

Patient satisfaction Response to patient questionnaire Internal / Department of

Health Patient Experience

Number of complaints Total no of complaints

% complaints against activity

Internal

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Quadrant Metric Sub-metrics KPI Driver

Access to services (RTT) - English

18 weeks RTT admitted

18 weeks RTT non admitted

18 weeks RTT incomplete pathways

6 weeks wait for diagnostics

Monitor / Department of Health

Access to services (RTT) - Welsh

26 week RTT admitted

26 week RTT non admitted

26 week RTT incomplete pathways

Patients waiting over 36 weeks for treatment

Welsh Assembly Government

Access to bone tumour

services

2 week cancer referral target

Cancer 1 month wait

Cancer 2 month wait

Monitor

Reportable cancellations % Inpatients cancelled Department of Health

Patient experience (continued)

Delayed discharges Number of beds days lost per month

% delayed discharges against occupied

beds on last Thursday of month

Internal

Department of

Health

Sickness absence % Sickness absence Internal

Staff appraisal % staff undergone appraisal in last 12 months

Internal

Staff turnover % staff turnover Internal

EBITDA EBITDA Contract

Net surplus Net surplus Contract

CIP delivery CIP delivery Contract

Capital expenditure Capital expenditure Contract

PSPP PSPP Contract

Resources

Cash balance Cash balance Contract

Demand for services Referrals received for consultant led services

Contract

Waiting lists No. of patients on the outpatient

waiting list

No. of patients on the inpatient waiting list

Internal

Activity Outpatients undertaken in month

Inpatients undertaken in month Contract

New: Follow up ratio New: Follow up ratio Internal

Day case rates % BADs activity Internal

Admission on day of surgery % of patients admitted on day of surgery

Internal

Theatre efficiency % of staffed lists utilised

Cases per session Internal

Average length of stay Average length of stay – overall Average length of stay – hips

Average length of stay - knees

Internal

Efficiency

Inpatient bed occupancy Inpatient ward beds utilised as a % of those available

Internal

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2.6 Following careful consideration a number of metrics which appeared in the 2011/12 Balanced

Scorecard have been removed as they are to be tracked via other forums or have been

superseded. These are detailed in table 2 below along with the alternative arrangements which will be implemented.

Table 2: Metrics removed

Metric Sub-metric Reason for removal Revised reporting arrangement

Deaths Total number of deaths

Superseded by unexpected deaths (new metric based on

previous low trends as a baseline)

In addition the total number of deaths (expected and unexpected)

will still be included within the Integrated scorecard

narrative

CQUIN - Overall Post discharge NSAIDS

Patient Access to

Certolizumab

Prescription of gastro protection for at risk

patients taking NSAIDS

Management of

deteriorating patients

Outpatient rescheduling

Telephone reminders

% EDD recorded on PAS

% EDD recorded in notes

Post operative pain management

Preoperative waiting times

in theatres

No longer CQUIN Reported via internal

Divisional ¼ly Reviews as appropriate

Access to services (RTT) - English

18 weeks RTT Admitted 95th percentile

18 weeks RTT Admitted Median

18 weeks RTT Non admitted

95th percentile

18 weeks RTT Non admitted

Median

18 weeks RTT Incomplete 95th percentile

18 weeks RTT Incomplete Median

Targets no longer monitored by Monitor

and local

commissioners, instead superseded by overall

18 week RTT

Reported via internal Divisional ¼ly Reviews as

appropriate

Income and

expenditure

Income and expenditure Superseded by EBITDA

and Net surplus

Not applicable

Cash balance Income and expenditure Replaced by liquidity ratio in line with

Monitor reporting

Not applicable

Demand for Services

Additions to the outpatient waiting list

Superseded by Referrals received for

Consultant led service

Reported via internal Divisional ¼ly Reviews as

appropriate

Daycase rate Overall % daycase rate Superseded by BADs rates

Reported via internal ¼ly Reviews by specialty

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3. RAG tolerances

3.1 Each sub-metric of the balanced scorecard has an agreed target for the year and tolerance levels for reporting as green / amber or red to the Board.

3.2 Where a target is external to the Trust the metric will be measured in line with that authority’s requirements. For internally determined metrics, tolerance levels applied have

been reviewed by the Executive Director responsible and reflect LTFM requirements, historical performance and were appropriate have been benchmarked against other Trust’s

performance.

3.3 As in previous years all tolerances will be re-reviewed at the end of quarter 1 to ensure they

provide a true and accurate reflection of performance and risk. A further review of both targets and tolerance will be undertaken at the end of the second quarter to ensure priorities

identified by the new Executive Directors are appropriately captured.

4. Data Quality

4.1 During 2011/12 an overarching review of the data quality for each metric of the Trust Board Balanced Scorecard was undertaken and presented to the Trust’s Audit Committee. Following

which a rolling programme of in depth reviews was undertaken by the Trust’s Information Department.

4.2 As further assurance both the Trust’s approach to self certification and monitoring its position against Monitor’s terms of authorisation has been reviewed as having significant assurance by

the Trust’s internal auditors.

4.3 The Data Quality rolling audit programme will continue into 2012/13 and will incorporate all

new metrics as appropriate. To specifically support the data quality process the Trust has asked KPMG as part of the internal audit plan to support the development of the data quality

team in delivering this programme.

5. Recommendations

5.1 It is recommended that the trust Board:

Agree the proposed changes to the Balanced Scorecard metrics for 2012/13

Note the planned data quality assurance processes.

Paper 10

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 10 BRIC Chairs Report.doc




Executive Responsible James Turner, Non Executive Director




Development





Objectives


Executive Summary

This report highlights the key business undertaken by the BRIC at its meeting on 21st March 2012.

Subject/Title Report from the Chair of the Business Risk & Investment

Committee (BRIC)

Nature of Report For Information �

For Discussion

For Approval �


Legal Implications

Recommendation The Trust Board are asked to • note the Chairman’s Report and the Self Assessment.


1

Paper 10

U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 10 BRIC Chairs Report.doc

James Turner Non-Executive Director



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Audit Committee Chair The Audit Committee Chair was welcomed to the meeting

Risk The Committee reviewed all of the Corporate and Strategic risks which had been allocated to the

BRIC. They concentrated on the Risk of the Failure to optimise capacity which had increased to reflect the impact of the RTT issue. It was agreed that the RTT recovery plan should be a

separate entry on the risk register and that the committee would be updated on the progress

against that plan until the issue was resolved.

The Committee approved the BRIC Chairman’s report on risk management, which had been drafted as part of the annual governance cycle, to give the Audit Committee assurance on the

overall completeness and effectiveness of risk management.

Business Cases

The Committee reviewed the Orthotics Manufacturing Unit Business case, which had been presented to them as it concerned an activity which could be considered as non core to the Trust.

The Committee supported the Business case

Governance

The Committee: • Received an update on the new main entrance project which included the steps which were

being taken to ensure the smooth operational running of the new facility

• Received the Internal Audit Reports on CIP and QIPP processes, which gave significant

assurance • Noted the areas of the CQC accreditation which came under the BRIC’s remit.

Strategies

The Committee endorsed the 2012/13 Capital Programme.

Regular Reports The Committee noted the following reports:

• 2011/12 Capital Update.

• Health & Safety report

• IM&T Report

• Human Resources,

• Treasury Management (Investment Register), this included a briefing on the key drivers

behind the current large cash balance. • The Work Plan was revised to take account of the BRIC’s role in overseeing the progress

against the RTT recovery plan.

James Turner

Non Executive Director

2

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U:\Trust Board & Committees\Public Trust Board\2012-2013\April 2012\Paper 11 Q&S Chairs Report.doc Page 1 of 3

Peter Jones �� 4358

Chairman



Executive Responsible Peter Jones, Non Executive Director/Chairman of Quality and Safety Committee



Jayne Downey, Director of Nursing






Objectives


Executive Summary

The Quality and Safety Committee met on the 30th March

2012.

A summary of the key issues discussed is given in the Chairman’s report.

Subject/Title Quality and Safety Committee Chairman’s Report

Nature of Report For Information �

For Discussion

For Approval


Legal Implications

Recommendation That the Trust Board note the Chairman’s report.


PROM’S – Patient Reported Outcome Measures

Paper 11


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Patient Story

• Mervyn Dean, Non Executive Director presented two written patient

stories based on conversations with recent inpatients on Sheldon Ward . In choosing the patients whose stories were presented Mervyn Dean was able to

gain assurance on the process for presentation of stories to the Committee. Both stories were extremely positive highlighting especially the excellent care given by

Dr Ho and the Nursing Team. Negative comments included car parking, which

Peter Jones, Chairman of the Quality and Safety Committee reported as being in the process of being resolved with the construction of the new Main Entrance.

Quality & Safety

• The Committee had a full discussion on the five recent serious incidents and

noted all reports. • The Committee noted the Quality Governance Framework; an action plan for the

document will be produced by the Deputy Director of Nursing and Director of

Nursing. • The Committee noted the Corporate Risk Register and it was agreed that the

Director of Nursing would update the risk register for the next meeting.

• The Committee received the draft Quality Accounts and were asked to share any

comments on the document with the Director of Nursing. The updated document will then to be shared with Shropshire LINk and the PCT.

• The Committee noted the MHRA Alert on Metal on Metal Hips and the Medical

Director updated the Committee on the steps that were being taken to deal with

this issue. • The Committee noted the Non Executive Lead for Resuscitation as Peter Jones,

Chairman of the Quality and Safety Committee and asked for an annual report

and any updated policy to be brought to future Committees. • The Committee received the Risk Assurance Report as a late paper and noted its

contents.

Clinical Effectiveness

• The Medical Director presented the PROMS update, which was broken down

anonymously into individual surgeons. The Committee agreed that this was a useful document to receive on a regular basis.

• The Medical Director presented two documents from the National Confidential

Enquiry into Patient Outcome and Death (NCEPOD);- � Are We There Yet? A Review of Organisational and Clinical Aspects

on Children's Surgery

Paper 11


� Knowing the Risk - A Review of Peri-Operative Care of Surgical

Patients Both reports have been responded to by the Trust and these were also included

for the Committee to review. • The Committee received the 2011-2012 Compliance with CQC Regulations Audit

from KPMG as 'limited assurance'. It was noted that conclusion of 'limited

assurance' was given due to the staffing difficulties with Governance during the

year and hence the process for updating evidence. The audit provided assurance that the Trust was compliant with the CQC Essential Standards. The Director of

Nursing shared with Committee that the process of compliance with the CQC will be reviewed in the next financial year and the Committee recognised the

accuracy of the report and agreed consequent actions.

Routine Matters

• The Committee noted the Clinical Audit Quarterly Report.

• The Committee agreed that the Work Plan would be updated by Peter Jones,

Chairman of the Quality and Safety Committee and Jayne Downey, Director of

Nursing.

Peter Jones, on behalf of the Quality and Safety Committee thanked Professor Iain McCall,

Medical Director for his continued support as Medical Director of the Trust and shared with the Committee how much he had enjoyed working with Professor McCall over the years. He

also thanked the Interim Director of Nursing for all her help and support in the work of the Committee.

Peter Jones Non Executive Director/Chair of the Quality and Safety Committee

Documents

A P NE UBLIC MEETINGthe introduction of a summative assessment rather than a formative assessment. Once the assessment becomes summative systems and processes have to be very precise